Atreatment for posttraumatic stress disorder (PTSD) hasbeen proposed by Shapiro (1989b) involving oculartracking, by the client, of a bilaterally moving stimuluswhile holding in mind a mental representation of thetraumatic event. Shapiro claimed to have happened uponthis procedure, eye movement desensitization (EMD),through serendipity. During a now famous walk in thewoods (Rosen, 1995, 1997; Shapiro, 1995; Welch, 1996),while thinking of an anxiety-provoking situation, she no-ticed that her eyes were involuntarily moving in a multi-saccadic manner, followed by the disappearance of theseanxiety-provoking thoughts. Shapiro also noted that fol-lowing this procedure she, and later her clients, found itvery difficult to retrieve the memory of the anxiety pro-voking material, and that even when the thoughts weredeliberately retrieved, she found that their anxiety va-lence had dissipated. This treatment procedure was firstinvestigated by Shapiro in 1989(a) and the method oftreatment quickly developed to the point of workshoptraining (Shapiro, 1992).

During the development phase of the process, theacronym “EMD” grew into EMDR (eye movement de-sensitization and reprocessing), to keep in line with thedescriptive rationale for its effects. It has now been pro-moted as an unique, fast-acting, and effective interven-tion method for treating a plethora of problems including,but not limited to, substance abuse (Shapiro, Vo g e l m a n n -Sine, & Sine, 1994), personality disorders (Fensterheim,1996), PTSD (Shapiro, 1989b), sexual dysfunction(Wernik, 1993), dissociative disorders (Paulsen, 1995),body dysmorphic disorder (Brown, McGoldrick, &Buchanan, 1997), and morbid jealousy (Blore, 1997).EMDR has even been advocated for enhancing perfor-mance in athletes (Foster & Lendl, 1995). Such claimshave been partly responsible for the development of agrowing rift within clinical psychology. Critics claimthat the level and method of marketing EMDR has out-stripped its evidence, and proponents claim that EMDRis being treated unfairly by the academic “fraternity”who expect a higher standard of evidence than would beaccepted for other, more conventional treatments.

Whatever the truth, widespread and vigorous appli-cation of any therapeutic technique requires evidencethat the procedure is not just more effective than a waitlist condition, but that there are incremental effects overplacebo treatments. It is also desirable that the mecha-

The author would like to thank the journal editorial team and Susan H. Spencefor their helpful comments on earlier drafts.

Correspondence concerning this article should be addressed to Grant J.Devilly, Ph.D., Department of Criminology, University of Melbourne, Victoria3010, Australia; E-mail: dev@crim.unimelb.edu.au .

THE SCIENTIFIC REVIEW OF MENTAL HEALTH PRACTICE Vol. 1, No. 2 (Fall/Winter 2002)

EYE MOVEMENT DESENSITIZATION AND REPROCESSINGA Chronology of Its Development and Scientific Standing

Grant J. DevillyUniversity of Melbourne

The development of eye movement desensitization and reprocessing (EMDR) has been hotly debated, withrhetoric often being posited as evidence either for or against the technique. This paper aims to provide a briefoverview of the procedure, a critical review of the studies completed to date, a meta-analytic review of theavailable data, and a chronology of the evolution of EMDR over the past 10 years. Tr e a t m e n t - o u t c o m estudies were of such disparate quality—even studies meeting similar broad criteria—that combining their re-sults in a meta-analysis was of very questionable value. Overall, an appraisal of the published research sup-ported the following conclusions: (1) There is overwhelming evidence that eye movements are neither a nec-essary nor a useful addition to the procedure; (2) there is strong and consistent evidence that EMDR is betterthan no treatment, yet only as good as any other treatment that utilizes some aspect of exposure therapy; and(3) there is strong evidence that a full-exposure-based intervention package is superior to EMDR. There is alsosome evidence that “reprocessing” is likewise superfluous to EMDR and that the effects of EMDR dissipateover time. It is also concluded that the current debate cannot be entirely settled through scientific investiga-tion due to the rapid and constant reshaping of what constitutes EMDR, the similarity to extant alternativemethods, and the lack of a falsifiable theory underpinning the procedure.

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nism responsible for improvement in patient functioningis isolated. Furthermore, evidence is needed that the in-tervention is at least effective as standard clinical care. Itis the purpose of this article to address these issues. Inorder to accomplish this goal, the treatment-outcome lit-erature was critically reviewed, effect size estimates forcompleted studies were derived, and the results were in-tegrated into an overall “state of affairs.” In addition, achronological review of EMDR research and of EMDRprotocol development was conducted in order to providethe reader with an appreciation of why this area of re-search is so controversial. Past reviews of the EMDRliterature have focused on methodological critiques ofthe EMDR research (Lohr et al., 1993), efficacy ofEMDR for specific conditions (Lohr, Tolin, & Lilien-feld, 1998), specific and nonspecific factors involved inEMDR (Lohr, Lilienfeld, Tolin, & Herbert, 1999), andfactors involved in the dissemination and promotion ofEMDR (Herbert et al., 2000). However, this reviewadopts a chronological approach to the controversiesconcerning EMDR, providing a historical context uponwhich effectiveness and efficacy can be judged and apresentation of the methodological weaknesses in the re-search that have been addressed over time.

In order to conduct this review, a literature searchwas performed on PsychInfo using the keywords “eyemovement desensitization and reprocessing” (and theacronyms “EMD” and “EMDR”), “treatment,” “out-come,” and “controlled.” Literature reviews by other au-thors were also checked for studies, and Web sites (par-ticularly that of the EMDR Institute) were checked foradditional studies. In order to provide a chronology of thedebate, some single case studies that were of importancein the early stages (1989 to 1994) were included in thecritical review, but otherwise all controlled clinical out-come studies that were in a publishable format and avail-able for independent review were selected.

EMDR BACKGROUND

Shapiro (1989a, 1989b) suggested that any therapistusing EMDR should be properly trained by herself and,later (1991b), that any research carried out by untrainedtherapists would be invalidated by this lack of skill. Al-though the level of EMDR training has yet to be deter-mined to correlate with outcome (see Rosen, 1999),Shapiro has discussed at length the development andevolution of EMDR in several articles (e.g. Shapiro1989, 1994, 1995, 1997, 1999). However, in light of thereview of the literature later in this article, a brief outline

of the technique is presented below as taught at trainingworkshops in 1992, and the development of the EMDRprocedure is further examined at the end of this review.

The Components of EMDR

As within any therapeutic framework, it is important toestablish rapport with the client in order to engender trustand make it clear that one is not simply applying a “quickfix” without understanding the person. During thisprocess the therapist should move from history taking toidentifying the presenting problem and obtaining someidea (preferably with quantification) of how it interfereswith daily functioning. Next, she should introduce theprocess and provide the client with a suitable rationale,appropriate to his level of understanding, of how thetechnique works, what he can expect during the session,and how it may affect him later. With respect to the ra-tionale of EMDR, the following has been typical:

Traumas cause a pathological change in the brain at theneural level resulting in these incidents becoming“locked” in the nervous system and not being processed inthe normal way and, therefore, not being dealt with.Repetitive eye movements may be the body’s natural wayof desensitizing the person to the memory and so, in-hibiting anxiety, the traumatic “overload” becomes re-solved. Do you have any questions?

I will be moving my hand in front of you at about thislevel [demonstrate] and sweeping it back and forth acrossyour field of vision like this [demonstrate]. I want you tokeep track of my finger tips with your eyes and withoutmoving your head. (Shapiro, 1992)

Aprototypical transcript explaining the procedural ques-tions reads as follows:

What we will be doing is often a physiology check. I needto know from you exactly what is going on with as clearfeedback as possible. Sometimes things will change andsometimes they won’t. I may ask you if the picturechanges—sometimes it will and sometimes it won’t. I’llask you how you feel from “0” to “10” sometimes it willchange and sometimes it won’t. I may ask if somethingelse comes up—sometimes it will and sometimes it won’t .There are no “supposed to’s” in this process. So just giveas accurate feedback as you can as to what is happening,without judging whether it should be happening or not. Justlet whatever happens—happen. (Shapiro, 1988, p. 66)

Next, the therapist should instruct the client to gen-erate an imaginary, representative picture of the dis-tressing issue (or associated bodily sensation) that is cen-

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tral to his problem. Having done this, it is easier to obtainhis negative belief statement about the event. An ex-ample of this would be, “I could have done more tohelp.” Then she should obtain the client’s desired (thoughrealistic) positive cognition for this same event (e.g., “Idid the best I could”). For both of these Shapiro (1989a)suggested that a validity of cognition (VoC) rating ofhow much the client believes each of these statements(on a 1–7 scale) should be made. Having completed thismuch, the therapist should then discuss the emotions thatthe mental picture evokes and also identify the body sen-sations that accompany these emotions. Next, she shouldacquire a measure of the degree of anxiety/disturbancethat this picture/feeling/sensation/cognition evokes by aSubjective Units of Disturbance Scale (SUDS) from 0 to10. Following these steps, the actual EMDR process it-self is applied.

While the client concentrates on the imaginary pic-ture and accompanying body sensations, he is instructedto concentrate on the therapist’s first two fingers, whichare moved rapidly back and forth across the line of vision12–14 inches away from the face. Each sweep shouldcover the extreme left and extreme right of the field of vi-sion (at least 12 inches) at the rate of two back and forthmovements per second. This rate may vary dependingupon the individual’s ability to track the movements. Ini-tially the direction should be on a horizontal plane, but ifthis has little effect it can be changed to a diagonal, ver-tical, or circular motion in order to “accommodate indi-vidual client differences.” Twenty-four back-and-forthsweeps should be given for each set, although if a highlevel of emotional distress is noticed, these movementsshould be continued until a plateau in affect is reached.Throughout nurturing prompts may be given (e.g.,“good,” “well done,” “that’s it”). At the end of one set,the client is instructed to “blank it out and take a deepbreath.” Following this, he is are asked whether any-thing else came up. If it did, he should concentrate on itfor the next set of eye movements until it is desensitized.If not, the client is instructed to bring the picture/feeling/cognition up again and give it a SUDS rating. T h i sprocess is continued until a rating of 0 (no anxiety) is ob-tained and the issue is desensitized. The desired cogni-tion is then concentrated upon during the eye movementsuntil a VoC rating of 7 (completely true) is obtained.This cognition and the original issue are then linked to-gether during the eye movements by keeping both inmind (referred to as the “installation” process; Shapiro,1995), and finally a body scan is completed, checking forany physiological residue. If there are any signs of ten-sion, the eye movements are again induced, while the

client concentrates on these sensations until they havedissipated. It should be noted that this is an outline of theprocedure as used by Shapiro (1989a) and taught at train-ings until at least 1992. An analysis of the progressionand addition of components to the EMDR protocol overtime will be presented later in this article.

However, first we should inspect the theoretical un-derpinnings of any treatment, as it is within this contextthat techniques are usually taught and disseminatedamong professionals.

THEORIES OF EMDR ACTION

Shapiro (1989a) discussed the similarity between theEMDR eye movements and those of REM sleep. A l-though this proposal initially seems attractive and thelittle-understood information processing perspective thatit implies appears credible, there are important inade-quacies in this assertion. First, Shapiro described EMDRas inducing multisaccadic eye movements. This is not al-ways the case: Following the researcher’s finger move-ments creates a smooth pursuit eye movement at thelower speeds sometimes used by EMDR therapists. Al-though similar to REM movements, they are not thesame. Second, there are no known neural mechanismsthat connect eye movements to neurological structures ofmemory. Shapiro also talked of Pavlov’s (1927) Excita-tion-Inhibition theory, whereby if at some point in thecortex excitation and inhibition conflict, the resultantstate is a pathological change and the subject may displayassociated symptoms. Shapiro suggested that this is whathappens in cases of PTSD: The subject receives a type ofinformation overload and the trauma is left in a “frozenstate.” She suggested that this primed state is then un-blocked by the EMDR, in a hitherto unexplained manner,and the information can be processed in the normal way.H o w e v e r, although conceptually Pavlov’s theory mayprovide an explanation, localizing memories (as Pavlovoriginally did) is not congruent with psychophysiologicalfindings (Bower & Hilgard, 1981). The implication thateye movements are linked to long-term memories has,therefore, very little theoretical grounding. This gap un-derscores the need for research to examine the utility ofeye movements within EMDR, the overall effect of thetreatment method, and the efficacy of EMDR relative toother treatment options.

Dyck (1993) proposed a counterconditioning modelto explain the efficacy of EMDR with PTSD whereby: (a)the attendance at therapy initially acts as a form of non-avoidance in confronting the anxiety associated with the

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trauma; (b) the eye movements initially act as a distrac-tion to the exposure, which results in nonreinforcement ofthe fear response; (c) subsequent trials of eye movementsact less as a distraction and the client is more fully ex-posed to trauma related thoughts and the associated anx-iety; and (d) this process generalizes over time, leading toan extinction of the fear response and attendant sympto-m a t o l o g y. However, the weakness in this model lies in thetheory that the client pays less attention to the distractionand that the exposure that occurs is sufficiently completeto promote extinction of the fear response and to providecorrective information. If the exposure is not complete,one would expect relapse at a later date, a phenomenonnoted in the PTSD literature (Devilly & Foa, 2001;Jaycox, Foa, & Morral, 1998) and in EMDR researchspecifically (Devilly, 2001a). It is suggested that a moreparsimonious adaptation of Dyck’s theory to practicewould be the utilization of distraction techniques duringexposure to i n i t i a l l y engage a reticent client in therapy,but that other, more encompassing exposure techniquesbe used later to ensure full extinction of the fear responseand promote new, more adaptive learning.

A more recent comment (Devilly, 2001a) suggeststhat EMDR is a variant of exposure (Foa & Kozac, 1986)that does not always extinguish the fear response in someclients, resulting in sensitisation in the long term as op-posed to desensitization.

CRITIQUE OF EMDR RESEARCH

The following section provides a historical review of theEMDR literature up to the end of 2000. This method ofevaluation, rather than delineating sections by popula-tion-specific criteria, has been adopted to facilitate anunderstanding of the development of the EMDR move-ment.

1989–1992

Shapiro (1989a, 1989b, 1990) reported on the efficacy ofeye movement desensitization (EMD), as it was thenknown, for traumatic memories among 22 Vietnam vet-erans and rape/molestation victims. Controls were giventhe same instructions as the treatment group but were notgiven the eye movements. The controls were, therefore,required to provide imaginal descriptions of the experi-ence and describe the body sensations they experiencedand their cognitions about the event. According toShapiro (1989a, 1989b) the treatment group experienceda remarkable recovery, suggesting that “a single [90-

minute] session” was sufficient to completely desensitizea traumatic memory and promote more adaptive and re-alistic cognitions. One- and three-month follow-upsyielded no evidence of relapse. The controls displayed nosignificant change in symptomatology, although whensubsequently treated with EMDR they showed the samelevel of improvement as the initial treatment group.

There are, however, several methodological limita-tions to Shapiro’s (1989a) study that limit the conclusionsthat can be drawn. Amajor criticism of this study is that itfailed to address the central issue, namely, whether theeye movements are responsible for the reduction in PTSDsymptoms, or whether other aspects of the treatment areresponsible for the reported improvement. For example,distraction techniques have long been used in the field ofpain management (e.g., Devilly & Sanders, 1993;Fordyce, 1975; Ve s s e y, Carlson, & McGill, 1994) and theeye movements may have just been a distraction (whichthe control group did not receive) that reduced anxietylevels during the sessions. However, this does not explainthe longer-term improvement that was obtained, whichnow appears inconsistent with more recent research (seeD e v i l l y, 2001a, for a discussion of the role of distractionin anxiety and the use of EMDR). A l t e r n a t i v e l y, exposureto the retrieved trauma memories may explain this im-provement in functioning.

Furthermore, Hedstrom (1991) argued that inducingeye movements promotes relaxation, as measured byalpha waves. Extrapolating from this result, it may be ar-gued that Shapiro’s control group was less relaxed duringthe treatment and the process of reciprocal inhibition, ofimagining a traumatic scene and also being relaxed, wasnot induced. Therefore, the control group respondedpoorly compared with the experimental group. However,this explanation assumes that the eye movements arepertinent to treatment delivery and that relaxation pro-motes desensitization, a view that is not generally heldwithin anxiety research.

M o r e o v e r, the subjects used in this study were not allsuffering from PTSD, and the “events” that caused theirdistress were not of a similar variety (e.g., rape). There-fore, it could be argued that this introduced too much het-erogeneity within the sample. However, a positive side tothis seminal research is that Shapiro’s results did allowfor future research to conduct power analyses in prepa-ration for dismantling studies. Of interest, though, is thatan a priori power analysis for an as yet untested hypoth-esis (which Shapiro originally possessed) even when lib-erally assuming a one-tailed (a = .05) analysis with alarge effect size (0.8) and acceptable power (0.8), wouldnormally require at least 21 subjects in each condition.

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However, a major criticism of Shapiro’s research isthat all the outcome data were based upon self-reported“subjective units of disturbance” (SUD) levels, usuallyseen as a process variable, and upon a “validity of cog-nition” scale. This VoC has to date not been psychomet-rically assessed and no research on its utility and sensi-tivity as a treatment outcome measure has been reported.There were no standardized, reliable tests with validatedpsychometric properties utilized to measure outcome,and thus there is no certainty that all the subjects weres u ffering from PTSD in the first place. Further, the studywas conducted by a single therapist (Shapiro) who ad-ministered therapy to both conditions and all outcomedata was obtained “face-to-face” by the same therapist.The demand effects of such an approach can not be over-stated, and the effect of experimenter bias has been welldocumented throughout clinical research (see Rosenthal,Persinger, Kline, & Mulry, 1963; Devilly, 2001a, for asummary of its possible implications for EMDR re-search). Because Shapiro has never conducted anothergroup treatment-outcome study on EMDR, the aboveweaknesses have not been addressed using the same ther-apist. However, this was a novel first investigative study,the results of which warranted further attention.

The apparently stunning results of Shapiro (1989a)spurred much interest into EMDR (Buttsworth, 1990;Robinson, 1992; Shapiro, 1991) and research subse-quently began to grow. Marquis (1991) reported on 78cases of trauma treated with EMD in general practice andthe treatment again evidenced remarkable effectiveness.H o w e v e r, a confounding variable within the Marquisstudy was that many of the clients were also receivingother forms of intervention, such as relaxation and cog-nitive restructuring. Furthermore, the diagnostic criteriafor PTSD in this study were not clear and outcome waspoorly measured with no standardized instruments. An-other major limitation of this research was the lack of anycomparison conditions. Moreover, it is not clear whetherall clients who received EMD from the clinic were in-cluded in this study’s results, which attempted a natural-istic design. This is an important point, one raised againlater: There is a basic need for scientific inquiry to dis-tinguish within its designs and statistical analyses be-tween a priori and post hoc testing. For example, wereclients who were seen in some unspecific way as “un-suitable” not included as participants? Were those whowere responding poorly during treatment removed fromthe study and treated with another therapeutic technique?What were the attrition rates based on treatment factors?

In similar fashion, Wolpe and Abrams (1991) reportedon a very successful case study of EMD with a rape

victim, but again other techniques (e.g., relaxation and invivo exposure) were incorporated into the treatment.Therefore, this study affords us with little insight into thee ffectiveness of the EMD technique specifically. Wo l p eand Abrams also made very sparing use of objective mea-sures, as was the case with another study in the same year.Puk (1991) described two case studies using EMDR, onean adult who was sexually molested as a child, and theother a woman with intrusive recollections of her sister’sfinal stages of lung cancer. Both were reported as re-sounding successes, but self-reported anxiety levels werethe only form of assessment. Although clinical anecdotesand process measures are of interest and can at times be in-structive, they rarely make for a scientific grounding forthe acceptance or rejection of a hypothesis.

Herbert and Mueser (1992) drew attention to thisdeficit in EMDR research, pointing out that in Shapiro’sinitial study no objective or standardized measures wereused to validate the self-report data. Further, they madethe point that there were extreme demand effects in thetherapeutic process that may have encouraged the sub-jects to report lowered anxiety levels after treatment.Also, due to the use of few standardized inventories inpast EMDR studies, there was little evidence as to howmany of the subjects in the EMDR literature actuallymet the D S M – I I I – R criteria for PTSD, besides being“bothered by traumatic memories.” These authors alsoraised questions as to the widespread use of EMDR inclinical practice prior to properly controlled and rigor-ously assessed research. They also devoted space to crit-icizing a new phenomenon: the restrictions upon thefreedom of the scientific community to openly investi-gate the efficacy of EMDR due to Shapiro’s methods ofdissemination. For example, they discussed the insis-tence (via a legally binding and signed document) that notrainee could teach EMDR without Shapiro’s consentand that the documents obtained during the somewhatexpensive training courses should not be distributed toother professionals.

Likewise, Lohr et al. (1992) published a methodolog-ical critique of the EMDR research up to that date. W h i l edrawing attention to the same flaws as mentioned by Her-bert and Mueser (1992), they also noted that many of thesubjects in past research had also been receiving therapiesother than EMDR. Further, they argued that the “believ-ability” in the rationale for Shapiro’s (1989a) control con-dition may not have equated with that of the experimentalgroup. Therefore, participants in the experimental andcontrol conditions may have experienced different levelsof rationale credibility and treatment expectancy, whichmay have had a large bearing on the results.

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H o w e v e r, single-case studies with liberal method-ologies continued to appear in the literature, such as a re-port by McCann (1992). In this article a 41-year-old sur-vivor of burn injuries was treated in one session withEMDR. However, no measurements were taken at alland instead the author relied on subjective reports, e.g.,“At 1 year follow-up, the patient continued to be asymp-tomatic and continued to gain new skills and new direc-tions in life” (p. 322).

Kleinknecht and Morgan (1992) reported on a casestudy of a man who had been shot and subsequentlytreated with EMDR. In this study, some standardizedmeasures were used (the Spielberger trait anxiety mea-sure, the Brief Symptom Inventory, and the Center forEpidemiologic Studies—Depression Scale). However,although pre, post and follow-up data were obtained, nobaseline measurements of symptoms, such as reexperi-encing the event, were taken. While there are better de-signs available for the single-case methodologies (seeKazdin, 1982), this study did provide more anecdotalevidence of EMDR efficacy.

It was not until Sanderson and Carpenter (1992) pub-lished their study with 58 phobic subjects that EMDR wasinvestigated with an appropriate design. EMDR was com-pared with image confrontation (IC) in a single-sessioncrossover design. For both conditions, SUD scores tofeared stimuli were significantly reduced and maintainedup to 1 month follow-up. However, there was no signifi-cant difference in treatment efficacy between the two con-ditions. These authors claimed, therefore, that the eyemovements per se were not the medium of change in theEMDR process, and that it was the imaginary exposure tothe feared stimuli that was responsible for any improve-ments. Unfortunately, as with past research, SUD scoreswere the only method of assessment, which again limitsthe use of this study in hypothesis testing.

1993

Pellicer (1993) reported an interestingly designed single-case study of a 10-year-old girl with recurrent night-mares. After 1 session of EMDR, Pellicer reported thegirl’s SUDS to the dream content (snakes) to have beenreduced to 0, and that she began to sleep in her own bed(instead of her mother’s, as had become the norm). Un-f o r t u n a t e l y, no measures such as the Child BehaviorChecklist or Revised Children’s Manifest Anxiety Scalewere administered, and it is possible that other factors,such as parental reinforcement and therapist instruction,may have been responsible for the behavioral changesobserved.

Boudewyns, Stwertka, Hyer, Albrecht, and Sperr(1993) reported upon a pilot study randomly assigningtwenty Vietnam combat veterans with PTSD symptoma-t o l o g y, obtained from a Special Inpatient PTSD Unit pro-gram (SIPU), to one of three conditions: EMDR condi-tion (n = 9), where subjects received two 90-minutesessions of EMDR; imaginal exposure control condition(n = 6), where the subjects received two 90-minute ses-sions during which they imagined the trauma, butwithout the eye movements; and a control condition(n = 5), where subjects received only the “SIPU milieutreatment.” Subjects were assessed at pre- and posttreat-ment on the Impact of Event Scale, the Mississippi Scale,and the Clinician Administered PTSD Scale. Physiolog-ical measures were also obtained at pre- and posttreat-ment. At both pre- and posttreatment, two sets of physi-ological recordings were taken—when “at rest” andwhen presented with a “trauma”-related cue. For the“trauma”-related cue at pretreatment, subjects recountedtheir traumatic memory of the event and this accountwas tape-recorded. This tape was then replayed to thesubjects while their physiological recordings were taken.At posttreatment, the “trauma”-related physiologicalmeasures were obtained while playing the same tape.These measures included heart rate, electromyographicresponse, skin conductance, and hand temperature. SUDlevels were also recorded, and a significantly greaterdrop in these levels was found for the EMDR conditioncompared with the exposure condition (p < .03). No sig-nificant difference in changes over time was found for ei-ther EMDR or imaginal exposure on any of the mea-sures relating to PTSD pathology. Although there was asignificant change on all the physiological measures be-tween describing the trauma and when at rest, no signif-icant changes in these responses were found followingtreatment, irrespective of treatment condition.

The authors suggested that the lack of change, asmeasured by the PTSD questionnaires, may be due to thetendency for the subjects in this population to overreports y m p t o m a t o l o g y. They noted that the vast majority of thesubjects were either receiving or had applied for a dis-ability pension, the maintenance of which was contingentupon continued symptomatology. They also suggestedthat, as the physiological measures were taken while lis-tening to a tape recording of themselves describing theirtrauma, any changes in the way they appraised the event,subsequent to treatment, would not have reflected newattributions arrived at due to the intervention. This pointis well taken, as the old recordings of the event may stillhave been semantically tied to their old perspectives ofthe trauma and its concomitant meaning (Foa & Kozac,

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1986; Rachman, 1980), whereas posttreatment beliefsrelating to the trauma may need to be triggered by a new,posttherapy recording.

Oswalt, Anderson, Hagstrom, and Berkowitz (1993)conducted one session of EMDR with 5 hospital inpa-tients with a diagnosis of PTSD and 3 student volunteerswho reported an “intrusive traumatic memory” (recruitedvia an advertisement in a campus newspaper). No stan-dardized measures were administered at intake or post-treatment with the exception of SUD ratings. The resultsof this study were imparted by eight case vignettes. Fiveout of the eight cases were “judged” by the authors as un-successful and three were judged as successful. Besidesthe extreme methodological flaws in this study, it is rele-vant to note that the three “successes” were the three stu-dent volunteers rather than the inpatients.

Cocco and Sharpe (1993) extended the case study lit-erature on EMDR to include the treatment of childhoodPTSD, using an auditory variant of the procedure. Thepatient was a 4-year-old boy who had been emotionallyand physically abused when intruders entered his houseand demanded money from, and physically assaulted,his parents. He complained of many PTSD symptomsand met diagnostic criteria for PTSD. His parents kept arecord over a 1-week period of nightmares about the in-cident, seeking reassurances, sleeping in his parents’ b e d ,telling “the story,” wetting the bed, and carrying a toygun with him on trips “just in case.” A high frequency ofall these behaviors was found. The Child BehaviorChecklist (CBCL) was also administered at pretreatmentand he was found to be within the clinical range for theThought Problems subscale. During the one EMDRtreatment session he was instructed to draw a picture ofthe invaders and another of his favorite hero and wasthen asked to look at the pictures and remember whathappened. The therapist then snapped his fingers on ei-ther side of the child’s head at the rate of 4 per second for48 clicks. After two sets of this procedure, during whichtime the boy demonstrated (with his pen) that the herohad shot the intruders, he reported that “they’re dead . . .[and] . . . can’t get me.” A 3-week follow-up found theboy to be in the normal range on the CBCL T h o u g h tProblems subscale and to be asymptomatic on all the be-havioral measures. This improvement was maintained at3-month follow-up. At 6-month follow-up, however, hehad returned to preintervention scores on bed-wettingand sleeping with his parents.

Although this case study presents an imaginative in-tervention for a very difficult problem, the procedureshould not be described as EMDR. No eye movementswere induced and the use of trauma-relevant drawings

may be seen as an intervention in its own right. The tech-nique also has much in common with emotive imagery(e.g., using hero images) as used successfully in the treat-ment of childhood phobias (e.g., Cornwall, Spence &Schotte, 1996; Jackson & King, 1981; Lazarus &Abramovitz, 1962). However, this was the first casestudy that suggested a dissipation of gains throughfollow-up.

Kleinknecht (1993) likewise reported a single-casestudy of a client with blood and injection phobias treatedover four sessions. The client was assessed at pre- andposttreatment and 14-week follow-up with a host of self-report scales relating to phobic anxiety and SUD ratings.She was also assessed both within and between sessionsusing physiological measures (blood pressure and pulserate). The results indicated a reduction on all self-reportmeasures and physiological reactivity to the fearedstimuli, both imaginary and in vivo. However, becausethis client was also receiving in vivo exposure during thesessions, the treatment method also involved systematicdesensitization and the findings therefore tell us little ornothing about the effectiveness of EMDR per se.

1994

The year 1994 saw an increased push for rigorous re-search methodologies in the evaluation of EMDR.Forbes, Creamer, and Rycroft (1994) reported a pilotstudy on EMDR with 8 clients suffering from PTSD.These clients were assessed at intake using the StructuredInterview for PTSD to ascertain the presence andseverity of PTSD symptomatology, and the StructuredClinical Interview for the DSM–III–R to assess for anycomorbid diagnoses. Three self-report measures werealso utilized to assess treatment outcome, namely theImpact of Events Scale, the Beck Depression Inventory,and the Symptom Checklist–90–Revised. Muscle ten-sion measures (EMG) were taken “to provide a physio-logical correlate of clinical improvement” (p. 115), aswell as SUD levels. The Stanford Hypnotic ClinicalScale was also administered at pretreatment to assess theeffect of suggestibility on outcome.

Subjects were treated with four 90-minute EMDRsessions spaced 1 week apart and were assessed 1 weekfollowing treatment and at 3-month follow-up. The re-sults suggested that the subjects improved statistically onall measures from pre- to posttreatment and that the im-provements were maintained at follow-up. However, de-spite the apparent improvements, 4 subjects remaineds u fficiently symptomatic to meet the full criteria forPTSD at both posttreatment and follow-up. Further, at

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posttreatment, 4 subjects met criteria for the avoidancesymptom cluster of PTSD, 6 for hyperarousal, and 7 forreexperiencing. At follow-up, 4 subjects again met cri-teria for the avoidance symptom cluster of PTSD and 7met criteria for both hyperarousal and reexperiencing.SUD levels and EMG recordings displayed marked de-creases, although statistical analyses were not possibledue to missing data.

Although this research was well documented andused appropriate measures, the subject numbers weresmall and there was no control group, points acknowl-edged by the authors. In addition, the participants weredrawn from subject pools with different traumatic eti-ologies, and it would have been interesting to determineany differences in outcome according to stressor type. Itshould also be noted that suggestibility correlated withimprovement from pre- to posttreatment the avoidancesymptom cluster of PTSD. Time since trauma also cor-related with reductions in hyperarousal from pretreat-ment to follow-up. However, these covariates were notpartialled from the results at the appropriate time points.Nevertheless, this study at least provided direction to-ward an appropriate research methodology and showedthat meaningful quantitative investigations into EMDRwere possible.

Jensen (1994) reported a study similar to Boudewynset al. (1993), whereby 25 Vietnam combat veterans withPTSD were randomly assigned into either an EMDRtreatment condition (n = 13) or a control condition(n = 12) of no extra treatment. These subjects came froman original pool of 74 candidates. Participants werescreened out if they showed: “an unstable psychologicalcondition,” “questionable motivation for completing thestudy,” “questionable symptomatology,” or “an unclearmilitary record.” The three pre- and posttreatment (ap-proximately 17 days after assessment) measures werethe Structured Interview for PTSD, SUD levels, and Vo Cscale. Two posttreatment measures were also used: GoalAttainment Scaling (GAS) and the Mississippi Scale forCombat-related PTSD (MPTSD). There were two thera-pists, both of whom had been trained by Shapiro inEMDR during a 2-day workshop. Both therapists werepsychology interns at a VA medical center and the sub-jects were randomly assigned into the two conditions.The EMDR subjects received one history-taking sessionand two treatment sessions, whereas the control subjectsdid not receive the treatment sessions.

The results indicated no differences among theEMDR and control groups at posttreatment on the Struc-tured Interview or the VoC, and there was no improve-ment within either condition. Likewise, there was no dif-

ference between the two groups at posttreatment on ei-ther the MPTSD or GAS. However, there was a signifi-cant difference on SUD scores at posttreatment betweenthe two conditions, with the EMDR condition showing agreater reduction. Videotaped sessions rated by an expertjudge led to the conclusion, by the judge, that the thera-pists did not spend enough time on the “active treatmentphase” of EMDR with the subjects who did not respondto the treatment. However, it must be stressed that thevideo rater (H. J. Lipke, an EMDR Institute–authorizedtrainer) would appear to have mixed the process oftreatment (i.e., did the therapists include all elements ofEMDR and were they proficient with its use) with treat-ment outcome (i.e., the result from administering a treat-ment). This point is demonstrated where the rater statedthat “the clients may have received enough treatment toopen difficult areas, but without enough fidelity to thetreatment to resolve these problems” (Jensen, 1994, p.321). This distinction has been discussed in greater detailelsewhere and interested readers are directed to Rosen(1999).

S u r p r i s i n g l y, in light of the outcome, Lipke com-mented that the results support the view that the study“could, theoretically, be somewhat supportive of EMDRas a therapeutic modality. However, negative resultscould not be used to criticize EMDR . . .” (Jensen, 1994,p. 321).

Jensen also stated that the consent form notified con-trol subjects that they were not in the experimental con-dition, which may have confounded the study. Nonethe-less, this design flaw would not explain why noimprovements in PTSD symptomatology were found atposttreatment for the EMDR condition. Criticisms of thisstudy by Shapiro (1996) have predominantly been re-lated to the fact that the therapists were interns and notexperienced clinicians. Although this point is legitimate,an extension of this argument would mean that about90% of all psychiatric outcome studies are of dubiousvalue. This would also mean that treatment adherenceratings are of no value if the therapist is still a student—a point with which few would agree.

Acierno, Tremont, Last, and Montgomery (1994)conducted a well-designed and -implemented single-sub-ject multiple-baseline study. A battery of standardizedtests were administered at pre- and posttreatment, andphysiological measures were also taken. The subject pre-sented with multiple simple phobias. The first two ses-sions addressed one phobia (dead bodies) and the nextfour addressed fear of the dark. She was instructed toconcentrate on the therapist’s stationary finger whileimagining the feared stimuli. This yielded no noted im-

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provements in goal attainment for either stimulus. Next,the subject received EMDR for six sessions with regardto dead bodies and five for her fear of the dark. This pro-cedure yielded minimal, if any, improvement on any out-come measure. However, the client was subsequentlytaken through graded in vivo exposure with reinforcedpractice. A 100% goal attainment was achieved usingthis approach for both phobias and self-report measuresof anxiety, and it was found that negative cognitions de-creased considerably. This study suggests that the com-bination of in vivo exposure and reinforced practice wasmore effective than EMDR for this patient and that pa-tient resistance to change was unlikely to explain thelack of effect with EMDR.

Vaughan et al. (1994) randomly assigned 36 patientswith PTSD (assessed using the SCID) to four sessions ofeither EMDR, image habituation training (IHT), or ap-plied muscle relaxation, after 17 of the subjects were ini-tially assigned to a 3-week wait list control. All activetreatments were superior to the wait list on a variety ofmeasures, but there was no significant difference amongthe treatment conditions at posttreatment or 3-monthfollow-up. However, inspection of the means revealed atrend for the EMDR condition to display larger im-provements. The authors suggested that the limitations ofthe study be made clear in that only four treatment ses-sions were provided and that this may not have beenlong enough to produce improvement.

Furthermore, they acknowledged that a larg e rsample would have been desirable to separate out thetreatments, as all CBT techniques for PTSD tend to be ef-ficacious to some degree. In addition, they acknowledgedthat the wait list was not as optimal a control conditionas a placebo. However, one must also note that IHT in-volved subjects listening to a looped-tape recording oftheir traumas, and not utilizing exposure in vivo and/oractive, present tense, first-person, imaginal exposure, ashad been used by Foa, Rothbaum, Riggs, and Murdoch(1991) in their study looking into the efficacy of expo-sure. This later method accesses the full range of affec-tive responses and has been found to be a very potenttreatment for PTSD. The Vaughan et al. study could not,therefore, be considered to compare EMDR with a rec-ognized CBT treatment package for PTSD.

Goldstein and Feske (1994) reported on an uncon-trolled series of 5 subjects with panic disorder treatedwith EMDR. These subjects displayed a decrease inpanic symptoms on a wide range of psychometric in-struments after five sessions. Effect sizes ranged from0.86 to 1.69 for pre- to posttreatment, although long-term follow-up was not obtained. This study spawned a

better controlled investigation (Feske & Goldstein, 1997)discussed later in this article.

One of the major issues in the EMDR procedure, asit currently stands, is whether it is necessary to includeeye movements as an element of treatment. However, asof 1994, only one controlled trial had assessed the ne-cessity of eye movements, utilizing a clinical samplewith the inclusion of appropriate controls. Renfrey andSpates (1994) reported upon 23 PTSD subjects who re-ceived either the EMDR procedure, the EMDR proce-dure facilitated by a light tracking task, or a variant of theEMDR procedure without the eye movements. The re-sults indicated that both the EMDR condition and theEMDR procedure without the eye movements wereequally effective in reducing PTSD symptomatology.This led the authors to suggest that eye movements werenot a necessary part of the procedure.

1995

Quantitative studies of treatment outcome using EMDRcontinued to produce conflicting results. As a conse-quence, much debate surrounding their methodology oc-curred. For example, Wilson, Becker, and Tinker (1995)outlined some of the design issues and attempted to rec-tify these problems with their own treatment-outcomeinvestigation. They administered three 90-minute ses-sions of EMDR to 80 participants displaying PTSDsymptomatology (according to the PTSD–Interview[PTSD–I]). These participants were assigned to eitheran immediate treatment group or a delayed treatmentgroup. Outcome measures comprised SUD scores, theImpact of Events Scale, the Spielberger State-Trait Anx-iety Inventory, and the Symptom Checklist. The treat-ment condition displayed significant decreases in pre-senting complaints of anxiety and increases in positivecognitions when compared with the wait list controls,yielding a PTSD composite treatment effect size of 1.82.It was also found that the wait list group, when subse-quently treated with EMDR, similarly improved. Treat-ment efficacy was not mediated by trauma type. How-e v e r, this investigation did not control for placebo eff e c t sor effects that may be nonspecific to EMDR. Further-more, subjects in the control condition were made awareof their conditional assignment, which constitutes amajor confound. The major scale for measuring PTSDsymptomatology, the PTSD–I, was also modified to in-crease its sensitivity over a short time period (1 week),which may have invalidated the measure at posttreat-ment. Also, the participants were seen as part of the ther-apists’ private practice, which may have introduced ex-

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traneous effects into this study. For example, it is notclear whether all subjects who received EMDR in thesetherapists’ practices were included in the analyses.

Another problem with this study was that subjects inthe EMDR condition were asked to write descriptions oftheir trauma. Such a treatment approach has been advo-cated in its own right (Pennebaker, Kiecolt-Glaser, &G l a s e r, 1988) and, more important, has been shown to bee ffective within multiple domains of health and personalwell-being (e.g., Esterling, L’Abate, Murray, & Pen-nebaker, 1999; Petrie, Booth, Pennebaker, Davison, &Thomas, 1995). Therefore, it could be argued that this in-troduced a further potential confound into the EMDRtreatment. Because this aspect of the intervention wasvery brief, however, it is improbable that this aspect ofthe procedure was responsible for all the improvement.

Wilson, Becker, and Tinker (1997) subsequentlypublished a continuation study that was a 15-monthfollow-up of the aforementioned participants. They con-cluded that the treatment gains had been maintained andin some cases built upon. Nevertheless, besides the pro-cedural problems of the initial study, this study was con-founded further by increasing estimates of effect size byusing only pretreatment standard deviations (which tendto be smaller than pooled standard deviations) andmixing methodologies for obtaining the reliable changeindex and measure of clinical change. In this analysisWilson et al. applied a reliable change index to thegrouped data as opposed to examining whether individ-uals reliably improved as initially proposed by Jacobsonand Traux (1991). However, Wilson et al.’s research ap-peared to again suggest long-term gains for EMDR-treated subjects.

Foley and Spates (1995) reported a dismantling de-sign with EMDR, designed to further investigate the ne-cessity of the eye movements, using students who dis-played anxiety for public speaking as subjects. T h e s eparticipants received one of four conditions: EMDR,EMDR with a moving audio stimulus to replace the eyemovements, EMDR with the eyes kept stationary (fo-cused on the therapist’s hand), or a no-treatment controlcondition. Foley and Spates concluded that eye move-ments were not necessary for improvement and that a de-crease in symptomatology was not uniform across mea-sures. Participants improved in all conditions except theno-treatment condition, suggesting the importance of de-mand and expectancy effects, the influence of imaginalexposure to anxiety-related stimuli, or both. A l t h o u g hthis sample was not drawn from a clinical population, theresults support the findings of Sanderson and Carpenter(1992), who used a clinical sample in comparing EMDR

with image confrontation and likewise found equivalentimprovement in both groups.

1996

Wilson, Silver, Covi, and Foster (1996) investigated thee ffects of a single session of EMDR on autonomicarousal (galvanic skin response, respiratory rate, fingertipskin temperature, blood pressure, and pulse rate) with 18subjects apparently suffering from PTSD. Two other con-ditions were also compared: a time interval control (TIC)and a tapping alternate phalanges (TAP) condition. Allsubjects in the TIC and TAP conditions who did not re-port full improvement (SUDs of 0) were then providedwith EMDR treatment. Although SUD levels and VoCwere collected, no standardized measures were utilized atany time points and diagnoses were never substantiated.The results led the authors to conclude that “the auto-nomic measures demonstrate the effectiveness of EMDRwith respect to single session treatment effects” (p. 226),with EMDR being the only treatment to display a signif-icant improvement in heart rate, skin temperature, sys-tolic blood pressure, and galvanic skin response at post-treatment. However, these results were obtained bymultiple t tests on each condition and seeing which weresignificant, without even providing effect sizes for eachcondition. It should be noted that this is an idiosyncraticmethod of analysis in that it does not take into accountthe variance within each condition and, in fact, the stan-dard deviations for the means at pre- and posttreatmentwere not reported. This is particularly troublesome whenone considers, for example, that the mean improvementfigure for heart rate in the EMDR group after TIC (4.4),which was significant at p < .001, is actually even lessthan the improvement of TAP (4.8), which was not sig-nificant. No clarification on this matter was possible, be-cause the data were unavailable and the first author wasunable to shed further light on the issue (D. Wilson, per-sonal communication, 1997). Even without these short-comings, the results are interesting in that Shapiro (1995)suggested that any form of bilateral stimulation, such astapping on opposing body parts, may have the same ef-fect as eye movements.

The measurement of physiological indices duringtreatment was also utilized by Dunn, Schwartz, Hatfield,and Weigele (1996). These authors randomly assigned 28university students who scored in the severe range on theImpact of Events Scale to either an EMDR treatmentsession or a similar treatment that mimicked EMDRwithout the eye movements, yoking subjects in each con-dition. Subjects in this placebo group were instructed to

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keep their eyes fixed on a stationary red dot. Measuresincluded EMG, finger skin temperature, heart rate andgalvanic skin response, and SUD ratings. Inter- and in-tragroup analyses showed that although the subjects inthe EMDR condition improved in SUD ratings, therewas no significant difference between groups. On thephysiological indices the EMDR condition showed im-provement in heart rate, whereas the control conditiondisplayed improvements in both heart rate and galvanicskin response. However, there were no intergroup dif-ferences on these measures. The authors interpreted theseresults as casting doubt on eye movements as the neces-sary component of EMDR when PTSD symptomatologyis reduced.

This position was strengthened further byBoudewyns and Hyer (1996), who allocated subjectswith combat-related PTSD to between five and eight ses-sions of one of three conditions: EMDR, an imaginaryexposure control (EC), or a no-imagery control proce-dure (C). Standardized self-report measures, interviewer-based questionnaires, and physiological indices were col-lected at pre- and posttreatment by an interviewer blindto group assignment. The results revealed the EMDRand EC treatment groups to be effective in reducingsymptomatology on most measures, but without an inter-group difference. On the Clinician Administered PTSDScale, however, the two treatment groups did not differfrom the control condition, thereby raising questions re-garding the role of imaginal exposure with this subjectgroup. In any case, the results add further weight to thenotion that eye movements or bilateral stimulation(Shapiro, 1995) are neither a necessary nor useful addi-tion to imaginal exposure.

This conclusion was further strengthened by Pitmanet al. (1996), who utilized a crossover design with 17Vietnam veterans with chronic PTSD, who received ei-ther an eye-fixed or eye-movement condition. This studyrevealed only moderate improvements in both conditionsand again suggested that eye movements may not be theactive therapeutic mechanism of EMDR when positivetreatment effects are found. In fact, the only statisticallysignificant interaction effects over time were in favor ofthe eye-fixed condition. More recently, a 5-year follow-up of the EMDR treated participants was conducted byMacklin et al. (2000). These authors found that themodest beneficial effects of EMDR on these veteranswere lost by follow-up, with a deterioration in sympto-matology even from pretreatment. In fact, compared withmatched controls who did not receive the intervention 5years previously, the EMDR treated veterans were moredistressed on 3 of the 5 outcome measures. Quite inex-

plicably, particularly in light of a negative effect size onall other measures, the authors of this study claimed thatbecause EMDR showed a small to moderate positive ef-fect size on 1 subscale of 1 measure (Impact of EventS c a l e — Avoidance, d = 0.37, even though statisticallynonsignificant), “the results do not rule out the possi-bility that EMDR may have produced some lasting re-duction in self-reported avoidance symptomatology. Ourdata also cannot rule out the possibility that more generaland lasting benefits might have been obtained withEMDR in less entrenched and chronically ill and/or non-veteran patients” (p. 26).

1997–1998

Following from their 1994 study, Feske and Goldstein(1997) examined the efficacy of EMDR and the necessityof eye movements for patients with panic disorder (pre-dominantly complicated by agoraphobia). Comparedwith a similar treatment without the eye movements,EMDR was superior on 2 of the 5 primary outcome mea-sures at posttreatment. But by 3-month follow-up this su-periority over the eye-fixed condition had dissipated.This line of research added to the body of evidence sug-gesting that eye movement is not a necessary ingredientto treatment efficacy and that other properties inherent tothe EMDR procedure may be responsible for treatmentgains. Results such as these led some of EMDR’s mostardent supporters to argue that even if the eye move-ments per se add nothing to the process, EMDR is still a“unique” process and that the procedure is “uniquely im-pactful” (Hyer & Brandsma, 1997, p. 521), a point ofview difficult to reconcile with the available evidence.

The findings of Feske and Goldstein (1997) werestrengthened further by the work of Muris and Merckel-bach (1995, 1998). A series of single case studies by theauthors in 1995 suggested that exposure was the neces-sary ingredient in the EMDR procedure when objectiveand standardized instruments were used. This pilot studyled to further controlled investigation within this domainwhen Muris, Merckelbach, Holdrinet, and Sijsenaar(1998) compared EMDR, in vivo exposure, and com-puterized exposure in 26 arachnophobic children. Thechildren were randomly assigned to one of the three con-ditions. In the first phase of the study they received 2.5hours of their assigned treatment and in the second phaseof treatment all subjects received 1.5 hours of exposurein vivo. Assessments were carried out at all time pointsand included standardized measurement instruments anda behavioral avoidance test. Results indicated that expo-sure in vivo significantly decreased anxiety symptoms

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within all domains, whereas the EMDR group improvedon only self-reported arachnophobia. The improvementrate of the exposure procedure was also found to be su-perior to that of EMDR. EMDR did not potentiate the ef-ficacy of a subsequent treatment and, of interest in itsown right, computerized exposure did not produce anysignificant improvement in symptomatology.

Rothbaum (1997) conducted a controlled study ofrape victims, comparing EMDR with a wait list control,utilizing standardized outcome measures rated by a blinda s s e s s o r. She found that, after 3 treatment sessions,EMDR reduced PTSD symptomatology more than thewait list control. However, as this study did not includeany therapeutic treatment conditions other than theEMDR, these results could be attributed to variables thatare nonspecific to EMDR. Because almost all treatmentswill out-perform a wait list control (e.g., Carlson,Chemtob, Rusnak, Hedlund, & Muraoka, 1998) thisstudy tells us very little about the relative efficacy ofEMDR or its active elements. Furthermore, it should benoted that the follow-up data suggest that those subjectswho were faring the worst were the ones most likely todrop out. At follow-up the effect size of EMDR treatmentrose to an exceptionally high d = 4.00 on some mea-sures, yet the variance at follow-up had become verysmall due to attrition. A small sample combined with a50% dropout rate (n=5) yield data of questionable gen-eralization. The attrition rate with this population wasfurther demonstrated when the wait list group was sub-sequently treated with EMDR and there was again a 50%dropout rate. However, this study served as a pilot studyfor a larger research project that is still ongoing.

A study conducted by the current author investi-gating the efficacy of EMDR and the necessity of eyemovements in treating war-related PTSD was also pub-lished in 1998. Devilly, Spence, and Rapee (1998) ran-domly assigned 51 war veterans with PTSD to one ofthree conditions: two sessions of EMDR, an equivalentprocedure without the eye movements using a flashinglight (Rapid Eye Dilation Desensitization and Repro-cessing [REDDR]), or a Standard Psychiatric Supportcontrol condition. A battery of standardized assessmentinstruments was administered at pre- and posttreatment,including an assessment controlling for treatment credi-b i l i t y. A3-month follow-up was conducted by mail to re-duce possible demand effects. Psychophysiological as-sessment was performed by taking blood pressure andheart rate readings when the participants were relaxedand when imagining their trauma pre-, during, and post-treatment.

The results indicated an overall significant main ef-

fect of time from pre- to posttreatment, with a reductionin symptomatology for all groups. However, no statisti-cally significant differences were found among thegroups. Participants in the two treatment conditions,however, were more likely to display reliable improve-ment in trauma symptomatology than subjects in the con-trol group. By 6-month follow-up, reductions in symp-tomatology had dissipated and there were neitherstatistical nor reliable differences between the two treat-ment groups. Overall, the results indicated that, with thiswar veteran population, improvement rates were lessthan had been previously reported. Also, where im-provements were found, eye movements were not impli-cated as the mechanism of change. Rather, the resultssuggested that other nonspecific or therapeutic processesaccount for any beneficial effects of EMDR. A m a j o rcriticism of this study, however, is that because only oneveteran agreed to be videotaped, fidelity ratings could notbe procured. Also it should be noted that this populationhas a more complex presentation with multiple comorbidconditions and may have required longer-term interven-tion. However, this does not explain Shapiro’s (1989a)original single-session results that included “veterans.”

Carlson, Chemtob, Rusnak, Hedlund, and Muraoka(1998) returned to comparing EMDR against poorly sup-ported, even inert, comparison treatments by randomlyallocating 35 combat veterans with PTSD to either 12sessions of EMDR, biofeedback-assisted relaxation, orroutine clinical care. Unsurprisingly, while all subjectsimproved, the subjects in the EMDR condition out-per-formed the subjects in the other two conditions on anumber of self-report, psychometric, and standardizedinterview measures. Treatment gains within each condi-tion were maintained to 3-month follow-up. Carlson etal. also claimed that these results were maintained to 9-month follow-up, as measured by the CAPS. However, atthis assessment period only 8 EMDR and 4 biofeedbackparticipants completed the questionnaire. The authorsthen applied t tests to the data, as opposed to more con-servative nonparametric testing usual with such an ex-ceptionally small sample. Such an approach greatly in-creases the likelihood of a Type I error. Furthermore,these t tests were applied using one-tailed significancetesting, which also increases the likelihood of finding asignificant difference. Nine of these one-sided t t e s t swere applied to the data without any correction, seven ofwhich were described as significant. However, even justapplying two-sided tests would have meant that onlythree would have been significant. It would be inter-esting to see the number that remained significant ifMann-Whitney U tests had been applied with Bonferroni

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corrections. Moreover, the data of one EMDR participantwas removed from the analyses due to “serious concernsabout the fidelity of responses” (p. 18). One can, there-fore, conclude very little from this follow-up. Either way,the large effect sizes on measures of PTSD at posttreat-ment (d > 1.1) and 3-month follow-up (d > 1.5) have notbeen obtained in other studies using the subjects from thesame population (e.g., Devilly et al., 1998; Pitman et al.,1996), although whether this difference is due to thelength of treatment provided remains unclear. Althoughthis study did use fidelity checks for the EMDR condi-tion, it is surprising that such checks were not also ap-plied to the biofeedback condition.

It should also be stressed that EMDR was the onlytherapy procedure in this study that included imaginalexposure, an already validated component in the treat-ment of combat-related PTSD (e.g., Keane et al., 1989).These results, therefore, are again uninstructive regardingthe relative efficacy of EMDR compared to an empiri-cally and clinically supported alternative approach.Moreover, the control group used did not control for thetheorized active components of the technique. However,this study did provide a complete treatment timeline (12sessions) and the results are probably more reflective ofE M D R ’s long-term use potency with veterans thanShapiro’s (1989a) original, and unreplicated, claim of aone-session cure for any traumatic memory.

A possible confound within Carlson et al.’s (1998)study, however, is that assessment was obtained during“face-to-face” interview. Although the interviewer wasblind to subject treatment allocation, demand character-istics are still inherent to this method of data collection.Both Carlson and Chemtob are known and vociferousadvocates of EMDR. When results such as theirs appearto be at odds with multiple other research groupsworking with the same population type, one has to con-sider the possibility that researcher allegiance and ex-perimenter demand effects may have played a role in thederived outcome (see Devilly, 2001a, for a discussion ofthis). A postal follow-up may minimize this effect.

Scheck, Schaeff e r, and Gillette (1998) likewise com-pared EMDR with an unvalidated therapy for womenunder the age of 25 with PTSD. Two sessions of EMDRwere compared with two sessions of active listening fol-lowing random allocation to groups. Unsurprisingly, theresults revealed EMDR to be more effective than the ac-tive listening group. Although a 3-month follow-up as-sessment was attempted, the authors noted that this wasachieved by reading questions over the telephone. More-o v e r, 33% of the participants had received additionalpsychotherapy during the prior 3 months. This study,

therefore, provides some support that EMDR is more ef-fective than active listening, yet again raises doubts con-cerning the long-term durability of EMDR.

In a meta-analysis of PTSD treatments, Van Ettenand Taylor (1998) concluded that at posttreatmentEMDR was as effective as behavior therapy on self-re-ported symptoms, but that behavior therapy was more ef-fective on observer-rated symptoms of PTSD. They alsoconcluded that both behavior therapy and EMDR were ase ffective as selective serotonin reuptake inhibitors(SSRIs) in treating PTSD, and at follow-up there were nodifferences at all between EMDR and behavior therapyefficacy. The authors also reported that as EMDR usedsignificantly fewer sessions over fewer weeks than be-havior therapy, the results of their study “suggest thatEMDR is effective for PTSD, and that it is more eff i c i e n tthan other treatments” (p. 140). However, as these con-clusions contrast quite sharply with other reviews (par-ticularly a meta-analysis conducted by Davidson andParker, 2001, discussed later in this review) it is impor-tant to clarify Van Etten and Taylor’s analytic approach.Rather than analyze between group effect sizes obtainedwithin each research study, they aggregated the eff e c tsizes for each treatment condition (e.g., EMDR, behaviort h e r a p y, SSRIs) a c ross all research studies. Although thisallows for a comparison between the relative effect sizesof, say, EMDR and SSRIs, when no individual treatmentstudy had ever directly compared these two treatmentmodalities, one must bear in mind that the results wereobtained under vastly different and uncontrolled researchmethodologies. In the light of this evidence alone, tothen judge one treatment as more efficacious or efficientthan another without direct comparison would obviouslybe a very unusual conclusion.

1999

This year saw a special issue of The Journal of AnxietyDisorders specifically devoted to the EMDR debate. Itcontained four controlled treatment-outcome investiga-tions and various commentaries regarding the procedure.The guest editors of this issue, commenting on the valueof invited papers, remarked that they “received bothmore and less than . . . [ t h e y ] . . . b a rgained for” (Acierno& Cahill, 1999, p. 1).

Cusack and Spates (1999) turned to controlling forother aspects of EMDR, continuing with this researchg r o u p ’s methodologically rigorous dismantling of theprocedure. They treated 27 subclinical trauma clientswith up to three sessions of either EMDR or a variant thatomitted the overt cognitive aspects (positive cognitions

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and the VoC scale were not utilized) during the procedure(termed “EMD” in the study). A battery of standardizedoutcome measures was administered by independentassessors, blind to the treatment condition of the partic-ipants, and fidelity by the therapists to the treatment pro-tocols was also assessed. Results showed an improve-ment in functioning within both conditions and theseimprovements were maintained to 2-month follow-up.However, there was found to be no difference betweenthe two conditions on any of the dependent variables andthe authors concluded that the cognitive aspects ofEMDR appear to be as superfluous to the technique asthe eye movements. However, this study still did notcompare EMDR to a validated treatment for PTSD, andalso screened many individuals out from treatmentduring the initial assessment due to comorbid diagnoses.Although such subject removal ensures a “pure” sampleof PTSD sufferers, one questions the external validity ofsuch an approach. Many long-term PTSD patients alsoabuse substances and manifest other anxiety and depres-sive disorders.

Carrigan and Levis (1999) attempted to isolate thee ffects of the eye-movement component of EMDR inthe treatment of public speaking anxiety. Seventy-onefemale college students who responded in a fearfulmanner on the Fear Survey Schedule II and on a stan-dardized self-report measure of public speaking anxietywere randomly assigned to one of four groups: imageryplus eye movements or imagery alone, coupled with ei-ther a relaxing or negative image. Dependent variablesincluded self-reported and physiological anxiety duringexposure and behavioral indices of anxiety while givinga speech. Although process measures indicated that ex-posure to fear-relevant imagery increased anxiety duringthe procedure, no significant differences among groupswere found on any of the outcome measures, except thatsubjects who received eye movements were less likely togive a speech posttreatment than subjects who did not re-ceive eye movements. Addition of the eye movements tothe experimental procedure did not result in enhance-ment of fear reduction. These findings lend weight tothose of Foley and Spates (1995) and suggest that thepositive effects of EMDR may be due largely to expo-sure. A criticism of these results, however, relates to theprocedural element of EMDR as used in this study. Astandardized number of eye movement sets (9) and du-ration of eye movements (15 seconds) were utilized, andthis does not readily equate with the necessary and usualtailoring of procedures to individuals during the deliveryof therapy. The authors acknowledge this point them-selves and respond that “a standardized, rather than ideo-

graphic, duration of treatment was chosen because of thenecessity of equating treatment across conditions. A l-though a yoking procedure would accomplish this goal,Church (1964) has presented some cogent arg u m e n t sagainst this procedure” (p. 107).

Rogers et al. (1999) treated 12 Vietnam veterans witheither one session of EMDR or one session of exposure—based upon the method of Lyons and Keane (1989)—each administered by different therapists. All participantswere inpatients undergoing treatment for combat-relatedPTSD who met criteria for PTSD according to the Clin-ician Administered PTSD Scale. Comorbid diagnoses ofpsychosis, dissociative disorder or personality disorder,or a previous history of exposure therapy or EMDR treat-ment acted as exclusion criteria. Dependent variableswere obtained by an assessor blind to condition alloca-tion, and included physiological reactivity (blood pres-sure and heart rate both when imagining the trauma andwhen at rest, similar to Devilly et al., 1998), SUD levels,and the Impact of Event Scale (IES). The results dis-played a trend for EMDR to produce more improvementat posttreatment on all self-report measures, but therewas no difference between groups on the physiologicalmeasures. In fact, on subjective ratings, the meansshowed a deterioration of the exposure group over time.No follow-up data were reported.

Interpretation of these results is difficult indeed dueto the limitations of the study: small sample size, con-current inpatient treatment, an absence of treatment in-tegrity ratings, and the use of only one standardized out-come measure (IES). Moreover, exposure was appliedidiosyncratically and within only one domain (imaginal)without an in vivo aspect. Thus, the study does not pro-vide an accurate assessment of the efficacy of exposuretherapy, especially since the exposure subjects were sig-nificantly worse at intake on self-monitored intrusionsand means on all pretreatment measures. In fact, SUDlevels and self-rated intrusions for subjects in the expo-sure condition worsened over time (although not signif-icantly), suggesting that the therapists sensitized ratherthan desensitized participants. For exposure therapy towork, and to be consistent with the theoretical underpin-nings of the approach, between-session habituation is re-quired—not just (or even) within-session habituation(Jaycox et al., 1998). Indeed the authors state that withinthis one session the participants were first given a ratio-nale for the intervention (an aspect usually taking 60minutes in itself) and then taught a “quick relaxationmethod” (an aspect usually taking at least 30 minutes).Furthermore, the 35-minute average exposure time isshort of the 50 minutes recommended by other re-

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searchers. Consequently, habituation, a process consis-tently related to successful behavior therapy outcome(Jaycox et al., 1998), was unlikely to have been achieved.Applying a single 60- to 90-minute session of this typeof therapy as an intervention technique, within either re-search or general practice, to treat any subject sampleraises ethical issues that lie outside the boundary of thisp a p e r. However, until this study, treatment adherenceemphasis had been placed upon the EMDR procedure.The Rogers et al. (1999) study emphasizes the need fortraining and adherence to all CBT methods, not justnewly developed techniques.

In contrast, Devilly and Spence (1999) comparednine sessions of EMDR against a cognitive behavioraltrauma treatment protocol (TTP). T T P was based on andextended from the work of Foa et al. (1991), and wascomprised of imaginal and in vivo exposure, stress inoc-ulation techniques, and cognitive therapy. Thirty-one par-ticipants (23 treatment completers) with PTSD from arange of traumatic experiences were randomly allocatedto the two treatments. These participants were treated bytherapists trained in both techniques. Outcome was mea-sured at posttreatment and 2-week and 3-month follow-upusing a full range of validated, clinician-administered,and self-report questionnaires that enabled comparisonto the past research of both protocols (i.e., the PTSD—In-t e r v i e w, Impact of Events Scale, Civilian Mississippiscale for PTSD, PTSD Symptom Scale—Self-Report,S p i e l b e rger State-Trait Anxiety Inventory, Beck Depres-sion Inventory, and Symptom Checklist–90–R), as well assubjective ratings of distress and goal attainment. Itshould, however, be noted that the follow-up assessmentswere administered via the postal service to decrease thedemand effects inherent in face-to-face assessment duringtherapeutic research. Sessions were also rated for treat-ment fidelity by an independent assessor. These ratingswere applied to both EMDR and the T T P t e c h n i q u e s .

It was found that, compared with EMDR, TTP wasboth statistically and clinically more effective in reducingpathology related to PTSD and that this superiority wasmaintained and, in fact, became more evident by the 3-month follow-up. This superiority was evident on all as-sessment measures and also translated into fewer TTPparticipants meeting criteria for PTSD following treat-ment. Ratings of treatment distress showed that both ap-proaches were equivalent, although the attrition rate washigher within the EMDR condition. A possible criticismof this study is that the CBT package contained elementsof treatment not included in past research (i.e., Foa et al.,1991) rendering its comparability to other studies as lim-ited. However, this research was the first of its kind to

compare a full CBT package with EMDR in the treat-ment of PTSD, yet the results appear to correspond withthose of Muris et al. (1998) who compared EMDR withexposure in the treatment of childhood arachnophobia(see above).

Two of the patients treated unsuccessfully withEMDR were later treated with T T P ( D e v i l l y, 2001b).The TTP was far more effective with these individuals,suggesting the difference between conditions was notdue to differences in patient allocation, although it ispossible that the improvement was simply a result ofhaving received additional treatment. However, in lightof the results of the larger study, this explanation is un-likely. Devilly (2001b) also outlined the full EMDR fi-delity checklist that was utilized in the two studies andwhich, added to the high fidelity ratings obtained, clari-fies the expected claims of procedural irregularity.

This Journal of Anxiety Disorders special issue alsoincluded two narrative reviews of the EMDR treatmentliterature. The first, by Cahill, Carrigan, and Frueh(1999), concluded that relative to no treatment, EMDRwas superior on measures of distress; relative to nonva-lidated treatments, EMDR was at least as effective andfrequently superior for trauma cases; except the afore-mentioned Devilly and Spence (1999) study, there wereno investigations comparing EMDR with a validatedtreatment for trauma; and eye movements are an inef-fective addition to the procedure. Likewise, the secondreview, by Lohr, Lilienfeld, Tolin, and Herbert (1999),evaluated whether EMDR displayed treatment eff e c t sover and above existing treatments, whether eye move-ments were necessary, and whether the beneficial eff e c t sof intervention with EMDR are obtained by interventionelements unique to that treatment modality. In all threecases the conclusion was negative. These authors fur-ther concluded that the burden of proof that the effects ofa novel treatment are not entirely accounted for by non-specific factors should rest with the founders and propo-nents of those interventions. These points were similarlyechoed in a short review by McNally (1999).

2000–

Goldstein, de-Beurs, Chambless, and Wilson (2000) con-ducted a randomized, controlled trial in which subjectssuffering from panic disorder with agoraphobia (PDA)were placed in a wait list control group (n = 14) or ad-ministered six 90-minute sessions of either EMDR(n = 18) or an attention-placebo intervention (ART;n = 13). A RT included progressive muscle relaxationtraining and association therapy (attempting to under-

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stand the reason for their problems through free associ-ation to memories of past panic attacks), both of whichare relatively inert procedures with this population. Allsubjects were diagnosed using the Structured ClinicalInterview for D S M – I V Diagnoses and were administereda battery of self-report questionnaires and diary and in-terview measures. Assessments were taken at pre- andpostintervention and again at a 1-month follow-up. Alltherapists had been trained in EMDR, treatment integrityratings were obtained, patient expectancy was accountedfor (ART elicited higher patient expectancy ratings thanEMDR), and attrition rates were examined. Analyzingcomposite scores, at posttreatment EMDR patients faredbetter than wait list controls on panic severity and diarymeasures, but not on the number of panic attacks and thefear related to PDA. There were no group differencesfound between ART and EMDR at either posttreatmentor follow-up. Furthermore, clinical significance mea-sures showed that at posttreatment EMDR-treated pa-tients were significantly worse than a nonclinical sampleon measures related to PDA. The authors concluded thatas there are extant effective treatments for PDA, EMDRshould not be used as a first-line treatment for this pop-ulation. Unfortunately, this study did not compareEMDR against an independently validated treatment ap-proach (e.g., in vivo exposure) and the treatment integrityraters were not independent of the research team. How-e v e r, this study did add to the mounting evidence againstthe specific utility of EMDR for anxiety disorders.

Herbert et al. (2000) examined the efficacy ofEMDR and commented on the growth of the EMDR“movement” since its inception. Specifically, they eval-uated aspects of the development of EMDR that em-ployed pseudoscientific tactics. Using EMDR as theirvehicle, the authors described the many practicescommon to pseudoscience (e.g., evidence based on anec-dotal reports; overuse of auxiliary hypotheses in the faceof disconfirming data in a way that precludes a falsifiabletheory; and dismissing null results as being due to inad-equate application of the EMDR protocol, yet acceptingpositive results as evidence of EMDR’s efficacy) andoutlined the implications of these practices for the pro-fessional community. In effect, these authors stronglysuggested that the EMDR movement has been markedlyaffected by pseudoscientific processes (particularly is-sues related to the dissemination of knowledge). Also,and consistent with previous reviews, these authors con-cluded that eye movements are an inert treatment ele-ment, that the benefits of EMDR tend to be limited toverbal report indices, and that the treatment elements ofEMDR that produce change are probably nonspecific

factors such as imaginal exposure (see Devilly, 2001a,for a more in-depth discussion of this point).

Such conclusions have been recently reaffirmed withthe use of a meta-analysis of EMDR studies conductedby Davidson and Parker (2001). Although these authorsfound that EMDR produced an effect on outcome mea-sures, they did not find an incremental effect over con-ditions that controlled for eye movements or that uti-lized exposure as a treatment element. Furthermore, theauthors also examined studies that utilized only thera-pists trained by the EMDR Institute and found that doingso had no discernable effect on their conclusions. It is im-portant to note that this meta-analysis differed from themethod used by Van Etten and Taylor (1998) in thatDavidson and Parker looked at effect sizes between con-ditions (e.g., exposure versus EMDR) within each indi-vidual study and did not aggregate effect sizes acrossstudies. This method of analysis better controls formethodological and procedural artifacts that may other-wise unduly affect the conclusions.

Spates’s research group has continued to investigatethe relative efficacy of EMDR by comparing it with Pen-n e b a k e r’s (1988) writing therapy for the treatment ofPTSD (Largo-Marsh and Spates, 1998). Tw e n t y - f o u rsubclinical subjects were randomly assigned to eithercondition and assessed on a range of standardized out-come measures that also included measures of hypnoticsusceptibility and treatment expectancy. The resultsshowed both treatments to be effective in reducing symp-tomatology and subjective disturbance. Hypnotizabilityand treatment expectancy did not predict outcome. Thisstudy showed that when a competently administered al-ternative therapy is compared with EMDR for partici-pants with PTSD, although not one of proven efficacycomparable to Foa’s or Devilly’s research group, thereappears to be no superiority in favor of EMDR. However,these authors also highlighted the procedural limitationsof the Wilson et al. (1995) study, in that writing out atrauma (as used as part of the EMDR protocol in theWilson et al. study) produced a therapeutic effect. Thus,the inclusion of a writing therapy component to theEMDR procedure undermines the claim that the Wilsonet al. (1995, 1997) studies examined the efficacy ofEMDR per se.

At a recent conference Thordarson et al. (2001) re-ported the “first-look” results from their trial comparingEMDR, an exposure-based treatment, and relaxation. Ineffect, these authors appeared to obtain similar results toDevilly and Spence (1999). They found that while therewas a nonsignificant advantage at posttreatment for theexposure-treated subjects, this advantage grew over time

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with a lowering of effect size in the EMDR condition.However, due to continued collection of the follow-updata, the posttreatment results had more statistical powerand hence the definitive result from their study is not yetavailable. By follow-up those treated with exposure weresignificantly better than those treated with EMDR, andsustained remittance was also higher in the exposure-treated group by follow-up. An unexpected feature ofthis research was that there was also a significant de-crease in symptomatology in the relaxation-treatedgroup. Further, there was no evidence that EMDRworked any faster than exposure and, in fact, there ap-peared to be a trend for exposure to work more rapidly(Dr. Steven J. Taylor, personal communication, 2001).The forthcoming paper detailing the specifics of this trialis eagerly awaited.

Other investigations of the efficacy of EMDR haveappeared since 1989 that have attested to its beneficial ef-fects for a whole host of conditions. Reports of suc-cessful applications of EMDR have appeared in relationto the amelioration of pain (Hekmat, Groth, & Rogers,1994); geriatric PTSD (Thomas & Gafner, 1993); disso-ciative disorders (Lazrove and Fine, 1996; Paulsen,1995; Young, 1994); PTSD in dementing patients (Hyer,1995); panic disorder and phobias (de Jong & tenBroeke, 1996); grief (Shapiro & Solomon, 1995); sexualdysfunction (Levin, 1993; Wernik, 1993); pathologicalgambling (Henry, 1996); chemical dependency (Shapiro,Vogelmann-Sine, & Sine, 1994); complex personalityproblems (Fensterheim, 1996); athletics (including horsedressage, Foster & Lendl, 1995); and business perfor-mance (Foster & Lendl, 1996). However, none of thesestudies compared EMDR with an otherwise well-estab-lished treatment. Instead, most were case studies withoutappropriate measurement or controls (see Kazdin, 1982).Given that these later studies tell us little about the effi-cacy of EMDR or the active processes within the proce-dure, a complete review of these studies is not necessaryfor evaluating EMDR’s efficacy.

EFFECT SIZE IN EMDR RESEARCH

Table 1 presents an analysis of group-based outcomewith respect to EMDR. To gauge the impact of this in-tervention type effect sizes were computed using the fol-lowing formula:

where S D = standard deviation; t = assessment timepoint.

Consistent with the preceding qualitative critique, itis clear that early studies tended to use no or few stan-dardized outcome measures, incorporated no fidelitychecks, and were contaminated by numerous method-ological flaws. With a plethora of methodologically poortreatment-outcome studies littering the journals and fre-quently being used as evidence either for or against a spe-cific stance, one should perhaps rely upon the researchgold standard suggested by Foa and Meadows (1997).These authors suggested that a good treatment-outcomedesign should include a clearly defined target set (e.g., di-agnostic symptom clusters), reliable and valid measuresof symptomatology (e.g., Structured Interview for PTSD,PTSD Symptom Scale—Self-Report), blind-assessor ad-ministration of the measures, training of these assessors,unbiased allocation to conditions, specific and detailedtreatment methods (e.g., provision of a manual), andchecks for fidelity to these methods. The use of blind as-sessors is predominantly advocated to reduce the de-mand effects and experimenter bias inherent in inter-views. However, another means of accomplishing thesame goal is to administer questionnaires through thepostal system. In an analysis of EMDR efficacy, Lohr etal. (1998) suggested the additional criterion that anytreatment evaluation of EMDR should control for thenon-specific effects of the treatment.

From Table 1, one can see that out of the possible 27studies, only 16 met at least 5 of the above criteria basedon Foa and Meadows (1997). However, not all of thesestudies compared EMDR with a tenable alternativetherapy, and most compared EMDR with a wait list con-trol or an inert treatment protocol. Of all these 27 studies,none found eye movement superiority on standardizedmeasures.

The only study to evaluate the “R” of EMDR (Cu-sack & Spates, 1999) also found that this feature addedlittle to effectiveness and, in fact, interfered with out-come on some measures. When the “EM” and the “R”have been shown to be ineffective, one is left only withthe “D” of desensitization. However, it is possible thatthe EMDR procedure itself is flawed due to distractionencroaching upon habituation and interfering with ex-tinction of the fear response (Devilly, 2001a), or that theaddition of the superfluous “EM” and “R” componentsinterferes with outcome. Therefore, the effect sizes ofthe EMDR procedure, in isolation of any manipulation,are presented in Table 1, and comparisons with alreadyvalidated alternative interventions are also provided. Inessence, the only studies that have compared EMDR

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CHRONOLOGY OF EMDR 129

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CHRONOLOGY OF EMDR 131

with an already validated and full treatment packagehave found EMDR to be inferior to that treatment.

As can also be seen, there is a marked disparity in theresults obtained for EMDR’s efficacy by various researchgroups. Obvious examples of such a disparity are thestudies in which combat veterans were treated usingEMDR. The results of Jensen (1994), Boudewyns andHyer (1996), and Devilly et al. (1998) are commensuratewith those of Pitman et al. (1996) and Macklin et al.(2000), yet all these results differ substantially from thoseobtained by Carlson et al (1998). Such disparities ap-pear to be dependent upon the effects of five main fac-tors, namely: participant status (e.g., veteran vs. genericPTSD); measures used (i.e., effect sizes are larger onmeasures specific to the subject groups presentingproblem); method of data collection (blind or postal as-sessments appear to obtain smaller effects); method ofanalyses (e.g., applying parametric testing to nonpara-metric data can inflate the Type I error rate); and whathas been termed researcher allegiance (i.e., university-based researchers who are independent of the EMDR In-stitute appear to obtain lower effect sizes than those con-nected to the institute, and/or do not find any superiorityof EMDR over other controlled treatments). However, adetailed investigation into these factors is outside thescope of this article.

SUMMARY OF REVIEW

As should be apparent, three major issues have been ad-dressed by previous studies: (1) Are eye movements es-sential to EMDR? (2) What is the overall efficacy ofEMDR? and (3) What is the efficacy of EMDR relativeto other treatments?

Eleven out of the 13 dismantling studies assessing theutility of eye movements found no significant benefit totheir inclusion in the procedure. The two studies that didfind a superiority for eye movements (Shapiro, 1989;Wilson et al., 1996) did not utilize standardized measures,control for therapy credibility/expectancy, investigate treat-ment fidelity, or maintain the various no-eye- movementgroups until follow-up. It appears from Table 1 that there isnow reasonably conclusive evidence that the eye move-ments are not in themselves curative, a conclusion consis-tent with that of past reviews (e.g., Lohr et al., 1998).

Turning to the treatment of combat veterans, EMDRe ffect sizes on PTSD specific measures show at worst al a rge negative effect of -0.82 after a 5-year follow-up(Macklin et al, 2000), and at best a large positive effect of1.59 after 3 months (Carlson et al., 1998). The Carlson et

al. findings are at odds with those of most of the other out-come studies and the previously discussed limitations ofthis study should be kept in mind. Overall, it appears thata short-term follow-up with this population yields smallto moderate effect sizes and that a long-term follow-up re-veals a deterioration of symptoms relative to intake.

Research on sexual assault victims suggests a verylarge effect size of up to d = 4.00 by 3-month follow-up.Nevertheless, this research is compromised by a 50% at-trition rate that may be largely specific to clients who donot improve. Research on phobia and public-speakinganxiety yields moderate to large effect sizes on problem-specific measures, whereas generic PTSD cases tends todisplay a variable effect size by follow-up, from minimal(Devilly & Spence, 1999) to very large (Renfrey &Spates, 1994). The method of data collection may havecontributed to this difference.

With regard to overall treatment eff i c a c y, EMDRfares very well against wait list or other no-treatmentcontrols, and likewise displays a healthy effect size rel-ative to some other unvalidated (or placebo) treatments(e.g., biofeedback). If, however, the comparative treat-ment includes some aspect of exposure therapy, EMDRconfers no obvious advantage. In fact, the one study tocompare EMDR with a validated treatment for child-hood arachnophobia showed EMDR to be significantlyinferior. In the only study that compared EMDR with avalidated approach for adult PTSD, EMDR was againfound to be both statistically and clinically inferior.

In other words, the above analysis suggests thatsome treatment is better than no treatment; a treatmentincluding exposure principles as a component is superiorto an inert or poorly delivered treatment; and a theoreti-cally consistent and delivered treatment based on expo-sure principles outperforms EMDR.

THE “EVOLUTION” OF EMDR:MICROMUTATION OR PREEMPTIVE SALTATION?

Shapiro (1996) noted that more controlled studies havebeen reported on EMDR than for all other interventionsfor PTSD put together, and offered a review of this re-search. She suggested that “external stimuli,” such as al-ternating hand taps and auditory tones, may be as usefulas eye movements. Unfortunately, this review omittedmany of the studies that reported a poor outcome forEMDR as well as those in which no relative efficacy wasevident for EMDR over controls using nonlateralizedstimuli (e.g., Sanderson & Carpenter, 1992; Foley &Spates, 1995). In this report, she also suggested standards

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for the evaluation of methodologies. In contrast, Foa andMeadows (1997) proposed their own standards for theevaluation of treatments. After a review of the evidence,Foa and Meadows reached different conclusions fromthose of Shapiro with respect to the efficacy of EMDR,stating that “the test of the efficacy of this much-dis-cussed treatment awaits adequately controlled studies”(p. 470). Similarly, Keane (1998) was less convinced thanwas Shapiro regarding the efficacy of EMDR.

However, of importance to the current discussion isthe development of EMDR over time. Good theories andtreatment models evolve over time. However, such the-ories explicitly state the conditions under which theycould be disconfirmed. Changes over time to the as-sumptions and procedures should also be made explicitand differentiated from earlier versions to preclude con-fusion. Failure to meet these criteria results in practicesbased upon unfalsifiable theories and general scientificd i s a r r a y. It is, therefore, important to put EMDR to thesetests if it is to be viewed as a serious scientific proposal.

In 1989 Shapiro claimed that eye movements werethe necessary (although not sufficient) ingredient of theprocedure, and it was not until 1994 that this claim wasadequately investigated and 1998 that a general con-sensus appeared to be reached.

Research assessing the veracity of claims typicallynecessitates the acquisition of grant money, approval byethics committees, acquisition of participants, the trialsthemselves, and the attainment of follow-up data beforethe analysis is undertaken and the research submitted forpublication. However, even then the review process it-self, and a backlog of already accepted articles, can pe-riodically add an extra 2 years onto the time the findingstake to reach the light of published day. With this inmind, many researchers spread word of their studies be-fore the articles appear in print.

H o w e v e r, only 2 years after her initial report,Shapiro (1991a) claimed that other forms of alternatingdirectional attention might be as useful as the eye move-ments, asserting that “another potentially fruitful area ofinvestigation may be the use of other stimuli such ashand- or finger-tapping during sessions” (p. 2). The firstreference to research suggesting the effectiveness ofstimuli other than eye movements was published byCocco and Sharpe (1993). These authors used auditorycues (finger snapping on either side of the head) insteadof eye movements in a case study to treat a small boywith PTSD following a robbery, as already described.When Renfrey and Spates (1994) published their studyon the utility of eye movements and found that there waslittle, the groundwork of “other stimuli” had already been

laid and the results then appeared unremarkable. By 1996this alternating directional attention had progressed toany “external stimuli,” thereby discounting all researchinvestigating the role of eye movements.

On another aspect of the process, Shapiro claimed in1989 that the description of EMDR in her published paperwas enough “to achieve complete desensitization of75–80% of any individually treated trauma-relatedmemory in a single 50-minute session” (p. 221), and in afootnote she asked readers who were interested in a fulldescription of the procedure to contact the author. Readerswho did so received a brochure of available training sem-inars. By 1991(b), Shapiro claimed that “while successfultreatment without proper training may be achieved per-haps 50% of the time, in other cases, untrained cliniciansplace the client at risk” (p. 188) and insisted that all re-searchers be trained by the EMDR Institute. By 1992EMDR had developed into a two-stage learning process,whereby trainees were presented with Level I and LevelII certificates that required two separate training sessions.By 1994 Shapiro disqualified research that did not sup-port EMDR’s efficacy on the grounds of a lack of LevelII training (e.g., Jensen, 1994), followed by disqualifica-tion due to the lack of fidelity checks (Shapiro, 1999).These issues were discussed by Rosen (1999), whopointed out that there was no evidence to support theseclaims and that the training level argument and inflatedimportance placed on treatment fidelity is a “specious,distracting issue that permits the continued promotion ofEMDR in the face or negative empirical findings” (p.173). As described earlier, the meta-analysis of Davidsonand Parker (2001) supported Rosen’s contentions thatwhether therapists had been trained by the EMDR Insti-tute had no effect on the results.

The original 1-session cure (Shapiro, 1989) likewisemutated slowly over time to the eventual claim that 5 ses-sions for the general population and 12 sessions for vet-erans were necessary (Shapiro, 1999). This claim wasmade despite the fact that both of these subject popula-tions had been included in the original 1989 study.

Of further concern, EMDR has recently necessitatedthe use of “positive future templating” (Shapiro, 1995).During this procedure the patient is encouraged to think offuture situations likely to arise and, via therapist modeling,develop a healthy coping response set. It is difficult to as-certain the difference between this procedure and guidedself-imagery and mastery, procedures long established asbeneficial within the cognitive behavioral paradigm (e.g.,Kirsch, Frankel, & Valone, 1977; Surman, 1979).

The “DNA” of EMDR appears a fickle constructwith yet further mutation occurring over a short period of

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time to encompass different protocols for dissociation,grief, phobias, and a whole host of differing presentations(see De Jongh, Ten Broeke, & Renssen, 1999; EMDRWeb site, 1999; Shapiro, 1995, 1997). By 1999 classicalEMDR had been shown to be less effective than a cog-nitive behavioral treatment package for PTSD (Devilly &Spence, 1999). However, EMDR now appears to en-compass preparation for and initiating in vivo exposure.The following components were advanced as necessaryto the EMDR protocol and were used for fidelity ratingsas part of the EMDR procedure: “8 = therapist helpedclient to incorporate a detailed template for fear-free fu-ture action; 9 = therapist and client arranged contract forin vivo action; 10 = client runs mental videotape for fullsequence in vivo action and reprocess disturbance”(Shapiro, 1999, p. 55). EMDR appears to be graduallyevolving towards Keane et al.’s (1989) and Foa et al.’s(1991) exposure protocols. Due to the ever-changing na-ture of what counts as EMDR, it is not surprising that acoherent theoretical basis for this technique has not beenseriously proposed. Throughout its evolution, EMDRhas maintained its acronym, offered no new theoriesadding to and consistent with already understood phe-nomena, has become less distinct from other therapeuticinterventions, and has not stated terms under which theprocedure’s tenets could be falsified.

When one looks back across time to the genesis ofEMDR, one is faced with the many incarnations of thetreatment. In the world of paleontology, such mutationsof the fossil record would cause widespread alarm. Withthis problem in mind, until testable (and hence falsifi-able) propositions are offered with regard to what con-stitutes the effective components of EMDR, further re-search in this area is of questionable value.

CONCLUSIONS

To date it has become increasingly clear that (1) EMDRis more effective than no treatment; (2) eye movementsper se do not contribute to therapeutic effectiveness; (3)the reprocessing (“R”) component of EMDR may be rel-atively inert; (4) full treatment packages utilizing com-petently administered exposure techniques are more ef-fective than EMDR in the treatment of anxiety disorders;and (5) being trained by the EMDR Institute has no sig-nificant effect on treatment effectiveness. Due to the in-sidious mutation of the EMDR procedure over time, it isdoubtful that debates regarding its utility can ever be set-tled within the scientific paradigm until falsifiable propo-sitions are advanced by its proponents.

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Carlson, J. G., Chemtob, C. M., Rusnak, K., Hedlund, N. L., &Muraoka, M. Y. (1998). Eye movement desensitizationand reprocessing (EMDR) treatment for combat-relatedposttraumatic stress disorder. Journal of Traumatic Stre s s,11, 3–24.

Carrigan, M. H., & Levis, D. J. (1999). The contribution of eyemovements to the efficacy of brief exposure treatment forreducing fear of public speaking. Journal of Anxiety Dis-orders, 13, 101–118.

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