07.31EMDR: Science or Pseudoscience
by Bunmi O. Olatunji
Eye Movement Desensitization and Reprocessing (EMDR) is a highly controversial treatment for a variety of psychological disorders with empirical evidence both supporting and negating its effectiveness and efficacy. The negating evidence proposes that EMDR appears to be aligned with the meaning of science but lacks the methodological as well as empirical validation necessary. Given the enormous popularity of EMDR, and the recent tendency towards the embrace of the false comfort of non-scientific treatment interventions, it is essential to carefully examine the components of EMDR. The following review will do so, as well as critically analyze the empirical data and ultimately determine if EMDR fits the definition of a true science, or rather represents a pseudoscience.
Eye Movement Desensitization and Reprocessing (EMDR) is a relatively new therapeutic intervention that has been said to help alleviate traumatic memories, as well as assist in the treatment of many other psychological disorders (Lohr, Lilienfeld, Tolin, & Herbert, 1999). Generally speaking, it is used to obtain, neutralize, and resolve traumatic memories considered to be at the root of psychological disorders. In 1987, a graduate student by the name of Francine Shapiro noticed, while walking in the woods and preoccupied with upsetting thoughts, that when her eyes spontaneously moved rapidly from side to side, her old memories and disturbing thoughts faded away (Herbert & Mueser, 1992).
The development of this apparently complex and integrative method has generated an enormous amount of excitement and support while simultaneously generating a substantial amount of controversy (Lohr, Kleinknecht, Tolin, & Barrett, 1995). EMDR has been labeled a scientific intervention, with claims of being the most effective treatment for Post Traumatic Stress Disorders and equally as effective for other psychological disorders. However, a number of recent studies have proposed that EMDR is an unproven pseudoscientific treatment intervention (Lohr, Lilienfeld, Tolin, & Herbert, 1999). As a result of the apparent disagreement on the efficacy of EMDR as a scientific treatment applicable to human problems, it is vital to critically analyze the purpose and procedure of EMDR for scientific and pseudoscientific content.
Science and Pseudoscience: A Broad Overview
Pseudoscientific manifestations are generally defined as a set of theories presented as scientific concepts, when in fact they are not. One vital element of a scientific theory is its ability to explain a wide range of empirical phenomena and correspondingly be validated or tested empirically in some meaningful manner (Carroll, 2000). Empirical validation of scientific theories demands the deduction of empirical predictions from those theories. To be meaningful, such predictions must, at the very least, in theory, possess the potential to be falsified. This scientific characteristic is known as falsifiability (Herbert, Lilienfeld, Lohr, Montgomery, O’Donohue, Rosen, Tolin, in press 2000).
A pseudoscientific theory claims to be scientific, or in actuality claims to be falsifiable. The reality is that theories that are pseudoscientific in nature are not falsifiable or they have already been falsified but modifications are made to the theories to discount the negating evidence (Carroll, 2000). Pseudoscientific theories are also allegedly based on empirical evidence, and may often appear to utilize scientific methodology, when in fact the rationale of pseudoscientific theories are based on misconceptions and its employment of controlled experimentation are often insufficient.
The “pseudoscientific misconception” is the notion that it is adequate to simply highlight the consistencies of its theory with data (Carroll, 2000). Certainly consistency with factual data is a scientific necessity, however it is not a sufficient attribute to be considered a scientific entity. Not only is it vital that a scientific theory be predictive by nature, it is also important that a truly scientific theory provide empirical means of testing those predictions. A theory that is challenged by factual data is clearly not a good scientific theory, however that does not imply that a theory, which is consistent with the facts, is correspondingly a good scientific theory (Carroll, 2000).
Purpose and Procedural Components of EMDR
It has proven to be rather difficult for EMDR advocates to sufficiently explain the functional mechanism behind its proposed effectiveness. The leading justification of its effectiveness is generally based on its apparent integration of psychological and neurological processes. Seemingly, recovery occurs after eye movements and other components of EMDR unlock pathological conditioning within ones information-processing system (Lohr, Kleinknecht, Tolin, & Barrett, 1995).
Generally speaking, the treatment consists of many sessions, and the number of sessions devoted to each phase of treatment is highly dependent on the condition of each client (Hurst & Milkewicz, 2000). The initial phase is typically dedicated to a history evaluation; the purpose of this is to determine if the client is suitable for the treatment. This initial assessment will take into consideration the clients’ coping ability, external stressors, current medical condition, etc. The second phase will introduce the client to the purpose and procedure of EMDR. At this juncture, imagery and relaxation techniques are often incorporated to strengthen the clients’ ability to cope with the recollection of traumatic memories (Hurst & Milkewicz, 2000). Ensuing is the identification of a traumatic memory and an image that best represents that memory (Shapiro, 1989). The client first selects a negative cognition (e.g., “I am worthless”) relating to the traumatic event, and likewise selects a positive cognition (e.g., “I am a nice person”) to replace the negative one (Hurst & Milkewicz, 2000). The client then rates the extent to which he or she believes the positive statement, using a 7-point Validity of Positive Cognition (VOC) scale. The image and negative cognition is then combined and the clients level of discomfort is assessed with the Subjective Units of Discomfort scale (SUDS) (Lohr, Kleinknecht, Conley, Dal Cerro, Schmidt, & Sonntag, 1992).
The client is then instructed to focus on the negative affect he or she is experiencing and simultaneously move his or her eyes back and forth. This desensitization process is repeated until the SUDS ratings are significantly reduced (Shapiro, 1989). Some variation of cognitive restructuring generally follows the desensitization procedure, at which point the positive cognition is reinforced in order to replace the negative cognition attached to the traumatic memory. The client holds the positive belief and the image in his or her mind and the eye movements sets are continued until the client is able to link the positive cognition to the traumatic memory (Hurst & Milkewicz, 2000).
Eye Movements: Analysis of the Foundation
Operationally defined, eye movements would have to be the functional mechanism behind the relative effectiveness of EMDR (Lohr, Kleinknecht, Tolin, & Barrett, 1995). Theoretically, saccadic eye movements unblock the information processing system (Lohr, Kleinknecht, Tolin, & Barrett, 1995) consequently allowing for the re-conditioning of positive cognitions in the place of negative cognitions. First and foremost saccadic eye movements and the type of eye movements used in EMDR are not equivalent. Saccadic eye movements are sudden, rapid (ballistic), and transpire at the point of fixation changes. The eye movements utilized in EMDR are relatively smooth and voluntary (Lohr, Tolin, & Lilienfeld, 1998). This contradiction in terms poses a very delicate question regarding the necessity of eye movements in EMDR.
Many studies initially supported the notion that saccadic eye movements are a vital component of EMDR. Recently, however, it has been empirically validated that the actual process of following a waving finger or a moving light with one’s eyes does not appear to be necessary (Lohr, Tolin, & Lilienfeld, 1998). Studies have produced similar results by utilizing alternative techniques such as standard imagery and finger tapping (Lohr, Tolin, & Lilienfeld 1998; Lohr, Kleinknecht, Tolin, & Barrett, 1995). After the emergence of these and other empirical studies opposing the necessity of eye movements, alternative explanations were proposed by EMDR advocates claiming that the alternative methods to eye movements used in other studies were equivalent to eye movements (Lohr, Kleinknecht, Tolin, & Barrett, 1995).
Critique of the Empirical Evidence
Clearly, this seemingly scientific interpretation of EMDR has raised many questions regarding its effectiveness and the mechanisms that contribute to its effectiveness. Many research efforts have addressed this very issue; does EMDR work? And if so, how (Cahill, Carrigan, & Frueh, 1999)? The empirical evidence confirming the effectiveness of EMDR does so very convincingly. In addition to being convincing, the supporting evidence shares yet another common theme, that being the methodological and assessment inconsistencies within their experimental designs (Herbert & Mueser, 1992). Given that a number of the studies supporting the effectiveness of EMDR have made considerable methodological improvements, the theoretical foundation of EMDR still remains at odds with the evidence addressing its efficacy (Lohr, Lilienfeld, Tolin, & Herbert, 1999).
It is well known that the objective analysis of a client’s psychological disorder is a very vital part of clinical assessment. Given the lack of diagnostic data in the studies advocating EMDR, one could legitimately conclude that the diagnostic statuses of the subjects were simply not taken into consideration. Furthermore, a proportion of the empirical evidence confirming the effectiveness of EMDR is based on case reports. Though case reports are a very practical component of scientific inquiry, generalizing from them can prove to be erroneous. Additionally, standard measures of assessments are often not used, and when utilized the results advocating the efficacy of EMDR have frequently been inconclusive or negative. This tends to lead to the selective use of data, particularly the partiality to confirming instances and the inattentiveness to contrasting results (Herbert & Mueser, 1992).
In the process of empirical validation it is of great clinical significance to determine which portion(s) of the treatment package are responsible for which treatment effect. The empirical evidence supporting EMDR has yet to systematically apply the contents of the treatment, making it impossible to isolate the general effects of EMDR from the alleged effects of eye movements or any other stimulation of the sort (Lohr, Kleinknecht, Tolin, & Barrett, 1995). The systematic application of treatment components, as well as the assessment of emotional processing (which some EMDR studies have neglected) is extremely necessary in not only the investigation of treatment efficacy, but also in the validation of the theory that justifies the treatment’s clinical application (Lohr, Tolin, & Lilienfeld, 1998).
Science and Pseudoscience in EMDR
Based on the empirical evidence, the question still remains regarding exactly how EMDR works. It does appear that the popularity of EMDR in both the mental health profession and the general public is due in large part to its apparently scientific features (Herbert, Lilienfeld, Lohr, Montgomery, O’Donohue, Rosen, Tolin, in press 2000). Take, for instance, the original notion that EMDR’s effectiveness is in some manner related to corrections in the excitatory/inhibitory balance in the brain (Shapiro, 1989). It was suggested that traumatic stimuli disturbed this delicate balance, resulting in a pathological change in the neural components, thus maintaining the stimuli in their original anxiety-evoking form. The traumatic stimuli would then remain in one’s active memory, and consequently be triggered as intrusive thoughts. The application of rhythmic, saccadic eye movements combined with the traumatic stimuli re-establishes this neural balance through the neural bursts evoked by the repeated saccades (Shapiro, 1989). This consequently restores the neural balance and reverses the neural pathology. Numerous modifications have been made to this initial theory in response to negating empirical results, which have contributed to a rationale that appears to be extremely scientific and consequently apparently valid.
Nevertheless, upon further analysis, it appears that the empirical foundation of EMDR, particularly its theoretical rationale, lacks scientific qualities. As alluded to earlier, an authentic scientific method depends highly on the concept of falsifiabilty (Herbert, Lilienfeld, Lohr, Montgomery, O’Donohue, Rosen, Tolin, in press 2000), the possibility of proving a prediction or theory to be false. EMDR violates this law by simply introducing supplementary theories in order to account for empirical results that negate its effectiveness. In essence, the development of EMDR consists of propositions of numerous theories, which are disguised as scientific, but cannot be empirically tested in a meaningful way. Due to continuous modifications, EMDR theories are relatively consistent with every conceivable empirical event and, consequently, no deduced predictions from those theories could ever falsify them (Herbert, Lilienfeld, Lohr, Montgomery, O’Donohue, Rosen, Tolin, in press 2000).
Many vague theories have been proposed in an attempt to avoid the actuality that EMDR is primarily engrossed with pseudoscientific content (Herbert, Lilienfeld, Lohr, Montgomery, O’Donohue, Rosen, Tolin, in press 2000), although the theories have basically degenerated to the point of being incapable of producing supplementary validated hypotheses. Such attempts include the notion that EMDR alters the clients’ perceptions of selected feelings by obstructing how they are actually experienced, or that the back and forth eye movements result in a ping-pong effect between the right and left hemispheres of the brain. This consequently restores memory, or perhaps by the saccadic eye movements sending signals to the brain which then tames the naughty part of the brain causing the problems (Carroll, 2000). The impetuous development of these alternative theories, the constant denial of evidence contradicting the efficacy of EMDR, and the apparent lack of concern over the absence of evidence supporting EMDR theory strongly suggests a pseudoscientific manifestation.
Despite the theoretical inconsistencies, the enthusiasm and support of EMDR has increased significantly, with more and more clinicians receiving training that is applicable in the clinical setting (Lohr, Kleinknecht, Tolin, & Barrett, 1995). This premature acceptance by psychologists of this pseudoscientific intervention appears to suggest a shift on their part in the basic necessity of scientific validation prior to clinical application (Rosen & Lohr, 2000). Although a consensus has yet to be achieved in regards to a universal definition of pseudoscience, it is no coincidence that EMDR fits the non-categorical and prototypical definitions of pseudoscience proposed by a variety of philosophers (Herber, Lilienfeld, Lohr, Montgomery, O’Donohue, Rosen, Tolin, in press 2000).
It would be splendid if EMDR advocates could empirically support the exaggerated claims they put forth regarding the efficacy of EMDR treatment. Nevertheless, it is exceedingly clear that EMDR not only lacks the theoretical foundation necessary to be considered a scientific method, the empirical evidence supporting its efficacy are also flawed and inconsistent. EMDR has not yet been validated convincingly by any controlled study that any of its therapeutic effects are not due to random chance, or other aspects of the treatment (e.g., patient expectancy, placebo effect, etc.) besides the eye movement procedure (Lohr, Tolin, &d lilienfeld, 1998). Based on these and numerous other inconsistencies, it is without question that extreme caution is advised in the clinical application of EMDR. It is very clear that the theory and practice of EMDR falls well short of scientific standards.
Bunmi O. Olatunji is a graduate student in the clinical psychology program at the University of Arkansas.
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