Wave of the Future

Can a flurry of eye movements cure people of the residue of traumatic experience? Pursuing the answer turned this into the story that ate my spring vacation.

Picture this. A woman walks into a therapist's office complaining of depression and unpleasant memories stealing up on her. The therapist sits the patient down, has her call up and concentrate on a specific mental image relating to one such memory, and asks the patient to follow with her eyes the therapist's outstretched finger as it is waved rapidly side to side 20 or so times in front of the patient's face. In one session, the patient is relieved of distress and the memories are anxiety-provoking no more.

This scenario is now being played out in the offices of 7,000 therapists in America and other countries. All of them have paid hefty fees to learn the simple-looking technique called Eye Movement Desensitization and Reprocessing (EMDR). Is it:

The trend du jour of psychotherapy?

Blatantly commercial enterprise?

The "cure" for victims of traumatic memories of questionable authenticity?

A quick psychiatric fix tailor-made for a generation unwilling to do the hard everyday work necessary for mental health in a complex world--the behavioral equivalent of Prozac?

A substantially untested treatment?

A promising treatment for such stubborn anxiety disorders as posttraumatic stress (PTSD), especially among Vietnam veterans?

EMDR, it turns out, is all of the above.

And this is the story that ate my spring vacation. I had been hearing about EMDR for over a year, but after listening to EMDR's creator, Francine Shapiro, Ph.D., talk at a meeting in March, and learning that there would be presentations on EMDR at the upcoming meeting of the American Psychological Association, I decided a news article was now in order. A few phone calls, some journal articles, that would be it. But nothing proves to be simple about EMDR except the hand waving.

Don't get me wrong, I'm used to information that's confusing, complex, even contradictory. But every time I try to nail down something about EMDR, nothing is quite what it seems, even the hand waving. Shapiro, for her part, diligently leads me to many people who have worked with EMDR. But there is no closure to any line of inquiry. For every claim of a positive result-and she overlooks anything otherwise--there is at least as much that is conflicting or negative. I ask every psychologist I talk to about EMDR. Many tell me they tried it but nothing changed. And results pointed out as negative don't always look too bad. It's clear: this is only proximately a story about a therapeutic procedure.

Born of improbability, the technique supposedly first presented itself to Francine Shapiro, an English teacher from New York who moved to California in search of new modes of healing after a bout with cancel One day in 1987, while walking in the park, she noticed that some disturbing thoughts, which had descended out of the blue, vanished as her eyes spontaneously darted from side to side. When they did come back, they "didn't have the same charge." They were like a faded newspaper story. She then forced other distressing thoughts to mind, applied the eye movements, and noticed that she no longer was troubled again.

She rounded up some friends to test the eye movements on, but soon found that "most people aren't capable of performing the eye movements on their own." So she began the hand waving.

Then she tested it on 22 persons with histories of trauma, and persons with "traumatic memories." The only criteria of distress, and of improvement, were their subjective ratings of disturbance.

Not long after, armed with patient videotapes and testimonials, she began taking her show on the road, giving workshops at meetings of professionals of various credentials. She has outraged many by her insistence that workshop participants sign a waiver that they will not apply the simple technique unless they enroll in one of her expensive training courses--and they will not teach the procedure to anyone else. This is not the usual way--free and open--science chooses to propagate itself.

For that reason among others, EMDR is not just a garden-variety fad coursing through the often-idiosyncratic world of psychotherapy. EMDR exposes a large and expanding rift separating the science of psychology and the practice of psychotherapy, an emerging class struggle between the re-search-literate and the practically trained. EMDR is a highly charged technique that splits the nation's increasingly troubled psychotherapeutic enterprise cleanly in two.

On the one side are the largely (but not exclusively) M.D. psychiatrists and Ph.D. psychologists, some of them researchers, all of them trained in methods of critical analysis. They tend to reserve judgment about new treatments until they can see proof of efficacy in controlled studies. Many no longer call themselves psychologists but neuroscientists, neuropsychologists. They see psychology reinventing itself in the laboratory. So they often go out of their way to distance themselves from those in the field, who practice what they believe above all to be nonscientific... "boobe-mysehs," says one M.D., in the Yiddish for old wives' tales.

On the other side are the growing proportion of psychotherapists who have only clinical training. Some have doctoral degrees mainly from free-standing schools of professional psychology (Psy. D.), not research universities. Many have master's degrees, in social work or education. Less schooled .in rigorous habits of the mind, they can be creative therapists. But spinning further and further from the science that psychotherapy was once grounded in, and answering largely to their own sensibilities fluttering in the zeitgeist, they can also be, it is felt, unusually open to feel-good therapies of questionable legitimacy, and may even employ them for disorders of equally dubious validity. Science-bashing is a popular sport these days, and these therapists are happy having little to do with science. Many aspire to "Oprah."

I can tell who is who the minute my phone call is answered. When I explain that I'm working on an article about EMDR, the M.D.s and Ph.D.s almost always respond monosyllabically--"Oy." Or, as one of them says, "I'm rolling my eyeballs at the bull-shit-you can quote that. Never underestimate the stupidity of people."

They find EMDR embarrassing--not because it doesn't work, but because there is no acceptable proof that it does. It exposes psychology to the potential for ridicule. "There are lots of claims but no data. People should not be allowed to make claims that go beyond what we know," insists University of Washington psychologist Neil Jacobson, Ph.D., an expert in clinical research. "The overselling of this procedure can be harmful. It's very easy to perform. That's part of its elegance. That's also part of what makes people nervous."

Many agree to talk to me only if our conversation takes place off the record. They tell me similar stories--that their scientific curiosity in the procedure prompted them to make inquiries about EMDR. After all, even the most hard-nosed researcher is eager to offer relief to survivors of war, rape, and other real trauma, many of whose suffering has gone on for decades. But they claim their mere inquiries have been interpreted by Shapiro as endorsement--and she inappropriately uses their names as supporters.

Some tell me that in the spirit of providing an opening to a new perspective such as EMDR might represent, they invited Shapiro to make a presentation in their academic enclaves. Although many were not convinced she was getting the positive results she claimed, she invited them to do research. But these psychologists find such invitations truly disingenuous--because she deliberately disregards research and just keeps marketing EMDR. "I feel intellectually misled;' one of the country's foremost experts on PTSD told me. "I thought she was really interested in outcome studies." I ask, "Does EMDR work?" The answer: "Who knows?" Others say they think EMDR will prove a disappointment, but "we have to play the game of science."

Howard Lipke, Ph.D., has been at the North Chicago Veterans Affairs Medical Center for 17 years, where he directs the inpatient unit for PTSD. He tells me right off the bat that "the VA has a history of rapidly improving concern for the treatment of PTSD." When I ask him what that means, he apologizes for the VA's early handling of the problems of Vietnam veterans. "We didn't do a good job at the start." EMDR has helped him make up for that.

"Lots of clinicians shied away from treating PTSD;' Lipke told me. "It brought up too many negative feelings. That was the state of the art in 1987, when I became director of the stress unit. There was not much we could do with intrusive memories, especially combat-related. These kids were 17 when they went to Vietnam, and they saw a lot of trauma."

Not long after Lipke's promotion, EMDR came along. "I had to try it. It was nontoxic." Lipke is now a staunch supporter of EMDR. He learned the procedure from Shapiro's written description and reported on five cases in 1992--no response in one patient, lessened anxiety in two, and in two others increased anxiety that later pushed them to "further sessions in which they uncovered more material that needed to be dealt with."

Whatever else you can say about EMDR, it is yet to be established that it is a uniquely effective treatment. Its effectiveness has not been measured against other treatments. And I unearthed only one truly controlled study, by Roger Pitman, M.D., associate professor of psychiatry at Harvard and head of the VA research service at the Manchester, New Hampshire, Veterans Affairs Medical Center. Pitman found that the approach was equally effective for Vietnam veterans suffering from PTSD, whether the patients simultaneously performed eye-tracking movements or simply tapped their fingers while bringing to mind a bad memory. The effect was not large, but it was an effect nevertheless. Of course, that means that EMDR did work, just that there's nothing magical or even essential about the eye movements.

"We know that EMDR is effective also when we substitute finger tapping or auditory tones," counters an unshakable Shapiro. So why call it EMDR? And just what is the effective ingredient in the procedure? "Who's to say a patient couldn't get the same effect from masturbating?" one prominent psychologist put it bluntly.

Talking to Shapiro about it is like falling down the rabbit hole. At first she tells me that EMDR works in one session. By our third conversation, she is telling me it takes three sessions. And therapists need lots of training--a posture some see as supporting the EMDR business enterprise.

If EMDR works, it is a great mystery why. When I first spoke to Shapiro, she offered a very mechanistic explanation, that traumatic memories are "locked" in a "neurochemical envelope" in the nervous system. One of the functions of dreams, she said, is to process traumatic information and "integrate it" with the rest of the nervous system. The EMDR eye movements are akin to those in dream sleep, known as rapid eye movement (REM) sleep, during which, she said, troubling experience is digested, processed, and integrated.

Rosalind Cartwright, Ph.D., doyenne of America's dream researchers, simply hooted at the simplistic suggestion of neurophysiological similarity between the eye movements of REM sleep and those of EMDR. The eye movements of REM sleep,she says, originate deep in the brain. And rather than whip experience into an intelligible, controllable narrative, they are what give dreams their bizarre discontinuity.

Undeterred, Shapiro trotted out a different explanation. "Perhaps:' she said, "it is a matter of dual attention." Here Shapiro may be closer to something.

"EMDR does seem to speed up the de-sensitization of traumatic anxieties;' confides Gordon Bower, Ph.D., a professor of psychology at Stanford and past president of the research-based American Psychological Society. I called Bower because he had sponsored a symposium on EMDR a few years ago at an APS meeting. "I'm getting ticked off," Bower hissed at me. "[Shapiro] presents it as if I'm a subscriber." What he is, he says, is "impressed with the initial results. I am interested in repression and in traumatic memory."

Bower remains "skeptical about the scientific validation. It needs a lot more research." A true test would use "anything equally engaging as the eye movements" while the patient experiences the aversiveness of an anxiety-provoking memory.

The EMDR procedure, virtually every observer agrees, makes no sense. Its outrageous simplicity is a mocking rebuke to standard psychology. One psychologist suggested that the lateral eye movements are simply what we do on our own when we go into the search mode of memory.

Bower, however, tries to frame it in the idea of "reciprocal inhibition," a form of counterconditioning first put forward decades ago by psychiatrist Joseph Wolpe, M.D., who introduced psychological desensitization. "You get up anxiety and try to elicit its opposite. The idea is to compete with the fear response. Eye movement may serve as a distracting or competing stimulus.

Those who flock to Shapiro's training weekends are usually not the Ph.D.s. But the therapists who do go become true believers. That may allow them to bring to the treatment of traumatic memory disorders something known to be more powerfully therapeutic than all the skepticism science can muster on its best day--their enthusiasm. Disorders like PTSD are notoriously difficult to treat, and therapists up against it often feel great discouragement, which no doubt gets communicated to patients. EMDR may be effective not because it opens neurophysiological envelopes but because it generates positive expectations.

Are these positive expectations about change the operative factor in EMDR? In any therapy? People are highly suggestible, says Jacobson. After one set, or "saccade," of eye movements, patients are asked to rate their level of anxiety or other discomfort. If it's too high, the therapist keeps applying EMDR a dozen or more times in one treatment session. "The demand factor is obvious;' Bower points out. Is it possible that EMDR gets such a positive response only because the treating therapist demands it, applies the saccades until there is positive movement--or the patient says there is?

It may be that what is most fueling interest in EMDR has nothing to do with memories but with the survival instincts of nervous psychotherapists. At their backs they always hear managed care hurrying near. At the most recent mental health gathering I attended therapists were dazed from predictions that only one out of three of them would survive professionally. EMDR then becomes a tool that could allow them to appear effective (read: profitable) within curtailed coverage of mental health visits.

That may also explain why therapists have begun to apply EMDR to a range of disorders that are far removed from PTSD. Phobias. Panic. Attention deficit disorder. Hyperactivity. Depression. Addictions. Eating disorders. Malaise of any kind. Sandra Wilson, a long-distance Ph.D.-candidate in psychology, told me she uses EMDR for every patient who walks in the door, because "all dysfunction is the product of traumatic experience." Other proponents tell me the same thing.

Help! I am sliding down a very slippery slope into a diagnostic puddle. Such therapists are eroding the concept of trauma until the events it describes sound suspiciously like my everyday experience--the life-as-catastrophe model of psychology. It is not nit-picking to protest the blurring of diagnostic labels--if words don't mean what they specifically mean then they signify nothing. The promiscuous labeling of any negative memory as traumatic taints the legitimate diagnosis of traumatic disorders.

And while we're on the subject, if EMDR is going to be heralded as cure, I need some certainty that patients really have some disorder, that objective criteria have been applied. "Why is it," I ask Shapiro, "that you just take it at face value when a patient walks in the door having diagnosed herself with 'troubling memories'?" I never do understand this.

I also want to know that patients are deemed "improved" by someone other than the treating therapist. There also need to be multiple evaluations of patients before treatment--because in these conditions symptoms normally wax and wane.

And just what is being called "cure"? "In a session of therapy, patients wind up feeling less anxious? Big deal," says one PTSD expert. The real test is, are they functioning differently for a significant period of time? Shapiro responds with testimonials. It sounds like a Slim Fast commercial.

In the end, it is not even clear that EMDR accesses memory. "What's needed are controlled studies of whether it affects real memory. It is possible to instill memories and then see if eye movement accesses it;' says Jonathan Winson, Ph.D., emeritus professor of neuroscience at Rockefeller University. Shapiro has identified him to me as a supporter. Yet there is irritation in his voice when I call. He does not confer on EMDR the legitimacy Shapiro expects by association with neuroscience. "There is no way for a scientist to state this has anything to do with brain function." Still, he has "the impression something real is going on. But studies are needed to validate the diagnosis and to get to the question of memory."

The question of memory. What a question it turns out to be! "What's striking," offers John Krystal, M.D., of Yale, one of the country's leading experts on PTSD, "is that people who are traumatized can go through periods with minimal recall of their trauma, and can recall it other times."

Life, Krystal would have us remember, is an active process of constant remodeling and reshaping of memory. It is naive of us to think of memory as a nugget of iron ore deposited in the brain, its hardness and shape forever fixed. No, memory is more like a kaleidoscope, changing shape and form when we look from the perspective of different experiences. We know from every-day life that some memories are more accessible when we get into certain frames of mind, such as a state of relaxation. Then there is the rich, associative quality of memory, whereby one memory evokes others--what classical psychotherapy relies on.

Classical psychotherapy takes as its starting point the premise that we all have the private--and often difficult--task of facing down our memories, marshaling whatever reason we can to take the fright out of them, integrating and editing them as we go. This scrutiny is something many people do on their own, regularly if not every day of their lives. It used to be more fashionable than it now is. People kept diaries, wrote letters, all the while shaping experience into something coherent.

James W. Pennebaker, Ph.D., a psychologist at Southern Methodist University, finds that he can help people overcome the effects of traumatic experiences if he forces them to write about their experience for five consecutive days. What this tells us is that the disappearing art of translating events into words allows people to master what life throws them; it dissipates negative emotions. The narrative structuring of experience counts. If we do not do it, we remain prisoners of our past.

Scientists are trying to figure out how it is that we can form memories but not always have ready access to them. "It's poorly understood from a biological point of view;' says Krystal. "It's better understood metaphorically--we say they are 'repressed." Isn't it ironic; we are tricked by our own inadequate vocabulary. The real piece of work is not EMDR but the brain's ability to store memories outside of voluntary awareness allowing us to believe they are lost to us until "rediscovered".

Ultimately, I must confess, something bothers me about EMDR, no matter how clinically effective it may turn out to be in the hands of some people. In performing EMDR, therapists keep from patients the knowledge that the hand waving is a decoy, that they have and always have had the ability to do the chasing down and memory editing of it, on their own.

So the technique cultivates and reproduces powerlessness. It does this to therapists in selling them by testimonials. But mostly, it employs deception to keep clients powerless--and so it perpetuates the culture of victimhood. I feel ethically bruised just watching therapists apply a procedure that embodies the very thing--dependence, powerlessness--they are supposed to be treating.

PHOTO: A woman's face being tested.