EMDR Therapy and Research: what have we got right and what can we improve?
Jessica Woolliscroft reports on Professor Christopher Lee’s keynote address to this year’s EMDR Europe conference. Lee is Associate Professor at the University of Western Australia, a Clinical Psychologist and an EMDRIA Trainer and Schema Therapy Trainer. He is a recipient of the Francine Shapiro Award for Research Excellence.
Try to imagine standing under a shower of cool, clear water on a very hot day or cracking open an ice-cold beer on a scorching hot beach. That was how I felt listening to Professor Lee as he amiably deconstructed, with disarming ease, the powerful forces eroding the evidence base for EMDR as a treatment for PTSD. Lee revealed himself to be a master of Powerpoint. He used his slides to dramatic effect to illustrate the unbelievably narrow criteria used by the APA (American Psychological Association) in comparison to the ISTSS (International Society for Traumatic Stress Studies) in selecting the research studies that will be included in their treatment guidance. I watched in amazement as Lee’s slides showed how 30 research studies supporting EMDR were gradually whittled away to a paltry five.
The upshot is that the APA guidelines for the treatment of PTSD, published in February 2017, were formulated using the results of only those studies published before 2013! It is sobering to realise that these guidelines are still being used now, in 2021, to determine which PTSD treatments are funded by insurers and health treatment providers. So, what were some of the criteria used by the APA to exclude research studies? APA expected every patient in the study to meet ALL – that is 100% – of the PTSD criteria, compared to NICE (which expected 80%) and ISTSS (70%).
This led Lee to suggest that future research projects should ensure that:
- all their patients are clinically assessed.
- at least 80% meet full PTSD criteria.
- Each research group has more than 13 participants (because NICE excludes any study in which participants in a group drop below 10).
- The research is well designed, with a sound methodology e.g. CONSORT (because many research designs get excluded).
Lee then shared a recent study that met all these criteria, Mavranezouli et al. (2020). This study had actually been commissioned by NICE to compare the cost effectiveness of different psychological treatments for PTSD. At this point in the presentation, we delegates were treated to an interactive poll. Lee asked us to guess which of the following treatments for PTSD were the most cost effective. I shall reproduce his slide here below and invite you too to place the following treatments in order of cost effectiveness.
This was an enlivening part of the presentation, as we voted in the poll and watched the numbers changing in front of our eyes. Not surprisingly, at an EMDR Europe Conference, EMDR topped the poll (bit of a design bias fault there). However, when the actual research findings were revealed by Lee’s slide show, there was still plenty to surprise the conference.
Not only did Mavranezouli et al. discover that EMDR was the most cost effective PTSD treatment, but shockingly that counselling was worse than receiving no treatment. Most surprising, in my opinion, was the finding that Trauma Focused CBT (TFCBT) was the second to least cost effective treatment. I hope that this NICE-funded research will go some way to correcting years of imbalance in provision within the NHS and by health insurers.
Lee then suggested that, given that PTSD for adults now has a solid evidence base, the priorities for future research should be the cost effectiveness of EMDR in five other areas:
- PTSD in children and adolescents.
- Early intervention in PTSD.
- Combat-related PTSD.
- Chronic and Acute Pain.
A recent study into the effectiveness of trauma-focused therapy for individuals receiving group treatment for depression (Dominguez et al., 2020) compared EMDR with CBT and Treatment as Usual (TAU). In this randomly controlled trial (RCT), 49 patients receiving group CBT for depression and anxiety in hospital over a two-week period, were also offered individual therapies. Only the group receiving EMDR showed a significant difference in depression diagnosis scores at follow up.
And yet, when this study was sent out for peer review, despite the dramatic research evidence, the response of the peer reviewers was: “The results of this study aside, at the end of the day I just can’t see how depression can be treated with a trauma focused approach unless the person has PTSD”.
Despite his understandable puzzlement at the response of the peer reviewers, Lee patiently explained how it might be that a trauma focused treatment such as EMDR can have a significant effect on depression.
The ACEs study has shown us all that adverse childhood events are strongly related to psychopathology. They are also related to chronicity of depression and treatment outcome (Nanni et al., 2012). Many adverse events such as bullying do not fit PTSD Criterion A, necessary to diagnose PTSD. People with depression experience intrusive memories almost at the same rate as people with PTSD (Payne et al., 2019). There is a correlation between distress about these memories and the severity of the depression (MIhailova & Jobson, 2018). Lee thereby provided an elegant justification for continuing to carry out research on the effectiveness of EMDR for depression, targeting adverse events and also the schemas of negative beliefs that keep the depression looping.
Lee then looked at Complex PTSD (cPTSD) which, he concluded, still needs more research. He shared research he has been involved in from the IREM study (Botherhoven de Haan et al., 2020, 2021) comparing imaginal rehearsal (IR) with EMDR for adults with PTSD since childhood. Each patient was their own waiting list control. They were seen twice a week, had no sessions of stabilisation and 12 sessions of 90 minutes each. Both groups showed significant improvements; there did not seem to be much difference between those using IR and those using EMDR. However, the study uncovered some interesting findings about this group of patients with cPTSD. The IREM study identified that factors such as how the treatment was delivered and personal indicators for change had a significant effect on treatment outcomes.
For example, the study found that patients with chaotic lives really benefitted from being seen twice a week, as the second session in the week was less likely to be derailed by their need to share the details of current crises. It also identified a Personal Advantage Index (PAI). These are personal attributes of patients that were significant indicators of their ability to benefit from treatment. This is useful knowledge for practitioners and services triaging for treatment as it helps to select the patients most likely to benefit from services that are (sadly) rationed.
Once again, the conference was invited to participate in an interactive poll. Which personal attributes would you select as the most significant indicators of a patient’s ability to benefit from treatment? The results of the conference poll are shown here:
Readiness to change – 23%
Experiential avoidance – 10%
Social problems – 5%
Willingness share traumatic experiences/ avoidance (shame or guilt) – 13%
Attachment – 19%
Openness to experience – 23%
Working memory – 6%
Lee then shared the results of the IREM study with the PAI listed in order of their influence on recovery.
This keynote speech was intellectually stimulating, incredibly up to date and, once again, seemed to fire many delegates’ enthusiasm for contributing to research in some way. Many delegates in the Q & A session asked the same question: “How can private practitioners, not affiliated to Universities or Health Services, contribute their practice-based evidence to the wider pool of research?”
Alas, this question is regularly raised in my experience and never truly answered. Surely it cannot be beyond the capacity of EMDR EUROPE to organise some form of mass study utilising the resources of members? Now we have all experienced our technological baptism of fire through the pandemic, can anyone design such an interactive research study using EMDR practitioners across Europe?
Now there is a challenge.
The slides are all from Prof Lee’s Presentation.
Boterhoven de Haan, K. L., Lee, C. W., Correia, H., Menninga, S., Fassbinder, E., Köehne, S., & Arntz, A. (2021). Patient and Therapist Perspectives on Treatment for Adults with PTSD from Childhood Trauma. Journal of Clinical Medicine, 10(5). doi:10.3390/jcm10050954
Boterhoven de Haan, K. L., Lee, C. W., Fassbinder, E., van Es, S. M., Menninga, S., Meewisse, M. L., . . . Arntz, A. (2020). Imagery rescripting and eye movement desensitisation and reprocessing as treatment for adults with post-traumatic stress disorder from childhood trauma: randomised clinical trial. Br J Psychiatry, 1-7. doi:10.1192/bjp.2020.158
de Jongh, A., Amann, B. L., Hofmann, A., Farrell, D., & Lee, C. W. (2019). The status of EMDR therapy in the treatment of posttraumatic stress disorder 30 years after its introduction. Journal of EMDR Practice and Research, 13(4), 261-269.
Dominguez, S., Drummond, P., Gouldthorp, B., Janson, D., & Lee, C. W. (2020). A randomized controlled trial examining the impact of individual trauma‐focused therapy for individuals receiving group treatment for depression. Psychology and Psychotherapy: Theory, Research and Practice. doi:10.1111/papt.12268
Dominguez, S., & Lee, C. W. (2019). Differences in International Guidelines Regarding EMDR for Posttraumatic Stress Disorder: Why They Diverge and Suggestions for Future Research. Journal of EMDR Practice and Research, 13(4), 247-260. doi:10.1891/1933-3184.108.40.206
Dominguez, S. K., & Lee, C. W. (2017). Errors in the 2017 APA Clinical Practice Guideline for the Treatment of PTSD: What the Data Actually Says. Frontiers in Psychology, 8(1425). doi:10.3389/fpsyg.2017.01425
Ehring, T., Welboren, R., Morina, N., Wicherts, J. M., Freitag, J., & Emmelkamp, P. M. (2014). Meta-analysis of psychological treatments for posttraumatic stress disorder in adult survivors of childhood abuse. Clin Psychol Rev, 34(8), 645-657. doi:10.1016/j.cpr.2014.10.004
Karatzias, T., Murphy, P., Cloitre, M., Bisson, J., Roberts, N., Shevlin, M., . . . Hutton, P. (2019). Psychological interventions for icd-11 complex ptsd symptoms: Systematic review and meta-analysis. Psychological Medicine. doi:http://dx.doi.org/10.1017/S0033291719000436
Mavranezouli, I., Megnin-Viggars, O., Daly, C., Dias, S., Welton, N. J., Stockton, S., . . . Pilling, S. (2020). Psychological treatments for post-traumatic stress disorder in adults: a network meta-analysis. Psychol Med, 50(4), 542-555. doi:10.1017/S0033291720000070
Mavranezouli, I., Megnin-Viggars, O., Grey, N., Bhutani, G., Leach, J., Daly, C., . . . Pilling, S. (2020). Cost-effectiveness of psychological treatments for post-traumatic stress disorder in adults. PLoS ONE, 15(4), e0232245. doi:10.1371/journal.pone.0232245