RESEARCH ON SOCIAL WORK PRA
10.1177/1049731504265830
CTICE
Edmond et al. / EMDR AND ECLECTIC THERAPY
Sexual Abuse Survivors’ Perceptions of the
Effectiveness of EMDR and Eclectic Therapy
Tonya Edmond
Washington University in St. Louis
Lacey Sloan
University of Southern Maine
Dawn McCarty
Lamar University
Objective: This article examines survivor perspectives of the effectiveness of two different treatments for trauma
symptoms among adult female survivors of childhood sexual abuse— Eye movement Desensitization and Reprocessing (EMDR) and eclectic therapy. Method: Qualitative interviews obtained in the context of a mixed-methods study
were conducted with 38 adult female survivors of childhood sexual abuse. Results: Two major differences in outcomes
between the two treatment approaches were observed. There were considerable distinctions between the two treatment groups in terms of the importance and effect of the client-therapist relationship, and in terms of the depth of
change reportedly caused by the different therapies. Conclusions: Survivors’ narratives indicate that EMDR produces greater trauma resolution, while within eclectic therapy, survivors more highly value their relationship with
their therapist, through whom they learn effective coping strategies.
Keywords:
EMDR; childhood sexual abuse; adult survivors; mixed methods
Eye movement desensitization and reprocessing
(EMDR) was first developed in 1987 when psychologist
Shapiro discovered that moving her eyes back and forth
while thinking about a distressing experience seemed to
dissipate the intensity of the feelings she associated with
that experience. She began experimenting with the discovery and in time developed a systematic procedure for
using the method that she initially referred to as eye
movement desensitization (EMD). Shapiro (1989) tested
her procedure with survivors of sexual trauma and combat and reported that EMDR produced significant clinical
improvements with only one session. Despite serious
methodological limitations, the findings generated a
great deal of interest in the method. In 1990, she added
“reprocessing” to the method’s name to reflect the belief
that information was being reprocessed and integrated
into memory through EMDR.
Shapiro (2001) specified that EMDR should be seen as
a treatment package with eight stages: (a) client history
and treatment planning, (b) preparation of the client, (c)
assessment, (d) desensitization, (e) installation, (g) body
scan, (h) closure, and (i) re-evaluation. Each stage is
Research on Social Work Practice, Vol. 14 No. 4, July 2004 259-272
DOI: 10.1177/1049731504265830
© 2004 Sage Publications
explicitly described by Shapiro and will not be elaborated
here. However, to provide a fuller understanding of the
method, the basic protocol used in EMDR follows.
The procedures for using the basic EMDR protocol
involve the following steps: (a) the client and therapist
identify the presenting (current life) issue that is to be the
treatment target; (b) the client is asked to identify a memory that seems connected to the current presenting problem, which then becomes the memory target; (c) the client
is asked to hold a picture of the memory in mind; (d) the
client and therapist identify negative and desired positive
self assessments associated with the memory; (e) while
holding the picture and positive self-perception in mind,
the client is asked to assess on a scale of 1 to 7 how true the
positive self-perception feels so that an initial Validity of
Cognition (VoC; Shapiro, 1989) score can be obtained;
(f) while holding the image and negative self-perception
in mind, the client is asked to identify any emotions that
are present in the moment; (g) while holding the picture
of the memory, the negative self-perception and emotions, the client is asked to assess on a scale of 0 to 10 how
disturbing the emotions are so that an initial Subjective
Units of Disturbance (SUDs; Wolpe, 1990) score can be
recorded; (h) the client is asked while holding the picture
of the memory, the negative self-perception and emo259
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tions, to identify any physical sensations present; and
(i) the therapist induces saccadic eye movements by having the client follow the therapist’s fingers in repeated
bilateral movements. The speed, direction, and number of
eye movements are adjusted to meet the unique needs of
each individual client, and although 90-minute sessions
are recommended, the number and length of sessions
needed also varies on an individual basis (Shapiro, 1995).
The SUDs and VoC scales are in-session measures
used by the therapist to track the client’s progress in processing the targeted traumatic material. A change in
SUDs level to a 0 or 1 is a good indication that sufficient
desensitization has occurred. A rating of 6 or 7 on the VoC
is considered to be a strong indication that significant
positive cognitive restructuring has occurred. The combination of a score of 0 or 1 on the SUDs with a 6 or 7 on the
VoC is viewed as an indication of trauma resolution for
the targeted memory or issue (Shapiro, 1995).
Although initially spawned by a serendipitous discovery, during the past several years, much work has gone
into refining the protocols and testing the efficacy of
EMDR. The initial wave of studies that followed
Shapiro’s original study (1989) provided additional support for the effectiveness of EMDR. However, these studies also had serious methodological limitations, as explicated by numerous reviewers. The methodological
limitations most often cited about those early studies
include the lack of confirmed diagnoses based on recently
administered, standardized assessment instruments; a
lack of clarity regarding whether clinically significant
symptoms were present prior to treatment; failure to use
objective, standardized instruments to evaluate outcomes; and vulnerability to measurement bias through an
overreliance on therapists’ impressions and unstandardized, subjective client self-reports as primary outcome
measures (Acierno, Hersen, Van Hassselt, Tremont, &
Meuser, 1994; DeBell & Jones, 1997; Greenwald, 1994;
Herbert & Mueser, 1992; Lohr, Kleinknecht, Tolin, &
Barrett, 1995; Shapiro, 1995, 1996a, 1996b).
In addition, a number of controlled experiments
yielded equivocal results about EMDR’s effectiveness
(Boudewyns & Hyer, 1996; Devilly, Spence & Rapee,
1998; Foley & Spates, 1995; Jensen, 1994). These studies
were criticized primarily on grounds of intervention
fidelity by EMDR proponents who argued that the
EMDR therapists in these studies lacked adequate EMDR
training and deviated from the recommended EMDR
protocol (Greenwald, 1994; Shapiro, 1996a, 1996b). It
should be noted that EMDR proponents typically level
this criticism when there are null findings in EMDR
studies (Herbert et al., 2000).
The most intriguing aspect of EMDR is the use of eye
movements, the necessity of which has generated much
debate. Some have argued that EMDR adds nothing
beyond existing cognitive-behavioral treatments such as
systematic desensitization (Acierno et al., 1994; Lohr,
Tolin, & Lilienfeld, 1998; Rosen et al., 1998). Rosen and
colleagues (1998) argued, for example, that without the
eye movements, what is left is imaginal exposure, desensitization, and cognitive reprocessing—traditional elements of behavior therapy. Most controlled component
analysis studies on this issue concluded that eye movements were not an essential component in achieving the
observed effects (Bauman & Melnyk, 1994; Devilly et al.,
1998; Foley & Spates, 1995; Renfry & Spates, 1994).
Only one of the component analysis studies supported the
necessity of the eye movement component (Gosselin &
Mathews, 1995).
Regardless of the role of eye movements, there is
increasing empirical evidence to suggest the efficacy of
EMDR. In a meta-analysis of 59 post-traumatic stress
disorder (PTSD) treatment outcome trials, Van Etten and
Taylor (1998) concluded that EMDR was equal to behavior therapies in its effectiveness in treating PTSD. Furthermore, they found that EMDR and behavior therapies
were more effective in treating PTSD symptoms than
other psychotherapies or pharmacotherapies, with the
exception of selective serotonin reuptake inhibitors
(SSRIs), which were seen as comparably effective. Additional support for EMDR has come as professional associations have reviewed the literature to develop empirically based treatment guidelines. Working under the
auspices of the APA Division 12 (Clinical Psychology)
project Chambless and colleagues (1998) identified
empirically validated therapies in the literature and categorized them as either well-established treatments or
probably efficacious treatments. EMDR was categorized
as probably efficacious for treating civilian PTSD. Similarly, while developing its treatment guidelines, the International Society for Traumatic Stress Studies gave
EMDR a Level A/B rating in terms of the evidence available to support its effectiveness for treating PTSD
(Chemtob, Tolin, van der Kolk, & Pitman, 2000). The A
aspect of the rating was given because of the number of
studies reviewed that found EMDR to be more effective
than routine care, treatment controls, or waitlists. The B
reflects the need for additional studies that are more
tightly controlled that can address the limitations of
EMDR studies to date (Chemtob et al., 2000).
Three recently published controlled studies have compared the effectiveness of EMDR to well-established
PTSD treatments—prolonged exposure (PE; Ironson,
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Edmond et al. / EMDR AND ECLECTIC THERAPY 261
Freund, Strauss, & Williams, 2002), stress inoculation
training with prolonged exposure (SITPE; Lee, Gavriel,
Drummond, Richards, & Greenwald, 2002), and exposure with cognitive restructuring (E+CR) (Power et al.,
2002). In each study, EMDR and the comparison treatment were comparably effective in reducing PTSD symptoms, however EMDR appeared to be somewhat more
efficient either through achieving gains in fewer sessions
or with less homework. All treatments appear to have
effectively maintained their therapeutic gains at followups, However in the Lee et al., (2002) study, EMDR
recipients seemed to have made small but significantly
greater improvements on trauma measures at follow-up
than was found for those who had received SITPE.
A review of the existing literature on EMDR reveals an
abundance of quantitative data evaluating its effectiveness. In stark contrast, there is an absence of qualitative
data, beyond case studies, that provide a sense of the
effectiveness of EMDR as experienced from the perspective of the client. Furthermore, although there appears to
be a growing interest in mixed methods—the incorporation of quantitative and qualitative methods—in research
designs, very few studies of this type have appeared in
print. Nor have there been any publications on EMDR
that have used a mixed-methods approach to examining
the effectiveness of EMDR. The purpose of the current
study is to address that gap. The qualitative data to be presented was collected within the context of an experimental design used to examine the effectiveness of EMDR in
reducing trauma symptoms in adult female survivors of
childhood sexual abuse.
It is important to note that the current study was conceptualized as a mixed-methods design prior to the implementation of the study. The principal investigator (PI)
wanted to utilize a strong experimental design to collect
quantitative data needed to answer the primary research
question regarding the effectiveness of EMDR and to
capture qualitative data about client perceptions of the
effectiveness of each treatment. The unusual nature of
EMDR with its use of eye movements seemed to warrant
examination of clients’ perceptions of the treatment. It
seemed plausible that even if the treatment was found to
be effective, as prior studies claimed, that clients might
prefer a more relational and familiar approach to treatment. Thus, the use of a mixed-methods approach seemed
to be the only logical way to proceed.
Given the state of our knowledge about the effectiveness of EMDR at the time, and the large number of practitioners using it, priority was placed on revealing the quantitative findings from the experimental design first. Thus,
the quantitative findings from the study were published
separately and will not be emphasized in this article (see
Edmond, Rubin, & Wambach, 1999). The experimental
design aspect of this project will be referred to as the parent study.
PARENT STUDY
A randomized experimental design with three groups
was used in the parent study. Fifty-nine adult female survivors of childhood sexual abuse who met the eligibility
criteria were randomly assigned to one of three treatment
groups: (a) individual EMDR therapy (n = 20); (b) individual eclectic therapy (n = 20); or (b) delayed treatment
control (n = 19). Each survivor received six, 90-minute
individual sessions of EMDR or eclectic therapy, focused
on resolving a specific, survivor chosen issue or memory
related to the sexual abuse. The delayed therapy control
group survivors received therapy from community therapists following a 6-week wait. Participants’trauma symptomology (anxiety, depression, post-traumatic stress, and
negative beliefs) was measured in pretests and posttests
on four standardized instruments (State-Trait Anxiety
Inventory, Beck Depression Inventory, Impact of Events
Scale, and the Belief Inventory) by the PI, as well as two
subjective in-session process measures (SUDs and VoC)
obtained by each survivors’individual therapist. On completion of the treatment protocol and posttesting, the PI
conducted semistructured interviews with the 40 survivors who received either EMDR or eclectic therapy. It is
the data from those interviews, which has not been previously reported, that is presented later in this article. Furthermore, in the discussion, the qualitative data will be
triangulated with the quantitative data obtained from the
experimental design to illustrate the value of a mixedmethods approach to effectiveness studies.
Description of Eclectic Therapy
Before moving into the qualitative study, it is important to provide a brief description of the treatments used
in the parent study and a summary of the quantitative results. Because a description of the experimental treatment
(EMDR) has already been provided, this section focuses
on the comparison treatment. Eclectic therapy in the
parent study was operationalized as a variety of theories,
methods, and techniques integrated into an individualized treatment approach to resolve trauma induced by
childhood sexual abuse. As a result, each individual par-
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ticipant assigned to eclectic therapy received an individualized treatment approach, that could not be standardized
across participants or therapists, and could not be
assessed for treatment fidelity as was done with EMDR.
One could argue that the study could have been stronger if
the comparison treatment had been a more standardized
method with established effectiveness such as PE or cognitive processing therapy because both methods have
been shown to be effective in the treatment of PTSD
(Foa, Keene, & Friedman, 2000). However, in addition to
PTSD, survivors of childhood sexual abuse often present
with many other symptoms. An eclectic treatment
approach was selected for the comparison group to provide the flexibility to address the wide range of symptoms
with which survivors present, and to be inclusive of the
common practice approaches of therapists treating adult
survivors in community settings. Furthermore, eclectic
therapy has been found to be effective in reducing trauma
symptoms in adult survivors when used in a group setting
(Roberts & Lie, 1989) and in individual therapy (Jehu,
1988, 1989).
The very nature of eclectic therapy dictates that a combination of therapeutic interventions are used in treatment. Prior to the implementation of the study, each participating therapist was interviewed and asked to identify
the types of theories, methods, and techniques they routinely used in their practice to treat trauma symptoms in
adult survivors of childhood sexual abuse. This data was
used to construct a Process Notes Form to record any
interventions used during the study with the survivors
who received eclectic therapy. Each therapist made individual choices as to the specific intervention approaches
used in any given session based on the unique needs of
each individual survivor, which means that EMDR was
compared with a wide range of intervention strategies.
The types of treatments used during the course of the
study included support (n = 20, 100%), information (n =
20, 100%), ego strengthening (n = 13, 65%), interpretation (n = 16, 80%), cognitive restructuring (n = 14, 70%),
problem solving (n = 13, 65%), dreamwork (n = 6, 30%),
neurolinguistic programming (NLP) (n = 3, 15%),
psychoeducation (n = 3, 15%), behavior modification
(n = 4, 20%), gestalt (n = 1, 5%), hypnosis (n = 2, 10%),
artwork (n = 2, 10%), assertiveness skills (n = 4, 20%),
writing assignments (n = 10, 50%), relaxation exercises
(n = 9, 45%), guided imagery (n = 12, 60%), visualization
(n = 15, 75%), and observation of children—a technique
sometimes used to remind survivors of their vulnerabilities given their age at the time of the abuse (n = 3, 15%).
Recruitment of Therapists and Participants
Four White, female therapists were chosen to participate in the current study because of their clinical skills
and experience, which ranged from 2.5 to 24 years, working with sexual abuse survivors. Two of the therapists had
master’s degrees in social work, and the other two had
master’s degrees in psychology. Before treating any participants, each of the therapists completed level-two
(advanced) EMDR training, (which has subsequently
been enhanced and changed to Part I and II). After completion of the training, the PI interviewed each therapist,
prior to them providing treatment in the study, to determine existing pretreatment biases. One of the therapists
was positively biased toward the method, one was
extremely skeptical to the point of being negatively
biased against the method, and the other two therapists
were viewed as neutral. Although fidelity checks, which
were conducted during the study, revealed that each therapist adequately administered EMDR, the skeptical therapist had the highest rating for accurately administering
it, and the positively biased therapist had the lowest rating. The skeptic in the group is a coauthor of this article.
Each therapist provided treatment to five survivors randomly assigned to receive EMDR and five randomly
assigned to receive eclectic therapy.
Newspaper ads and flyers to agencies and clinicians in
central Texas were used to recruit participants into the
study. Although it would have been valuable to have a
mixed gender study, only adult women were recruited.
This decision was made primarily based on concerns
about the difficulties involved in recruiting a sufficient
number of male survivors to allow for meaningful statistical comparisons based on gender. Given the greater prevalence of childhood sexual abuse among women, the continued social stigma that makes it difficult for male
survivors to come forward, and the time constraints of an
unfunded dissertation, the successful recruitment and
inclusion of men did not seem feasible. Moreover, maleonly and mixed-gender EMDR studies appear throughout
the literature with no noted differences in outcomes based
on gender.
Each potential participant was screened for eligibility
via a telephone interview, which was followed by a 90minute in-person office interview. Eligibility criteria
included being an adult female survivor of childhood
sexual abuse with no previous exposure to EMDR, no
concurrent therapy, and no contraindications for use of
EMDR (ocular problems, serious medical condition,
active suicidal ideation, inadequate ego strength, or se-
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Edmond et al. / EMDR AND ECLECTIC THERAPY 263
vere mental disorders such as psychosis). Of the 83 potential participants who expressed interest in participating,
59 met selection criteria. Each potential participant was
given an overview of the research design, as well as a
description of EMDR and eclectic therapy. All of the
potential participants were informed that the Internal
Review Board (IRB) of the University of Texas at Austin
had approved the study. Two separate consent forms were
obtained from the participants, one to participate in the
study and another to audiotape the qualitative interviews.
Participant Characteristics
With respect to the overall sample (N = 59), the survivors were predominately White (85%) with a mean age of
35 years (SD = 7.95; range = 18 to 51). Of the women of
color in the study (15%), 2 self-identified as African
American, 1 as Hispanic, 1 as Asian, 1 as Pacific Islander,
1 as Finno-Ugaric (Finland), 1 as Russian Jewish, 1 as
Lebanese, and 1 as Racially Mixed. The participants were
highly educated, with years of education obtained ranging from 11 to 17 and with a mean of 15. The majority of
the participants were employed full-time (62%) with an
additional 15.5% working part-time. The mean household income for the sample was $29,178. In terms of relationship status, 36% were married, 24% were single, 20%
were divorced, 17% were living with a significant other,
and 3% were widowed. Slightly less than one half (45%)
the participants had children.
The women in the study reported severe sexual abuse
histories that on average began at the age of 6½ and ended
at age 13. For 61% of the survivors, the sexual abuse
occurred between three and four times a month to three to
five times a week. Nearly one half (49%) endured the
abuse for 5 or more years, and 48% of the women were
molested over time by multiple perpetrators, the vast
majority of whom were male family members (biological
fathers 42%, grandfathers 24%, brothers 23%, uncles
15%, and stepfathers 12%). Most of the women (58%)
were physically abused within their family of origin, and
even more (66%) experienced physical and sexual
revictimization in adulthood. Of the survivors, 90% (n =
52) had received some type of therapy focused on the sexual abuse issues prior to participating in the study. In addition, 89% of the survivors (n = 53) had obtained some
type of therapy not focused on the sexual abuse.
Instruments
The primary outcome measures used were (a) the State
Anxiety scale of the State-Trait Anxiety Inventory (STAI;
Spielberger, Gorsuch, Lushene, Vagg, & Jacobs, 1983),
which assesses anxiety related to any specific issue of
concern; (b) the Impact of Events Scale (IES; Horowitz,
Wilner, & Alvarez, 1979) that assesses post-traumatic
stress symptoms for any specific trauma; (c) the Beck
Depression Inventory (BDI; Beck & Steer, 1993); and (d)
the Belief Inventory (BI; Jehu, Gazan, & Klassen, 1985),
which identifies and measures common distorted beliefs
among adult survivors of childhood sexual abuse (for a
detailed description of the psychometrics of these instruments please see Edmond et al., 1999). The PI at pretest,
posttest, the 3-month follow-up, and the 18-month follow-up administered each of these measures for all three,
treatment conditions.
In addition, two subjective in-session process measures were used in the study, the SUDs and the VoC.
These instruments are part of the standard administration
of EMDR and have been used in numerous EMDR studies as one method of measuring reported change. The
SUDs (Wolpe, 1990) is a 10-point scale used to obtain a
verbal report from a subject about one’s level of emotional disturbance associated with a specific traumatic
experience. It is a scale that is routinely used in systematic
desensitization with the goal of bringing the score down
to a zero or one (Lohr, Kleinknecht, Conley, et al., 1992).
This measure was taken at pretest and posttest, by their
individual therapist, and by the PI at the 3-month and 18month follow-ups for the EMDR and the eclectic
treatment conditions only.
The VoC is a semantic differential scale, ranging from
1 (completely false) to 7 (completely true), used to rapidly
assess the client’s cognitive beliefs associated with the
trauma. It relies on client verbal self-report before and
during administration of the EMDR procedure (Shapiro,
1989). A rating of 6 or 7 is considered to be a strong indication that significant positive cognitive restructuring has
occurred. This measure was taken at pretest and posttest
by their individual therapist, and by the PI at the 3-month
and the 18-month follow-ups for the EMDR and the
eclectic treatment conditions only.
Quantitative Results
Results of the quantitative analysis (MANOVA) revealed that there were statistically significant betweengroup differences (EMDR, eclectic therapy, and control)
at posttest (n = 59; Pillais = .399; F = 3.37; p < .01). Using
Wilks’s lambda (1.0 – .614) it was determined that 39% of
the variance in the dependent variables (STAI, BDI, IES,
and BI scores) at posttest were accounted for by treatment
condition, which is indicative of large treatment effects.
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EMDR produced a composite effect size (ES) of 1.46.
EMDR was significantly better than the control group on
all four objective measures, and eclectic therapy was significantly better than the control group on three of the
four measures. Although the control group survivors’
level of anxiety, depression, post-traumatic stress symptoms and negative beliefs about their abuse were virtually
unchanged from pretest to posttest, the survivors who
received EMDR or eclectic therapy experienced statistically and clinically significant reductions in trauma
symptoms. The results indicated that both treatments
were effective, however there were no significant differences on the objective measures in the effectiveness
between EMDR and eclectic therapy at posttest, a finding
not uncommon in intervention studies, and consistent
with those found in recent EMDR studies involving comparisons to cognitive-behavioral treatments (Ironson
et al., 2002; Lee et al., 2002; Power et al., 2002). However, a statistically significant difference (n = 59; Pillais =
.341; F = 9.32; p < .001) between EMDR and eclectic
therapy was found on the subjective process measures at
posttest, and Wilks’s lambda (1.0 – .659) revealed that
34% of the variance in the dependent variables (SUDs
and VoC scores) was accounted for by treatment condition. On the subjective measures, EMDR produced a
composite ES of 1.36. In addition, 65% of the EMDR
group versus 25% of the eclectic group reported scores
indicative of trauma resolution. Thus, based on data from
the subjective measures, a significantly (p < .05) higher
number of EMDR than eclectic group members reported
resolution of their targeted memories or issues at posttest.
For a detailed description of the results see Edmond et al.,
(1999).
The lack of statistically significant differences between EMDR and eclectic therapy on the standardized
measures at posttest, although significant differences
were found on the subjective measures, generates questions regarding the true impact of either treatment. The
analysis of the qualitative semistructured interviews conducted with the survivors who received EMDR and eclectic therapy provides an opportunity to gain deeper insight
into the effectiveness of each treatment from the perspective of the survivors.
QUALITATIVE METHOD
Qualitative Design
The PI constructed a Client’s Perceptions Questionnaire as a semistructured interview schedule with 14
open-ended questions. The interview schedule contained
questions that were created to solicit detailed information
about survivors’ perceptions of the type of therapy they
received in the current study. In particular, we were interested in the survivors’ perceptions of effectiveness. Participants were asked, “How are you doing now as compared to when you entered the study?” “In what way if
any was the therapy helpful to you?” “Did it have any
effect on the issues that you wanted to address?” If they
answered in the affirmative they were asked, “do you
think that the benefits gained will be lasting?” “Do you
think you will need more therapy to resolve your sexual
abuse issues?” “What are your thoughts/feelings about
your therapist?” “How did the therapy that you received
in the study compare to other therapy or counseling that
you have received?” “What did you like or value the most
about the therapy you received?” What did you dislike or
find least valuable about the therapy you received?”
The PI, who had not been involved in the provision of
any treatments, but had completed the screening and testing interviews, conducted tape-recorded interviews with
the 40 research participants who received either EMDR
or eclectic therapy. The nature of the interviews required
disclosures about the type of therapy received, which precluded the possibility of the interviewer being blind to the
treatment condition. Of the 40 interviews, only 38 tapes
could be analyzed. Two of the tapes were inaudible, and
the corresponding field notes insufficient for a full analysis. Of the 38 interviews that could be used, 18 involved
survivors who received EMDR and 20 who received
eclectic therapy. Each taped interview lasted from 20 to
50 minutes. All participants provided informed consent
to audiotape the interviews. Given that the interviews
contained specific information about the type of therapy
that each participant received, the person conducing the
qualitative analysis could not be blind to their treatment
condition.
This was unfunded research; resources, consequently,
were limited, which required that the three coauthors conduct all tasks related to the qualitative aspects of the study.
Because the first two authors were involved in several
aspects of the parent study, only the third author was
allowed to be involved in the coding and qualitative data
analysis to increase reliability by reducing potential
researcher bias. This was seen by the research team as the
best option available because the third author was not
involved in the provision of treatment, qualitative interviewing, or in the quantitative analysis of the data from
the parent study. In fact, she had no knowledge about the
outcomes of the parent study, and no prior exposure or
training in EMDR before beginning the qualitative data
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Edmond et al. / EMDR AND ECLECTIC THERAPY 265
analysis, creating the potential for a more reliable, less
biased interpretation of the data. Reliability and validity
were further strengthened in the qualitative analysis by
the use of a structured five-stage analysis process originally described by McCracken (1988). In addition, the
mixed-methods approach allowed for triangulation of the
qualitative data with the quantitative data, as reported in
the findings and the discussion, and the results were
consistent.
The third author manually coded the interviews from
transcripts or directly from the interview tapes, and the
codes were then analyzed in increasingly higher levels of
generality moving from individual utterances to observations, themes, and finally patterns present in more than
one interview. More specifically, in Stage 1 of the procedure, the researcher pays attention to the fine details of the
interview or simply observes the individual utterances
from each transcript. The second stage takes these individual observations and further develops them within the
context of the entire transcript. Stage 3 moves the analysis
to the next level where the researcher expands the scope
and looks for the presence of interconnected observations
across all interviews. Stage 4 begins a process where patterns or themes across the interviews are more clearly
defined and judgments are made about the most significant or strongly supported themes present in the data. In
the fifth stage of the process, themes from each interview
are developed into theses (McCracken, 1988).
The data analysis process began with the researcher
listening to and transcribing the audiotapes to get a general sense of the data. She had a copy of the interview
questions (the most relevant of which are listed above),
which she used as the initial coding guide. In Stages 2
and 3, eight coding categories emerged: (a) relationship
with the therapist and its ties to reports of success; (b)
change experienced (interpersonal, intrapersonal, mood/
emotional, and physical); (c) nature of change (deep or
day-to-day coping); (d) responsibility for change (self or
other); (e) finished with therapy for this issue (yes/no);
(f) got what you needed (or not); (g) level of functioning expressed; and (h) willingness to use the therapy
again (or not).
In Stages 4 and 5, three major theses or major codes
developed from the analysis: relational significance,
nature of changes, and finished. In the Findings section,
data regarding relational significance is reported under
the heading of client-therapist relationship, the phrase
nature of change was retained and used as a heading to
report the data related to that theme, and the data related
to finished can be found under the heading of Perceived
Need for Additional Therapy.
FINDINGS
In presenting the qualitative findings, several direct
quotes from the survivors are used. Effort was made to
include as many voices as possible, so as to not overrely
on the experience or perspective of a few participants. A
participant code will be used to differentiate each respondent. For the sake of brevity, ET will reflect eclectic therapy and EM will represent EMDR. The corresponding
numbers represent the code number assigned to them in
the parent study. Analyses of the qualitative data revealed
two major differences in survivors’ perceptions of the
outcomes achieved by EMDR and eclectic therapy. There
were substantial distinctions between the two treatment
groups in terms of the importance and effect of the clienttherapist relationship, and in terms of the depth of change
reportedly caused by the different therapies.
Client-Therapist Relationship
The women who received eclectic therapy placed
much more importance on the relationship between the
client and the therapist than did those who received
EMDR. The entire eclectic group (n = 20) either fully or
partially attributed the success of their therapy to their
relationship with their therapist. This is evident in the way
the survivors in the eclectic group talked about their therapeutic gains in connection to the support, acceptance,
validation, and nonjudgment that they received from their
therapist:
Support
ET Participant 19: For me, just literally having somebody who
wants to sit and listen to me for an hour and values my time
(tearful) and my sharing enough to be grateful that I’m doing it,
is very supportive, very healing.
Acceptance
ET Participant 50: I feel like one of the main things I got from just
being with her [therapist] was just—she was a constant reminder to be a lot more compassionate with myself and I think
that just doing that has already helped the focal issue I came in
with.
Acceptance and Nonjudgment
ET Participant 26: We bonded in a way on a personal level so it
made it easier for me to disclose a lot of really horrible things
about the abuse and I think that above all helped me gain a lot of
what I gained from the treatment and from the eclectic therapy.
Acceptance and Nonjudgment
ET Participant 16: Because [she] approaches me the way she does,
I feel like I can tell her anything and it’s ok. There’s nothing so
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bad that I couldn’t tell her and she couldn’t help me with it. I feel
like I have gotten through the worst of the shame. I thought I
could never even express it and [I did, and] the world didn’t fall
apart. In fact, it makes me stronger by expressing [it].
Validation
ET Participant 20: And, I think that one of the most significant
things for me too was [her] validation of my feelings which was
in a strange sort of way a revelation for me to come in and say
that I had trouble with anger and to have her listen to me and say,
“well it sounds like you have a lot to be angry about” was a really profound thing for me to have somebody say you have a
right to be angry.
Although the importance and healing nature of the clienttherapist relationship in therapy is supported in the literature
(Corey, 1996) and abundantly apparent in the comments of the
survivors who received eclectic therapy, it is absent among
those who received EMDR. The survivors who received
EMDR rarely mentioned their therapist unless directly asked.
In addition, although all of the women who received EMDR
spoke highly of their therapist, they did not attribute the success
they experienced in therapy to either the personal qualities of
the therapist or to the therapeutic relationship, but rather to
the technical EMDR process and/or to how well the respective
therapist followed the procedural protocols. When the
survivors who received EMDR talked about their experience in
therapy, they said such things as:
EM Participant 17: I would have to say that it probably was the
method because I did meet with [the therapist] one time after
the six sessions and it was different. I think it was being so focused, both of us, you know on the memories or pictures and I
think it probably was the method—there was something about
the method that created an intensity I guess . . . its like it brought
back the feeling of what was happening at the time that memory
took place so I think it probably was the method and also because there was this protocol that she followed and so it was like
I said it was really focused and you were kept very on task.
EM Participant 1: She was very bold. She knew it [EMDR] very
well. I think she is an advanced EMDR specialist or something
like that. She is good because if one angle wouldn’t work she’d
try a different angle. And, not just with the finger movement,
the hand movement, the terminology, the words she would use
to help me weave into what ever was going on.
Given that more than 90% of the survivors in the study had
received prior therapy, it is very likely that they came into the
study with expectations of the therapeutic relationship. The absence of the expected relationship ties was not lost on some of
those who received EMDR:
EM Participant 48: Unfortunately because of the EMDR process, I
don’t feel I got to know her (therapist) as well as I would have if
it was a regular therapist-client. That intimacy—you don’t develop that intimacy [in EMDR]. . . . and, in traditional therapy
you are also influenced a lot by what you think your therapist
wants, but with EMDR, [she] was almost just like a hand.
EM Participant 35: I would want to use it (EMDR in the future) in
combination with being able to talk a bit more—you know
sometimes it’d get on my nerves—I’d want to keep talking.
Nature of Change
The second major finding from the qualitative analysis
was that survivors who received EMDR and eclectic therapy differed in their perceptions and descriptions of the
nature of the therapeutic changes they reported. Survivors
from both treatment groups indicated that they had made
significant improvements. Their subjective perceptions
are supported by statistically and clinically significant
findings in the quantitative analysis. However, although
the descriptions from the survivors in the eclectic group
tended to reflect improvements in their overall ability to
cope with the effects of their childhood sexual abuse, the
EMDR group described making changes on a deeper,
more profound level indicative of trauma resolution.
Changes Attributed to Eclectic Therapy
The theme of coping with the abuse was evident in the
direct references that the survivors in the eclectic group
made to developing and using coping skills, as well as in
the more general way they reported improvements in
mood, behavior, and overall functioning. There were indications that eclectic therapy “kept [problems] to manageable levels.” Survivors reported learning about and
using a variety of techniques such as imagery, relaxation,
as well as cognitive strategies to help them cope with the
ongoing traumatic effects of their sexual abuse.
ET Participant 6: I gathered tools, I learned some mechanisms on
how to feel better about myself; things I could do throughout the
week before I’d see her again.
ET Participant 13: (Eclectic therapy) gave me different ways to
look at things and different ways to approach issues—how to
make desired behavioral changes.
In terms of affect and behavior, survivors reported things
such as experiencing a reduction of negative feelings, feeling
more at ease with what happened to them, having better impulse control, and taking fewer medications. Numerous examples of the improvements in overall functioning that survivors,
who received eclectic therapy described were found.
ET Participant 34: I’ve been functioning better in my personal relationships and at work.
ET Participant 50: [My] self-esteem is probably generally better
too.
ET Participant 10: I think before I was just surviving, and now I feel
like I can do this and enjoy life and be happy and joyful. Smile
more.
ET Participant 6: I think I have moments where, yes, I’m hyper critical and I blame myself for whatever’s going on. These are just
moments though instead of it being an overriding thought. I always thought that it didn’t matter, “I’m not good anyway, I’m
bad.” And, I don’t have that any more.
ET Participant 39: (I) feel more at ease with the things that happened to me.
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ET Participant 27: And now the panic is gone, and there is like fear
and revulsion but not the immobilizing kind—so now I’m
aware that I can act on my own behalf.
ET Participant 2: I think it’s for me very exciting not to have the
nightmare—to feel more in control in a positive way, and to be
able to really experience some happiness for the first time in a
while and not see everything through this fog.
The significance of the changes experienced by the
survivors who received eclectic therapy was also evident
in the way in which they talked about issues of personal
empowerment, which occurred with far more frequency
in the eclectic group than in the EMDR group. Furthermore, the skills learned in eclectic therapy along with the
self-esteem boost of a supportive therapeutic relationship
seemed to leave this group of survivors feeling more responsible for their own change, within themselves, as
well as in their environments.
Another interesting observation with the survivors
who received eclectic therapy was the language they used
when discussing the change they experienced. The terms
were quite revealing. They are better, can deal with it, feel
things are more manageable, experience a reduction or
have fewer or less of whatever emotions they do not want
to feel.
Their therapy may have been a healing experience,
however they do not yet seem healed. The survivors appear to have experienced important changes, however at
the core of their being, they clearly have not gotten over
the abuse they suffered as children. Despite the many
and varied positive changes reported, a number of survivors seemed disappointed in the lack of change they
experienced.
ET Participant 25: I think a lot of things are basically the same. I’ve
just been reminded of some tools I can use to help communicate, and tools to use to diffuse and make myself feel better. I
kind of feel like all the problems are still there. All the issues are
still present and not resolved.
ET Participant 20: I don’t feel less angry. I’m not really having any
different kind of responses to the stimuli that makes me angry or
anything like that but I’m definitely working at trying to make
some changes that way instead of going, “Gosh, I’m getting angry and it’s a drag”; I’m looking for some solutions.
ET Participant 51: While it’s (eclectic therapy) able to keep things
bearable, it doesn’t solve them.
Changes Attributed to EMDR
In contrast to the type of changes described by the survivors who received eclectic therapy, the survivors who
received EMDR seem to have made changes on a deeper,
more profound level. A useful analogy reported by one of
the EMDR recipients is that of an onion. She reports that
“instead of working from the outside layers of an onion to
reach the core inside as traditional therapy does, EMDR
allows you to go straight to the core, resolve the issue, and
lets the changes reverberate through the onion effecting
all the outer layers” (EM Participant 53). The women who
received EMDR described this type of core change in a
number of different ways. The following illustration is
reflective of what was described by several others:
EM Participant 1: I think it goes right to the cellular level so for me
like I said it goes deeper than talking about it or even sometimes
doing the sadness or the anger around the issues because it goes
to the core, it goes right to the core, and it like releases that core
so that if there’s any residue of anything else, for example, with
me I felt much more confident, yea much more confident about
my boundaries so for me it was like I scooped it all out and
tossed [it] aside, because I don’t have to have it there any more
so to speak.
Cessation of disagreeable feelings. One example of the type
of core change frequently described by survivors who received
EMDR was a cessation of feelings associated with the sexual
abuse. This was reported on a continuum of complete loss of
feelings associated with the abuse to a change in the level of
power the feelings have over everyday life and relationships.
EM Participant 22: I just almost have no feelings about it. It’s not
like I have happy feelings now, I just have no feelings about it.
I’m not even angry about it. I don’t know why, and I don’t care
why. It’s not my worry.
EM Participant 31: By doing the first incident with my stepfather,
all we did was one time, but I’m actually able to sit here right
now and say that, all of that for two and a half years of it, it just
simply does not cause me pain to think about it at all. It doesn’t
cause me pain for any of it [which is] just totally amazing. I almost feel like, not that it didn’t happen, I mean I know it happened but I feel very relieved because I don’t have to carry
around the pain of it, and I don’t have to carry around the weight
of it.
EM Participant 46: But I can say for myself that it broke something
loose—I tried to get mad at dad, but I couldn’t.
EM Participant 17: When I sit and think about what was bothering
me when I came in (to EMDR therapy) I’m not concerned about
that now, and I’m not thinking about it—I’m not having pictures
of it. . . . I can think of that picture and not feel particularly
stirred up about it.
EM Participant 22: Other things continue to come up, but I’m not
affected to the magnitude as before—a fleeting thought as compared to being consumed.
EM Participant 1: It feels like it’s no longer a heavy memory that I
don’t want to look at. I’ve looked at it and I’ve felt it and I’ve
shifted, and it’s not there any more. [It] doesn’t have the control
over me like it did.
These types of statements reflecting a cessation of
trauma-specific emotional distress did not come out in the
interviews with the survivors who received eclectic
therapy.
Perceptual shifts in self and others. No less significant is the
second area of change reported by the survivors who received
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EMDR: shifts in the perception of self and others. Survivors
reported getting rid of the guilt and feelings of responsibility
for the abuse they experienced as children. They reported that
the loss of guilt was strongly associated with the progress they
made through EMDR. These perceptual shifts also relate to the
core-level changes the survivors associated with EMDR. They
were reported as pervasive changes in how they see, interpret
and understand their childhood abuse. One woman used an
analogy of being afraid of the “boogie man” in the dark and that
“EMDR turns on the light so you can see things clearly and see
that there is nothing to be frightened of” (EM Participant 30).
She also talked about how the EMDR caused a paradigm shift
for her and that she moved from a level of unawareness that was
transformed to awareness. She indicated that EMDR reframed
her beliefs, which is what made it so successful for her. Another
woman reported that somehow the EMDR shifted images to
earlier images to get to the origin of the shame and other feelings associated with her abuse. She stated that she, “realized
that it [the abuse] was not my fault at all” and that her “shame is
gone” (EM Participant 29). Another woman’s analysis was
“It’s like a cleaning of the mind so you can focus and see things
how they really were” (EM Participant 54). This woman also
reported seeing her childhood from a different perspective, that
her parents’ problems are not her own, which relieved her guilt
and changed her belief systems about the abuse. Yet another
participant simply reported, “I just see the world differently. It
looks brighter” (EM Participant 33).
Again, these types of statements of change, of perceptual shifts were not present in the descriptions of change
provided by those survivors who received eclectic
therapy.
Other EMDR recipients reported similar perceptual
changes:
In this study, a qualitative analysis was used to compare the perceptions of treatment effectiveness reported
by adult female survivors of childhood sexual abuse who
received one of two different treatment approaches for
resolving psychological trauma—EMDR and eclectic
therapy. The analysis revealed meaningful differences
between the two groups in terms of the importance of the
relationship between the therapist and client, and in the
nature of the therapeutic changes experienced. Each of
these findings warrants further consideration and is discussed. First, however, it is worth mentioning, that
despite those qualitative differences, both groups of survivors reported comparable levels of satisfaction with
their treatment.
The Client Satisfaction Questionnaire-8 (Attkisson &
Greenfield, 1994), which has a scoring range of 8 to 32,
was administered at posttest and at a 3-month follow-up
with each participant. At posttest, the EMDR group mean
of 29.75 was slightly higher than the eclectic group mean
of 29, however the difference was not significant. Similarly at the 3-month follow-up, the EMDR group mean
was 30.5 and the eclectic group mean was 28.5, which
again was not significant. Survivors from both groups
were highly satisfied with the treatment they received in
the current study, and that satisfaction was maintained
over a 3-month time period.
EM Participant 31: I feel much more that decisions that I make are
not being influenced by anything that has happened in the past,
and that’s really important to me to be able to make decisions
based on reality instead of false perceptions of things from the
past.
EM Participant 48: I had kind of reached a point where that [traditional therapy] had gotten me so far but I couldn’t get beyond a
certain point, and EMDR helped bring everything together for
me. It kind of helped me understand everything I had been
through before and kind of put it in a place and processed it.
EM Participant 49: The something that shifted is a more concrete
sense of self apart from what was happening around me. It is
actually the ability to perceive that there is a difference between
what’s being done to me and who I am. There is a part of me
that I now know was separate from what was happening to
me . . . what happened to me didn’t happen to me because I deserved it or I’m bad or I asked for it. It’s much clearer and [I
have] much more solid knowledge that it happened to me because I happened to be there, a kind of accident of birth and
place.
EM Participant 53: I feel like the information we were accessing
was changing me, or it was either resolving or changing or doing something at a core level that would then allow me to get the
things that I needed in my life, or to self-actualize or become
who I’m destined to become in my life.
EM Participant 47: It (the abuse) has totally changed. I can accept
myself for who I am and I can accept what happened and I don’t
judge myself any more.
Perceived need for additional therapy. A further indication
that the change produced by EMDR occurs at a deeper level,
than that which is produced by eclectic therapy, can be found in
the reported difference in perceived need for additional therapy.
Among the survivors who received EMDR, one half (n = 9)
reported feeling that they had completely resolved their sexual
abuse issues and did not think that they would need further therapy for it. They made statements such as: “Right now I feel real
concluded. I’ve done a lot of work before and with this, it feels
[like] a real conclusion.” “It gets done quick and it really does
get done.” “Feels totally resolved.” Of the remaining survivors
who received EMDR (n = 9), five women were unsure of
whether they would need additional therapy for the sexual
abuse issues, while only four felt certain that they would. Those
findings contrast sharply to the responses of the survivors who
received eclectic therapy, all of whom (n = 20) reported that
they had not resolved their sexual abuse issues and would therefore need more therapy.
DISCUSSION AND APPLICATIONS
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Edmond et al. / EMDR AND ECLECTIC THERAPY 269
Although the survivors who received eclectic therapy
associated their success, in part or in whole, to the relationship with their therapist, the survivors who received
EMDR did not. One is immediately drawn to the question
of why such a difference would emerge. One possible
explanation can be found in Shapiro’s book where she
describes EMDR as an inherently client-centered
approach that emphasizes the client’s innate capacity to
heal through the activation of a physiological adaptive
information processing mechanism that requires “minimal clinician intrusion” (Shapiro, 2001, p. 18). This does
not, however, negate the significance of a strong therapeutic alliance. Indeed, Shapiro (2001) talked about the
importance of developing rapport, facilitating bonding,
and establishing “a firm therapeutic alliance” (p. 122).
In eclectic treatment, the therapists were teaching the
survivors techniques to cope with their symptoms, to
make them more manageable, which may have contributed to the survivors’ perceptions of the therapist as responsible for the effects. In EMDR, the therapists activated the adaptive information processing mechanism
through the EMDR protocol and followed the client’s
process to a point of resolution, perhaps instilling a
greater sense of self-efficacy.
One possible benefit of a difference in the significance
of the client-therapist relationship in EMDR is the potential for less transference-countertransference to enter into
the trauma resolution process. Given the often, interpersonal nature of trauma-inducing events, a reduction in
issues related to transference could also potentially result
in a more rapid recovery by reducing emotional harm or
conflict in the treatment. Clearly much more needs to be
explored to understand this treatment difference and its
implications for trauma resolution.
The second finding in the study is particularly salient
given our interest in survivors’ perceptions of the effectiveness of the treatments received. Although those who
received eclectic therapy reported positive clinical
changes, they tended to be improvements in their ability
to cope with their abuse, whereas those who received
EMDR reported changes that ranged from a complete
eradication of the issues to major changes in their perceptions of self and others.
The claim of complete eradication is particularly compelling. This would reflect trauma resolution, the holy
grail of desired clinical outcomes. Given the importance
and implications of such a finding, it would be helpful to
triangulate the data, which requires revisiting the quantitative findings. In the parent study, two subjective process
measures were used in EMDR and eclectic therapy to
assess emotional distress and desired cognitions—the
SUDs and the VoC. These measures are used in EMDR as
a way to gauge whether the targeted issue has reached a
point of adaptive resolution. They were incorporated into
the eclectic treatment protocol to have consistency in
measurement across treatments. Both groups were exposed to an equal number of in-session measurements, so
difference in outcomes cannot be attributed to demand
characteristics.
As indicated earlier in this article, at posttest 65% of
those who received EMDR had scores indicative of
trauma resolution compared to 25% of those who received eclectic therapy. At a 3-month follow-up, although
61% of those who received EMDR reported scores indicative of trauma resolution, the number in the eclectic
group dropped in half to 12.5% (Edmond et al., 1999). At
18 months posttreatment, 57% of those who received
EMDR still had scores reflective of trauma resolution
whereas none of those who received eclectic therapy did.
Furthermore, the 3- and 18-month follow-ups indicate
that the resolution held over time, which would be expected if the survivors’ perceptions of effectiveness at
posttest were accurate.
In the qualitative interviews, one half of survivors (n =
9) who received EMDR reported feeling completely
resolved, five were unsure whether they would need additional therapy, and four felt certain that they would.
Whereas all of those in the eclectic group reported that
they had not resolved their sexual abuse issues and would
need subsequent therapy. These numbers are very similar
to the quantitative data found in the SUDs and VoC scales,
which shows consistency across two different forms of
subjective measurement.
Another way of triangulating the claim of trauma resolution is to look at the actual amount of subsequent therapy obtained in the 18 months after the completion of the
parent study. (It should be noted that as a result of attrition, the 18-month follow-up included 17 survivors who
received eclectic therapy and 14 who received EMDR.)
Eleven of the survivors who received eclectic therapy and
8 who received EMDR obtained subsequent therapy after
the study ended. This reveals that a smaller number of
survivors sought subsequent therapy than had been anticipated through the qualitative interviews. Although all
the survivors who received eclectic therapy indicated a
need for additional therapy, only 11 obtained it, making
the difference between the two treatment groups minimal
(11 vs. 8). Only 6 survivors from each of the two treatment groups (n = 12) did not receive subsequent therapy.
Quantitative analysis revealed that there were no statistically significant differences between the two treatment
groups in terms of subsequent therapy obtained. How-
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ever, there were some notable qualitative differences
worth mentioning. Nine of the survivors who received
eclectic therapy reported that they focused on the same
target issue in their subsequent therapy as they had in the
study. This is a clear indication that the target issue had
not been adequately resolved. This was the case for only
one of the survivors who received EMDR. Unfortunately,
data was only collected on whether they had focused on
the same target issue so it is not possible to describe the
treatment focus of the other survivors from the EMDR
group. Furthermore, those who received EMDR but
obtained subsequent therapy obtained on average a
smaller number of sessions (6 vs. 20) than those who
received eclectic therapy. This data is also consistent with
the survivors’ perceptions of trauma resolution and their
perceived need for subsequent therapy, providing additional support for the claim that a meaningful clinical
difference exists between the two treatment conditions in
terms of trauma resolution.
The current study provides a unique contribution to
understanding the effectiveness of EMDR in treating psychological trauma in adult female survivors of childhood
sexual abuse. The data indicate that survivors experience
a deeper sense of trauma resolution with EMDR than is
found among those who receive eclectic therapy. Lest
there be an assumption of bias in favor of EMDR, it
should be noted that the authors of this article came to this
work with varying degrees of knowledge and skepticism
about EMDR. The PI conducted the parent study as her
dissertation research, which she initiated from a standpoint of skeptic. One of the coauthors of this article was
one of the therapists in the study and, as indicated earlier,
was found to be the most skeptical therapist, but also the
one with the highest treatment fidelity score. The third
author had no prior knowledge or exposure to EMDR
before conducting the qualitative analysis. We believe
that our starting points in this research endeavor add an
important layer of objectivity and reliability to our findings. This is not stated to privilege objective over subjective ways of knowing, but to preemptively address potential assertions that we are EMDR proponents who found
what we were looking for in the data to confirm what we
wanted to see. This is an especially important point considering that resource limitations resulted in only one person being involved in the qualitative coding and data
analysis, which prevented the use of interrater reliability
and represents the primary limitation of the current study.
This use of a second coder would have strengthened the
reliability of the qualitative data analysis but was simply
not feasible.
It is also important to mention that in the parent study
the survivors received only six sessions of therapy, which
were more sessions than had been provided in any EMDR
study at that point in time, but considerably less than what
has been traditionally used to treat survivors of childhood
sexual abuse. The fact that so many survivors sought therapy before and after the study indicates the need for longer term work, a point that clinicians should bear in mind
when developing treatment plans. In addition, for the purposes of the study, EMDR was used in isolation from
other treatment approaches when, in practice, it would
most likely be incorporated into other treatments, especially with survivors that suffer from complex trauma
reactions.
The findings generated by the qualitative analysis provide an opportunity to gain new insights into the experience of therapeutic change facilitated by two different
forms of therapy, insights unattainable through quantitative methods. Although employing strong experimental
designs is necessary and valuable when testing the effectiveness of interventions, much can be gained from listening directly to the voices of clients. The quantitative
findings indicated that both treatments yielded positive
clinically and statistically significant findings, yet the
qualitative findings indicate that those positive benefits
varied in meaningful ways not reflected in the quantitative findings. This would suggest that mixed-methods
approaches to evaluating interventions have more to offer
than either approach can provide individually. Given the
number of intervention studies that fail to find significant
differences between comparison treatments, researchers
should strongly consider adopting a mixed-methods approach. It would be interesting to see for example,
whether these findings would be replicated in a comparison between EMDR and PE or some other standardized
treatment. Perhaps through this process additional therapeutic outcomes of interest could be identified and used
to develop standardized measures that could capture indicators of treatment effectiveness currently not being
recognized.
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