An adult male experiencing symptoms of depression was administered five discrete treatments based upon Eye Movement Desensitization and Reprocessing (EMDR). The first treatment was with the ocular hand-tracking described by Shapiro (1995), the next four were computerized simulations. Each method showed effectiveness in reduction of self-reported depressive symptoms immediately following treatment. No appreciable difference was shown between ocular hand-tracking and isomorphic computer simulations; marginal difference, however, was shown between left-right tracking (either in vivo or computerized simulation) and frontal presentation of visual stimuli. The results suggest a nontrivial effect of the treatment(s), and in particular suggest the left-right tracking component of the treatment merits further study.
Introduction
Depression has been suggested to be in part the result of active behavior on the part of the individual experiencing symptoms (Beck, 1979; Glasser, 1975; Wubbolding, 1988). According to this line of reasoning, part of the treatment of depression becomes 1) determining the particular behavior(s) in which an individual engages which "cause," exacerbate, or at least maintain symptoms, and 2) assisting the individual to stop. Wubbolding, for example, might turn what the linguist describes as a nominalization, namely depression, into the verb depressing, and ask the (nominally) depressed individual, "How are you depressing yourself?". The answer that question elicits may identify the process, or model, of depression for that particular individual. One answer to that question given by the subject in this study was: frequent recall of visual images which elicit sadness. The originator of EMDR suggests the possibility of treatment for depression with the method as one of its "advanced clinical applications" (Shapiro, 1995, 327). Thus, the approach taken in this study, namely the attempt to lessen the effect of the visual images reported by the subject, is not without support from contemporary (and successful) treaters.
It is not suggested by the writer that this limited application of EMDR or EMDR-like techniques are substitutes for a comprehensive treatment plan. Such a plan would likely use more sophisticated assessment instruments than the subjective units of discomfort (SUD) scale used in this report (Shapiro, 1995), and may include medical management and psychotherapy.* This report is a microscopic glance at the effectiveness of the EMDR technique itself, and a peak, at what may constitute its active ingredient.
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*The subject in this study was under the care of a physician. Further details will be found below.
Method
Subject
The subject was an adult male who met DSM-IV criteria for depression (American Psychiatric Association, 1994). Subject reported a major depressive episode ten months previous to the treatment described in this report, and another episode of major depression five years earlier (1991). Subject was under the care of a physician, which included oral administration of 20 mg. Paxil per day. Treatment over the prior ten months included biweekly, then monthly, psychotherapeutic sessions with a clinical social worker. These sessions had terminated one month prior to the beginning of this study by consensual agreement of both treaters and the subject, due to what the subject called "an optimistic prognosis." In response to the question, "How are you depressing yourself?" subject reported primarily visual memories (images) from the past causing sadness. The subject agreed that the word "ruminate" accurately described his mental preoccupation with such visual images, but found the word "obsess" too strong.
Assessment
In addition to subject's self-report of diagnosis by physician and corroboration by the clinical social worker, subject's verbal responses to researcher met DSM-IV criteria for depression. Subject was also given a computerized version of the Beck Depression Inventory (BDI) and the Dissociative Experience Scale (DES). Subject self-reported a SUD value of "8" on a 0-10, eleven-point scale for each of the visual images employed as "target" images in this study (Shapiro, 1995). While multiple baselines were established at the beginning of this study consistent with the approach of Single Case Research Designs (Kazdin, 1982), a computer problem with the Toshiba 105CS (laptop) on which those tests were administered and stored, prevent their presentation here. However, a SUD rating was established prior to, and after, each treatment session.
Treatment
Before beginning treatment, the subject was familiarized with the ideas of a cognitive/behavioral approach to depression, specifically, that an individual takes an active role in behaviors, either cognitive processes or actual physical behaviors, which if not cause, serve to amplify or maintain the affective experience of depression. The subject was further acquainted with the concepts and procedures of EMDR and generally accepted the idea that if the reported visual images had a less depressing impact upon him, his depression would be less. The specific treatments were five. In each treatment the subject was instructed to hold in mind one of the visual images previously identified as leading to sadness while following the researcher's hand or computer images with the eyes. Because there was some choice as to which images to choose, images utilized were those with a SUD rating of "8." The first treatment used was the ocular hand-tracking described by Shapiro (1995). The second through fifth treatments were computer simulations designed to simulate EMDR treatment. The first computer simulation was comprised of a visual image displayed alternatively at the left and right visual field (See figure 1) on a computer monitor at the rate of approximately once per .5 seconds.
The specific image was a tarot card showing a woman bound and blindfolded. The second computer simulation was the same as the latter in all respects except that the image utilized was that of a dot (See figure 2). The dot was chosen for its expected neutral affective content in contrast with the first image of the bound and blindfolded woman.*
The third computer simulation was again, executed in similar fashion to the preceding two, yet in this instance the image was displayed only at the center of the visual field, with apparent left-right movement of the arms of the individual shown in the picture displayed (See figure 3). The image chosen in this instance was again a tarot card, picked primarily for practical reasons: the position of the figure's arms were held in such a way as to make the animation possible. This animation was accomplished by "reversing" the image within a computer program, then alternating display between the original and reversed images. All three of the preceding examples were programmed and displayed on a Macintosh computer, model Performa 460, using the programs ClarisWorks and Jade. The final computer simulation utilized a Macintosh HyperCard stack, "Snodgrass and Vanderwart Pictures," which displays line drawings in the center of the visual field at the rate of approximately once per .5 seconds (Snodgrass, 1987, 1980).
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*It may be prudent for the researcher to point out that the use of tarot cards has no significance other than their content consistent with the theme of depression in the two cards utilized, and the ease of animation noted within the text.
Results
SUD scores in each of the five treatments decreased from a rating of "8" prior to treatment, to "1" or "0" immediately following treatment (See Table 1). However, each SUD rating returned to an intensity of "8" by the next treatment session. Shapiro's ocular hand-tracking and the first two computer simulations, which displayed a distinct left-right computer image, each brought the SUD rating to "0." Both centrally displayed sets of images, treatments four and five, resulted in a SUD rating of "1." Due to computer difficulty with the Toshiba (laptop) noted earlier, no pre-/post-treatment data is available from the BDI or DES.
Table 1
Pre- and post treatment SUD scale ratings
Pretreatment Posttreatment
Tx administered:
1. Standard EMDR 8 0
2. Left-right "bound-figure" 8 0
3. Left-right "dot" 8 0
4. Left-right "arm movement" 8 1
5. Sequential display 8 1
Discussion
Each of the five treatments used brought the SUD rating down significantly, from a score of "8" to a score of either "0" or "1" in single treatment session. At a glance, it appears that each was a treatment success. However, while the results are encouraging, a number of factors must be considered.
First, while the treatments were ultimately aimed at depression, treatment results are measured as a subjective rating of the distressing qualities of one particular visual image, at one discrete moment in time (one of five different images for each of the five treatment sessions). That is, while our first glance at the results is encouraging, a SUD value is not an evaluation of depression or its absence. Second, each SUD scale returned to its previous rating of "8" by the next treatment. By that reckoning, each treatment might be viewed a treatment failure. Neither interpretation is very useful.
The reader is reminded that the components of EMDR utilized (visual stimuli and left-right tracking) excluded both the negative cognition, which Shapiro asserts is associated with target images, and the positive cognition, which EMDR insists must be installed. The absence of these treatment components in this study may account for the failure of the treatments to "stick."
What we have, this writer suggests, is substantial reason to conclude that a carefully aimed cognitive/behavioral intervention may result in significant impact in at least one piece of the puzzle that is a psychiatric or psychological disorder, in this case depression.
It should be noted as well that this case study is not a measure of EMDR, and certainly not the proposal of an explanatory model. It looks at one component of the EMDR treatment regimen, namely the presentation of visual stimuli. The study was designed to zero-in on components of the EMDR program which in the writer's estimation are the salient features of the EMDR approach, namely the coupling of a distressing image with a more neutral experience, then progressively designing out the left-right (lateral) component. The low post treatment SUD scores in all five treatments appear to support the effectiveness of the visual presentation; the slightly higher SUD ratings resulting from decrease, then absence of the lateral component suggest more than a trivial importance to the alternating, if not explicitly, left-right component.*
Shapiro views the dynamic of EMDR as one of accelerated information processing (1995) or dual attention stimulation (2001) ; Dyck suggests a conditioning model (1993); Armstrong and Vaughan offer an orienting response model (1996). None of these models adequately address the specifically left-right, or generally alternating, component. While this writer, and this brief case report, will not resolve the current debate in the EMDR arena, it is suggested that future research pursue the left-right and alternating movement questions.
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*The writer has web-published a brief thought-piece suggesting possible correlations between left-right and other spatial orientations and sensory modalities. See Burik, J. (1994) Eye movement therapy?.
References
American Psychiatric Association. (1995). Diagnostic and Statistical Manual, 4th Ed.
Armstrong, M. and Vaughan, K. (1996). An orienting response model of eye movement desensitization. Journal of Behavior Therapy & Experimental Psychiatry, 27, 21-32.
Beck, A. et al. (1979) Cognitive Therapy of Depression. New York: Guilford Press.
Dyck, M. (1993). A proposal for a conditioning model of eye movement desensitization treatment of posttraumatic stress disorder. Journal of Behavior Therapy and Experimental Psychiatry, 24, 201-21.
Glasser, W. (1975). Reality Therapy: a new approach to psychiatry. New York: Harper & Row.
Kazdin, A (1982). Single-Case Research Design: methods for clinical and applied settings. Oxford University Press.
Shapiro, F. (2001, 1995). Eye Movement Desensitization and Reprocessing: basic principles, protocols, and procedures. New York: Guilford Press.
Snodgrass, J. & Vanderwart, M. (1980). A standardized set of 260 pictures: norms for naming agreement, familiarity, and visual complexity. Journal of Experimental Psychology: Human Learning and Memory, 6, 174-215.
Snodgrass, J. et al. (1987). Fragmenting pictures on the Apple Macintosh computer for experimental and clinical applications. Behavior Research Methods, Instruments, & Computers, 19, 270-274.
Wubbolding, R. (1988). Using Reality Therapy. New York: Harper & Row.