Do Protocol Differences in Active Patient Participation Lead to Differences in Perceived Personal Control in the Present in Patients During Trauma Treatment with Imagery
Rescripting or EMDR?
Master Thesis in Clinical Psychology
Name: Iben Bøje
Student number: 9717722
Supervisor: Prof. Dr. A. R. Arntz Second reader:
Index Abstract 3 Introduction 4 Method 13 Participants 13 Measures 14 Interview measures 14 Self-report measures 16 Procedure 17
Design and recruitment 17
Assessment 18 Groups 19 Statistical analyses 21 Results 23 Equivalence of conditions 23 Results of analyses 24 Discussion 30 References 38 Appendix I 49 Appendix II 63
Abstract
Perceived personal control in the present has been seen to reduce symptoms in patients suffering from PTSD. In a study based on Boterhoven, Lee, Fassbinder, Voncken, Meewisse, Van Es, Menninga, Kousemaker, & Arntz (2017), it was tested whether, due to differences in protocols, Imagery Rescripting (ImRs) and Eye-Movement Desensitization and Reprocessing (EMDR) would differ in terms of the degree to which they enhance patients’ perceived personal control in the present. It was hypothesised that due to its protocol requiring a more active involvement by the patient during treatment, ImRs would enhance perceived personal control in patients to a greater degree than would EMDR or assignment to a waiting list. A total of 72 patients were divided over the three groups of the study, namely ImRs, EMDR, and waiting list. The ImRs and EMDR patients were assigned ad random to either condition, but the waiting list patients were not. The present study only used participants who completed therapy, and hence, no data was lost. The treatment consisted of a maximum of 12 therapy sessions, and assessment took place at set intervals. Statistical analysis was done using a mixed regression model, and results showed that whereas both treatment groups were more efficient than waiting list assigment in enhancing patients’ perceived personal control in the present, ImRs and EMDR did not differ. It is concluded that despite protocols differing in terms of active patient involvement, both treatments are effective when it comes to enhancing patients’ sense of perceived personal control in the present.
1. Introduction
By definition, Posttraumatic Stress Disorder (PTSD) is a severe condition: The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) mentions exposure to one or multiple traumatic events as a primary criterion for a PTSD diagnosis (American Psychiatric Association, 2013). The core symptoms of the illness are
re-experiencing of the traumatic incident, avoidance and numbing, negative changes in thought and mood, and increased arousal (American Psychiatric Association, 2013). The
consequences of suffering from PTSD are far-reaching: duration of the symptoms may vary from three months to several decades, and patients experience serious impairment in social, relational, and professional areas of life (American Psychiatric Association, 2013). In
addition, according to a recent meta-analysis, PTSD is associated with a greater frequency in pain-related complaints, as well as in cardio-respiratory and gastrointestinal diseases (Pacella et al., 2012). In the United States, the population prevalence is approximately 3.5%, and the lifetime prevalence is 8.7%, although prevalence differs among various professional groups and according to the type and intensity of the trauma (American Psychiatric Association, 2013). Due to the devastating consequences of the disorder, a vast amount of research has been conducted in order to attempt to uncover its causes, possible risk factors and any preventive measures (Brewin et al., 2000, Bisson, 2007). In addition, important steps have been taken in terms of developing effective, evidence-based trauma treatments (Bradley et al., 2005; Bisson et al., 2013; Jonas et al., 2013). Nevertheless, it is necessary to recognise the fact that no single treatment is universally effective, and furthermore, that patients differ in terms of the degree to which they perceive of a certain treatment as being tolerable (Bisson et al., 2013). Estimates of dropout from trauma therapy vary greatly across studies, but a recent
meta-analysis reports a general dropout of 18% (Imel et al., 2013). Whereas research has shown that it is difficult to use pre-treatment variables in order to predict dropout or treatment outcome (Van Minnen et al., 2000), it does seem as if individual patients differ in terms of which treatment they respond best to (Bradley et al., 2005; Arntz et al., 2007; Cloitre, 2009). Therefore, it is important to continue research on treatments for PTSD, in order improve the match between the individual and the most effective treatment. Research, then, should
concentrate not only on determining the efficacy of the various trauma treatments, but also on better understanding what differentiates treatments in terms of individual treatment outcome. The international random controlled trial (RCT) on which the present study is based, aims at broadening our knowledge of effective trauma treatments by comparing two protocolised treatments for PTSD in patients with childhood trauma, namely Eye-Movement
Desensitization and Reprocessing (EMDR) and Imagery Rescripting (ImRs), respectively (Boterhoven et al., 2017). In addition, the present study hopes to clarify a possible effect of protocol differences between the two treatments in terms of active patient involvement during therapy sessions.
Since its framing by Shapiro in 1995 (Shapiro, 1995), EMDR has been extensively researched, in terms of its efficacy as well as with regards to possible working mechanisms. Studies on treatments for PTSD consistently indicate that effect sizes of EMDR are
comparable to those of trauma-focused cognitive behavioural therapy (TFCBT) (Seidler & Wagner, 2006, Shapiro et al., 2012, Watts et al., 2013), and furthermore, that TFCBT and EMDR seem to be superior to other treatments for PTSD (Bisson et al., 2007). Although the efficacy of EMDR as a treatment has been demonstrated repeatedly and is by now generally acknowledged, there is still uncertainty as to exactly how and why it works (Van den Hout & Engelhard, 2012). During EMDR, the patient is asked to recall his or her traumatic memories, while at the same time visually tracking a moving object, such as a flickering light or the
therapist’s fingers. Although several theories have been proposed as to the working
mechanisms of EMDR, the most supported explanation is that of the working memory theory. This theory posits that aversive memories, held in the working memory during EMDR, are made less vivid and emotional due to the fact that working memory space is simultaneously occupied by a second task, e.g., the eye movements, and because during subsequent
reconsolidation, the aversive memory is stored in a less vivid form due to the dual task (Andrade et al., 1997; Van den Hout et al., 2001; Gunter & Bodner, 2008; Van den Hout & Engelhard, 2012). Additional support for the working memory theory is provided by research indicating that dual tasks other than tracking finger movements, such as auditory shadowing and drawing, yield similar results in terms of rendering autobiographical memories less vivid and emotional (Gunter & Bodner, 2008; Van den Hout & Engelhard, 2012).
Like EMDR, Imagery Rescripting (ImRs) applies the use of imagery to therapeutic purposes. Here, too, the patient is asked to recall and visualise traumatic events during sessions. ImRs differs from EMDR, however, in terms of the way in which the processing of emotional content takes place: whereas during EMDR, the processing is thought to occur by means of distraction by a dual task, during ImRs, the patient is asked to actively change the content of the traumatic imagery. Crucially, the idea behind this rescripting is not denying the fact that the traumatic event in fact took place, but instead, changing the significance of the traumatic memory to the patient (Arntz et al., 2007; Arntz, 2012). ImRs, then, may be aligned with information-processing theory, which states that fear information is stored in networks, and that fear reduction is accomplished by activation of the fear network by means of exposure, followed by the provision of information incompatible with the fear information (Foa & Kozak, 1986; Bouton, 1988; Foa & Kozak, 1999). In some ways, then, the rationale for ImRs resembles that of exposure theory. According to Arntz, Tiesema, and Kindt (2007), however, ImRs differs from exposure therapy in the sense that the latter merely reduces fear,
whereas ImRs offers the patient an opportunity to focus on other, possibly more pressing, post-trauma emotions such as anger, guilt or shame. This is important, they state, because during a traumatic experience, the victim is often forced to suppress acute feelings and action tendencies in order to survive the situation. Such inhibition may possibly lead to learned helplessness and to a disrupted view of oneself and of the world, and is it therefore crucial to recovery that the victim is offered a chance to vent their suppressed emotions and action tendencies (Arntz et al., 2007). In the first scientific article on the subject, ImRs is described as consisting of the elements of “imaginal exposure”, “cognitive restructuring”, and “mastery imagery” (Smucker et al., 1995). A central aim of the therapy, it is stated, is to empower victims of traumatic incidents by creating mastery imagery during rescripting, thereby challenging the imagery of victimisation (Smucker et al., 1995). An important striving of ImRs, then, besides reducing the impact of the trauma memory, is to allow victims of traumatic incidents to move beyond their feelings of helplessness and develop a sense of control and competency (Smucker et al., 1995; Arntz & Weertman, 1999; Holmes et al., 2007; Arntz et al., 2007; Brockman & Calvert, 2016). In addition, by focusing on a variety of emotions instead of solely on fear, ImRs may also promote change in dysfunctional schemas and self-perception (Smucker et al., 1995; Arntz & Weertman, 1999; Edwards, 2007;
Brockman & Calvert, 2016).
Compared to EMDR, less research has focused on ImRs, although during the last decade, there has been an increase in scientific articles on the subject. The use of imagery for therapeutic purposes has a longstanding tradition within various cultures (Edwards, 2007; Arntz, 2012), and the technique of imagery rescripting has important parallels to the work of Pierre Janet in the late nineteenth century (Edwards, 2007). However, only relatively recent articles by Smucker, Dancu, Foa and Niederee (1995) and Arntz and Weertman (1999) placed ImRs within a contemporary scientific framework. Initially, it was presented as an addition to
cognitive therapy (Holmes et al., 2007; Edwards, 2007), but today, it is being used increasingly as a stand-alone treatment as well (Wheatley et al., 2007; Arntz et al., 2013; Raabe et al., 2015). In terms of efficiency as a trauma-focused treatment, ImRs has elicited promising results (Arntz et al., 2007; Arntz et al., 2013; Raabe et al., 2015), and research indicates that it is at least as effective in treating patients with PTSD as prolonged exposure (Grunert et al., 2007) or CBT with prolonged exposure (Brockman & Calvert, 2016).
Furthermore, ImRs has proven effective for a great variety of other psychiatric disorders such as personality disorders (Arntz, 2011), depression (Brewin et al., 2009), social phobia (Frets et al., 2014), and obsessive compulsive disorder (Speckens et al., 2007). Importantly, research shows that compared to other trauma-focused treatments such as exposure therapy, ImRs seems to have less dropout and be better accepted among patients as well as among therapists (Arntz et al., 2007; Arntz et al., 2013; Brockman & Calvert, 2016).
Like EMDR, ImRs is a protocolised treatment, although protocols differ somewhat depending on the goals of therapy (Brockman & Calvert, 2016). Common to all protocols is the idea of the patient switching between themselves in the present and themselves as they were during the traumatic incident. Furthermore, the protocols involve rescripting of trauma imagery, done by either the therapist or by the patient themselves (Brockman & Calvert, 2016). In the version of the protocol used in the present study (see Appendix I) the rescripting was initially done by the therapist, but at mid-treatment, the patient was asked to take over. An important premise of the treatment, then, was active patient participation.
Whereas EMDR and ImRs have both proven effective in the treatment of PTSD, they obviously differ in terms of how they aim to bring about recovery. An important difference between the protocols of the two treatments is the degree to which the patient is asked to assume an active role during the treatment process. During EMDR, where the central active element is thought to consist of memory reprocessing, the role of the patient seems to be
rather passive in the sense that they are asked merely to remember the traumatic experience and visually track a moving object. Furthermore, although the EMDR protocol contains several phases for stabilisation of the patient, these are merely additions to the central idea of dual-task processing. During ImRs, on the other hand, cognitive reprocessing thought to be aided by the patient actively participating in the treatment by entering the visualisation of the traumatic experience and taking control of it. As mentioned above, an important aim of ImRs is to “replace victimization imagery with mastery imagery” (Smucker et al., 1995), and to “increase the sense of empowerment” in the patient (Arntz & Weertman, 1999).
In view of the DSM-5 criteria for PTSD, the difference between EMDR and ImRs in terms of offering the patient active control during therapy is interesting. According to the DSM-5, the primary criterion for being diagnosed with PTSD is that a person was exposed, directly or indirectly, to “death, threatened death, actual or threatened serious injury, or actual or threatened sexual violence” (American Psychiatric Association, 2013). Without exception, these are situations where one might feel an immense loss of control, and research has shown that feelings of helplessness may contribute to the development of PTSD (Foa et al., 1989; Roemer et al., 1998; Brewin et al., 2000; Maier, 2001; Rizvi et al., 2008; Declercq et al., 2011). In addition, studies indicate that people with PTSD feel less self-efficient and less in control than people without PTSD (Ginzburg et al., 2003; Pietrzak et al., 2009). Loss of control, then, appears to influence the development or aggravation of PTSD symptoms. Interestingly, on the other hand, feelings of empowerment and of being in control have been shown to reduce PTSD symptoms in victims of various sorts of trauma (Benight & Bandura, 2003; Frazier et al., 2004; Ullman et al., 2007; Najdowski & Ullman, 2009; Pietrzak et al., 2009; Larsen & Fitzgerald, 2011; Perez et al., 2012). Importantly, though, research shows that the positive effect on PTSD symptoms of empowerment and of feeling in control depends on the sort of control experienced by the individual, and with regards to traumatology, various
sorts of control have been studied (Kushner et al., 1993; Skinner, 1996; Frazier et al., 2002). One distinction which is often made is that between actual and perceived personal control: whereas actual personal control might influence the outcome of an event and is therefore vital to a person’s safety, the idea of perceived personal control represents the person’s belief that he or she is able to control the impact of the traumatic event on their life (Najdowski & Ullman, 2009). Whereas both sorts of control are relevant to trauma therapy, there is evidence that the perception of being in control is essential to diminishing the symptoms of PTSD and may in fact be a better predictor of psychological wellbeing than actual control (Foa et al., 1989; Skinner, 1996; Frazier et al., 2002; Benight & Bandura, 2003; Frazier et al., 2004). Perceived personal control is often conceptualised in a temporal framework, where a distinction is made between perceived personal control in the past (the victim’s beliefs regarding their degree of control during the traumatic event), in the present (the victim’s beliefs about their degree of control over their life in the present), and in the future (the victim’s beliefs about their ability to prevent the traumatic event from reoccurring) (Skinner, 1996; Frazier et al., 2002). Whereas the dimensions of past and future personal control render mixed results in terms of trauma recovery, perceived personal control in the present,
described as a feeling of currently being in control of one’s life, and especially of one’s treatment process, appears to be a very powerful concept with regards to diminishing PTSD symptoms, based on clinician-based as well as on self-rated judgments (Frazier et al, 2002; Frazier et al., 2004; Pietrzak et al., 2009; Ullman et al., 2009; Najdowski & Ullman, 2009; Larsen & Fitzgerald, 2011). Also, studies show that perceived personal control in the present can act as a protective factor for trauma victims (Ullman et al., 2007), and that it is part of the resilience protecting the individual from traumatic stress (Pietrzak et al., 2009; Pietrzak, 2010).
As mentioned before, the protocols of EMDR and ImRs differ in terms of the degree of required patient participant during therapy sessions. Whereas during EMDR, the patient seems to undergo the treatment relatively passively, during ImRs, they are expected to take active part in the rescripting of the traumatic event. Furthermore, whereas an explicit aim of ImRs is to empower the patient, this aim is not stated as such by the EMDR protocol. Due to these differences, it seems arguable that in the study by Boterhoven et al. (2017), the degree to which patients are rendered control during their recovery process differs between the two conditions. As a consequence, it is conceivable that patients in the two conditions may differ in terms of the degree to which they experience perceived personal control in the present during and after their treatment process. Because research shows that perceived personal control in the present positively influences recovery, it is important to consider whether inherent differences in protocols between EMDR and ImRs produce varying degrees of perceived personal control in patients. After all, considering the fact that a feeling of perceived personal control in the present has been seen to aid the reduction of PTSD symptoms, such inherent differences could influence the recovery process and cause differences in efficacy between the two treatments.
In the study by Boterhoven et al. (2017), EMDR and ImRs are compared in terms of their effectiveness as treatments for PTSD in 142 patients with childhood traumas. In each condition, the patient receives a maximum of 12 sessions, and progress is measured at set points of the study. The measurement points are at waiting list assignment (when treatment starts more than three weeks after inclusion), at pre-treatment (at no more than three weeks prior to treatment commencement), at mid-treatment (for certain questionnaires), at post-treatment (after post-treatment conclusion) and at two follow-ups (at eight weeks after post-treatment conclusion and at one year after treatment conclusion). Due to the more active patient involvement during ImRs, it is conceivable that patients having received ImRs might
experience a higher degree of perceived personal control in the present as a result of the treatment than might patients who have received EMDR. The present study, then, focused on the question of whether, in the study by Boterhoven et al. (2017), patients with PTSD having received treatment with ImRs would experience a higher degree of perceived personal control in the present than would patients with PTSD having received treatment with EMDR, or having been assigned to a waiting list. It was hypothesised that at post-treatment, at treatment cessation, patients in the ImRs group would experience a higher degree of perceived personal control in the present than would the patients in the EMDR and waiting list groups. Also, it was hypothesised that from post-treatment, at treatment conclusion, to the first follow-up, eight weeks later, this effect would still be visible, and hence, patients in the ImRs group would still experience a higher degree of perceived personal control in the present than would patients in the EMDR group (patients in the waiting list group were not included in this comparison). Additionally, because control of the treatment process has been seen to be particularly powerful in terms of reducing PTSD symptoms (Frazier et al., 2002; Frazier et al., 2004; Najdowski & Ullman, 2009; Larsen & Fitzgerald, 2011), an attempt was made to locate a proximal measure for this concept within the study by Boterhoven et al. (2017). As a result, the degree of perceived helplessness during confrontation with past trauma imagery was measured. Confrontation with past trauma imagery represents an integral part of both therapy forms, and feelings of helplessness, or the lack thereof, during this procedure may be seen to mirror a patient’s perceived control of this part of the treatment process. Here, it was expected that at post-treatment, patients in the ImRs group would experience a lower degree of
perceived helplessness when confronted with past trauma imagery than would patients in the EMDR or waiting list groups, due to the more active role of the patient during ImRs than during EMDR. Also, it was expected that from post-treatment, at treatment cessation, to the first follow-up, eight weeks later, patients in the ImRs group would still experience less
perceived helplessness during confrontation with past trauma imagery than would patients in the EMDR group (patients in the waiting list group were not included in this comparison).
2. Method
2.1 Participants
For the present study, a power analysis was run using G*Power version 3.1.9.3 for Mac OS X (Faul et al., 2009). It is important to mention that the power analysis was merely an approximation, due to the fact that the statistical analysis applied in this study was not featured in G*Power. With α at .05, and the effect size of ƒ20.3, which is conventionally
considered a medium sized effect for a multiple regression analysis with three groups (Cohen, 1992), the required sample size was 72. Hence, for this study, the sample size consisted of 72 participants, allowing for 24 participants in each of the three groups, namely waiting list, Imagery Rescripting (ImRs), and EMDR. This study makes use of participants originally recruited for the study by Boterhoven et al. (2017) by mental health clinics in The
Netherlands, Germany, and Australia. It is necessary to mention the fact that some mental health clinics did not, or not fully, report the demographic data for all of their patients, and hence, these data are missing for a total of 19-20 participants, divided randomly over the three groups of the study. The demographic information reported below, therefore, may not be entirely consistent with the entire study sample.
The sample for the present study, for which demographic data were available, consisted of 39 women (75%; 54.2% of the entire sample size) and 13 men (25%; 18.1% of the entire sample size), varying in age from 19 to 57 years (M = 36.94; SD = 10.46). Of the participants for whom demographics were available, 24 (48%; 33.3% of the entire sample size) were
currently using some form of medication for psychological complaints, and 26 (52%; 36.1% of the entire sample size) were not currently using such form of medication. Of these
participants, only 13 (26%; 18.1% of the entire sample size) had never previously received any form of psychological therapy. 7 participants (14%; 9.7% of the entire sample size) had previously received individual ambulant treatment; 3 participants (6%; 4.2% of the entire sample size) had received group therapy, 1 participant (2%; 1.4% of the entire sample size) had received partner therapy, and 26 participants (52%; 36.1% of the entire sample size) had previously received several different forms of psychological therapy, including admittance to a psychiatric hospital. Of the participants for whom demographic data were available, 34 (66.7%; 47.2% of the entire sample size) occasionally used alcohol, whereas 17 (33.3%; 23.6% of the entire sample size) did not. Of these participants, 6 (11.8%; 8.3% of the entire sample size) occasionally used some form of drugs, whereas 45 (88.2%; 62.5% of the entire sample size) did not. The present study used data only from participants who completed therapy and therefore, no data was lost.
2.2 Measures
2.2.1 Interview measures
M.I.N.I. International Neuropsychiatric Interview (M.I.N.I. Plus), version 5.0.0. The M.I.N.I.
Plus (English version, Sheenan et al., 1998; Dutch version, Van Vliet et al., 2000) is a structured interview designed to diagnose a range of DSM diagnoses. For the present study, the DSM-IV version was used. The M.I.N.I. Plus is divided into 26 modules each covering a different area of psychiatric disorders. Each module begins with a series of screener
questions, and for all modules, the patient must answer with only a ‘yes’ or a ‘no’. With regards to the English version, the reliability and validity have been seen to be sufficient (Sheenan et al., 1998), but this information is not available for the Dutch version. For the
present study, the M.I.N.I. Plus was used by some mental health clinics as one of the two alternatives for assessment of the patient’s psychiatric diagnosis during intake.
Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I). The SCID-I (English
version, Spitzer et al., 2002; Dutch version, Van Groenestijn et al., 1998) is a semi-structured interview designed to diagnose a range of DSM diagnoses. For the present study, the DSM-IV version was used. The validity and reliability for the SCID-1 vary by psychiatric disorder; for PTSD, the Kappa value is .77, which reflects a good reliability (Lobbestael et al., 2011). For the present study, the SCID-I was used by some mental health clinics as the other alternative for assessment of the patient’s psychiatric diagnosis during intake.
Imagery Interview, designed for the study by Boterhoven et al. (2017). The Imagery Interview
is a semi-structured interview used to assess the way in which a patient visualises their index trauma, as well as the way in which visualising their trauma affects them emotionally in the present. For the present study one item was used, namely “I feel helpless”. This item was included in order to measure the degree perceived of helplessness when confronted with imagery related to the traumatic experience. Possible answers were 1. “Not at all”; 2. “A bit”; 3. “Quite a lot”; 4. “Rather much”, and 5. “Extremely much”. Due to the fact that the
Imagery Interview was designed especially for the study by Boterhoven et al. (2017), no information is available as to its validity and reliability. The Imagery Interview was used at Waiting list, Pre-treatment, Post-treatment, and Follow-up 8 weeks assessments (see Appendix II).
Life-Events Checklist for DSM-5 (LEC-5). The LEC-5 (Weathers et al., 2013) is a self-report
instrument designed to assess the occurrence of traumatic events during a person’s lifetime. In the present study, the LEC-5 was used as an interview. The LEC-5 assesses 16 potentially traumatic events, such as natural disasters or sexual abuse, as well as one item where the patient may add events not yet mentioned in the list. Answers can be related to personal
experiences, experiences as a witness, or experiences recounted by others. The convergent validity of the LEC-5 has proven sufficient to assess exposure to traumatic events, but insufficient for use as a diagnostic instrument for PTSD (Life Events Checklist for DSM-5). In the current study, the LEC-5 was used to create a list of traumas for treatment, as well as for identifying the index trauma. The LEC-5 was used immediately after inclusion of the patient in the study.
Life-Events Checklist for DSM-5 Extra (LEC-5 Extra). The LEC-5 Extra (Weathers et al.,
2013) is a self-report instrument which adds three items to the LEC-5, concerning more general traumatic events which cannot be pinpointed to one specific episode. Answers can be related to personal experiences, experiences as a witness, or having learned of the event from others. The LEC-5 Extra was used immediately after inclusion of the patient in the study.
2.2.2 Self-report measures
Dutch Remoralization Scale. The Remoralization Scale (Vissers et al., 2010) is a self-report
instrument designed to assess the restoration of morale during the therapeutic process. In the present study, it was used to assess a patient’s sense of perceived personal control in the present. For this present study, a scale of seven items assessing matters related to perceived personal control in the present was created, namely: 1. I am in control of my life; 2. I am usually confident about the decisions I make; 3. On the whole, I am satisfied with myself; 4. Right now, I see myself as being pretty successful; 5. At this time, I am meeting the goals I set for myself; 6. I can think of many ways to reach my current goals; 7. I have
self-confidence. Each question offers the following range of possible answers: 1. Disagree completely; 2. Mostly disagree; 3. Mostly agree; 4. Agree completely. The reliability for a subscale including all seven items was good, Cronbach’s α = .93. For the present study, the Remoralization Scale was used at Waiting list, Pre-treatment, Post-treatment, and Follow-up 8
weeks assessment. The questionnaire was presented as part of a battery of computerized questionnaires which participants filled out on their own. During this process, the participant was alone in the room, but a research assistant was available for questions in the adjacent room. While answering the questionnaires, participants did not take a break, and one test sit required approximately 1,5 hours.
In Vissers et al. (2010), the test-retest reliability (r = 0.89) and the internal consistency α = 0.91) of the Remoralization Scale are reported. In the same report, the construct validity was investigated using a demoralization scale (r = –.72) and scales that measure anxiety (r = – .52), depression (r = –.50), somatic symptoms (r = –.36), and social dysfunction (r = –.37). Lastly, the sensitivity to therapeutic change was examined and found to be good (Vissers et al., 2010)
2.3 Procedure
2.3.1 Design and Recruitment
For this study, participants were recruited by mental health care centres in Australia, Germany, and The Netherlands. Therapists at these sites were supplied with checklists featuring the in- and exclusion criteria for the study, and they conducted a primary eligibility screening according to these criteria. In cases where a patient seemed eligible at first look and expressed an interest in participating in the study, their name was passed on to the site
coordinator and to the research assistants, who then supplied the patient with written information concerning the study. If patients expressed continued interest in participation during a subsequent telephone conversation with a research assistant, a motivational interview with the research assistant was scheduled, during which the final screening according to the criteria of the study took place. Eligible patients then signed the informed consent form and were included in the study. At study conclusion, participants were rewarded 25 Euros.
The inclusion criteria of the study were: PTSD as defined by the DSM-IV, assessed with the SCID-I or the MINI-Plus; (2) PTSD a the main complaint; (3) Duration of PTSD is longer than three months, (4) The index trauma happened before the age of 16, and patient agrees that index trauma is focus of treatment; (5) If a recent trauma occurred, the recent trauma took place longer than six months ago and is not the index trauma, (6) Age 18-70 years, (7) Ability to understand, read and write Dutch, German or English (depending on the country in which the study took place), (8) Ability to plan 12 sessions of 90 minutes within 6 to 8 weeks, time in between the sessions needs to be at least 2 days. The exclusion criteria were: (1) Acute PTSD, (2) Alcohol or drug dependency or abuse as defined by the DSM-IV; (3) Use of benzodiazepine (patients were motivated to stop); (4) Comorbid psychotic disorder, (5) Bipolar disorder (current or past) as defined by the DSM-IV, (6) Acute suicide risk, (7) IQ lower than 80, (8) Scheduled to begin another form of PTSD treatment, (9) More than two sessions of EMDR or ImRs prior to the study, (10) Upcoming changes in antidepressant medication.
Upon inclusion in the study, the patient was randomly assigned to one of two conditions, namely EMDR and Imagery Rescripting (ImRs). Patients who were obliged to wait for longer than three weeks before treatment start were assigned to a waiting list and received an
additional assessment. For the present study, each condition (waiting list, ImRs and EMDR) consisted of 24 participants.
2.3.2 Assessment
For the present study, assessment took place at various time points. For the waiting list group, assessment took place at waiting list assignment and pre-treatment. For the two treatment groups, assessment took place at pre-treatment, post-treatment, and follow-up 8 weeks.
Remoralization Scale and Imagery Interview assessment took place at all of the said assessment points.
All assessments consisted of a battery of questionnaires and included individual computer-based questionnaires as well as questionnaires presented by a research assistant. After
treatment conclusion, the participant waited 8 weeks, after which they received an evaluation with the therapist. If additional therapy was deemed necessary, the patient was referred within the same mental health institution. Also, the patient took part in an exit interview with one of the researchers regarding their view on the effect of the treatment they had received.
2.3.3 Groups
The present study consisted of three groups, each featuring 24 participants. Participants were added to the waiting list condition if treatment commencement was scheduled more than three weeks after inclusion, or assigned ad random to one of the two treatment groups.
Waiting list: The waiting list group consisted of participants who had to wait for more than
three weeks before therapy commencement. Before being assigned to the waiting list group, patients were assessed according to the design of the study.
ImRs: The therapists conducting the ImRs therapy were all experienced therapists with an
expertise in trauma treatment. The therapists received a two-day preparatory training by Prof. Dr. Arnoud Arntz, Professor of Clinical Psychology at the University of Amsterdam, an expert in imagery rescripting and co-author of the overall research project. After inclusion in the study, the patient and the research assistant put together a list of traumas, including the trauma identified by the patient as the index trauma. This list was passed on to the therapist, who during the first therapy session helped the patient set up a hierarchy of traumas to treat during subsequent sessions. All subsequent sessions began with a review of the preceding session, and all sessions included assessment by the therapist with regards to possible changes in medication and impact of the previous session. The treatment used for the study was
protocolised and consisted of a maximum of 12 sessions (See Appendix I). The protocol consisted of three phases, all of which were carried out during each session. During phase 1, the patient was asked to close their eyes and visualise the traumatic scene from the
perspective of themselves experiencing the traumatic event in the present tense (the study by Boterhoven et al. (2017) focused on childhood traumas, and hence the patient visualised themselves as a child). The course of phase 2 depended on who did the rescripting during the session. During sessions in which the rescripting was done by the therapist (session 2-6), phase 2 consisted of the patient visualising the same traumatic scene, again from the
perspective of themselves as a child. The therapist then asked the patient to visualise that he or she (i.e., the therapist) would enter the imagery scene, and that he or she would intervene in order to help and comfort the patient within the imagery. In sessions where the rescripting was done by the patient (session 7-12), he or she was asked to change their perspective to that of a bystander looking at the traumatic event as it took place. The patient was asked to act on what they saw, to intervene if they felt that it was appropriate, and to offer help and comfort to the younger version of themselves during the time of the trauma. During phase 3, the patient again was asked to switch perspective to the version of themselves experiencing the traumatic event in the present tense (i.e., as a child), and to feel the effect of the intervention and comfort provided by the therapist or by themselves as a bystander. Also, the younger version of the patient might ask their current (adult) self to provide them with what they felt they were still in need of (Smucker et al., 1995; Arntz & Weertman, 1999). Therapy was discontinued when the patient indicated that the meaning of the traumatic memory and
imagery had been altered, and that the need for trauma-focused therapy was no longer present. EMDR: The therapists conducting the EMDR treatment in the study were all experienced
therapists with an expertise in trauma treatment. All therapists received a preparatory training by Dr. Christopher Lee of the University of Western Australia, School of Psychiatry and
Clinical Neurosciences; an expert in EMDR and co-author of the overall research project. As during ImRs, the patient and a research assistant set up a list of traumas to treat and identified the index trauma, both of which were passed on to the therapist. During the first session, the therapist and the patient decided on a hierarchy of traumas. All sessions included a short assessment by the therapist with regards to possible changes in medication and impact of the previous session. The EMDR treatment conducted in the study followed the protocol by Shapiro (2001), which consists of eight phases. Whereas phase one and two focused on formulating a treatment plan, stabilization and establishing a relationship between patient and therapist, the emotional processing itself usually took place from phase three (Shapiro, 1995; 2001). The patient recalled the traumatic event while pairing it with a negative cognition and rating their level of distress on the Subjective Unit of Disturbance Scale (SUDS). The patient then visualised the traumatic event while tracking the movement of the therapist’s fingers or performing another dual-attention task. Eventually, when the memory of the traumatic event had been rendered less vivid and emotional to the patient, and the rating on the Subjective Unit of Disturbance Scale was 0, the patient and the therapist evaluated the degree of processing and alterations of the negative cognition. Phase eight took place during the following session and consisted of revaluation and observation of possible generalization of the memory reconsolidation to other traumatic events (Shapiro, 1995; 2001).
2.4 Statistical analyses
In order to test whether there was a difference in degree of perceived personal control in the present, between the ImRs group, on the one hand, and the EMDR and waiting list groups on the other, a mixed regression analysis was conducted. The amount of assessment points differed between the waiting list group, who had two assessment points (at waiting list and at pre-treatment), and the two treatment groups, who had three (at pre-treatment, post-treatment
and follow-up 8 weeks). As a result, the dataset featured systematic missing data, which made the use of a mixed model essential. The effect of time was measured on a continuous scale. Furthermore, the choice of a statistical analysis was in part determined by the fact that the data of the study were not normally distributed. According to Verbeke and Lesaffre (1997), a mixed regression analysis is quite robust to non-normality with regards to the fixed-effects parameters.
The difference in degree of perceived personal control in the present from post-treatment to follow-up 8 weeks between the two treatment groups was measured with a mixed regression analysis. The choice of this particular statistical analysis was decided by the non-normality of the study data.
The degree of perceived helplessness when confronted with past trauma imagery was measured with an item from the Imagery Interview. In order to see whether there was a difference in perceived helplessness when confronted with past trauma imagery between the ImRs group, on the one hand, and EMDR and waiting list groups on the other, a mixed regression analysis was conducted. Primarily, this choice was based on the fact that here, too, the dataset featured systematic missing data. Secondly, the non-normality of the data required a test which could robustly handle this violation of assumptions.
The difference from post-treatment to follow-up 8 weeks between the two treatment groups with regards to the degree of perceived helplessness when presented with past trauma imagery was also measured with a mixed regression analysis. This choice was based on the
non-normality of the study data.
For the statistical analyses, IBM SPSS (Statistical Package for the Social Sciences) Version 24 was applied.
3.1 Equivalence of conditions
The participants of the three groups did not differ significantly from each other in age, F(2, 49) = .32, p =.729. Nor did they differ significantly from each other in terms of gender, 𝑥𝑥2(2) = 2.05, p = .203, reception of previous treatment, 𝑥𝑥2(10) = 13.46, p = .086, alcohol use,
𝑥𝑥2(2) = 3.60, p = .094, or drug use, 𝑥𝑥2(2) = .586, p = .434. Participants in the three groups did
differ significantly from each other in terms of current medication use, 𝑥𝑥2(2) = 5.60 p = .035. The demographic information shows that in the waiting list and EMDR groups, there are more patients not currently using medication than patients who do currently use medication. For the ImRs group, however, this is reversed: here, there are more patients currently using medication than patients who do not. The demographic information does not specify the sort of medication used, but the study inclusion criteria guarantee that medication use was restricted to certain sorts of medication, and that no changes in medication took place during treatment.
3.2 Difference over time in Perceived Personal Control in the Present between ImRs, EMDR
and Waiting list
See Table 1 for means and standard deviations at pre-treatment and post-treatment assessment. The difference in degree of perceived personal control in the present over time between the ImRs group, on the one hand, and the EMDR and waiting list groups, on the other, was significant, F(2, 69) = 8.41, p <.001. There is a difference over time, then, in perceived personal control in the present between the patients of the three groups. The information in Table 1 indicates that whereas for the ImRs and EMDR groups, the means at time point 2 (post-treatment) are higher than at time point 1 (pre-treatment), this is not the case for the waiting list group: here, the means at time point 2 (pre-treatment) are lower than at time point 1 (waiting list). This means that whereas for the ImRs and EMDR groups, the
degree of perceived personal control in the present increased during the time of the treatment process, it in fact decreased for the waiting list group (see Fig. 1).
The difference in degree of perceived personal control in the present between the ImRs and the EMDR groups, leaving out the waiting list group, was not significant, F(1, 46) = .07, p = .935. When leaving out the waiting list group, the ImRs and EMDR groups did not differ in terms of the degree of perceived personal control in the present. This is contrary to
expectation, as it was hypothesised that the patients in the ImRs group would experience a higher degree of perceived personal control in the present over time than would the patients in the EMDR condition. For both groups, the degree of perceived personal control in the present had increased significantly from pre-treatment to post-treatment assessment, F(1, 46) = 29.10, p < .001 (see Fig. 1). Hence, it can be concluded that whereas being assigned to the waiting
list group did not positively affect the degree of perceived control in the present in patients, the patients in both the ImRs and EMDR groups felt increasingly more perceived personal control in the present during the time of their treatment process. Receiving treatment, then, seems to be more beneficial to the degree of perceived control in the present than assignment to a waiting list. Likewise, it is possible to conclude that since, from pre-treatment to post-treatment, the patients in the ImRs and EMDR groups did not differ in terms of their degree of perceived control in the present, the two treatments are comparable in terms of their ability to enhance patients’ degree of perceived control in the present.
Fig. 1. Means and standard deviations for perceived personal control in the present for
waiting list, ImRs, and EMDR at pre-treatment and post-treatment assessment.
Table 1
Means (M) and Standard Deviations (SD) of Perceived Personal Control in the Present for ImRs, EMDR, and Waiting list at Pre-treatment and Post-treatment Assessment.
Waiting list ImRs EMDR M (SD) M (SD) M (SD) Pre-treatment
Perceived personal control in the present 2.22(61) 1.43(.44) 1.74(.57) Post-treatment
Perceived personal control in the present 2.13(70) 1.89(.58) 2.19(.79)
3.3 Difference over time in perceived personal control in the present from post-treatment to
follow-up 8 weeks assessment between ImRs and EMDR
See Table 2 for means and standard deviations at post-treatment and follow-up 8 weeks assessment. It was tested whether from post-treatment to the follow-up, 8 weeks after treatment termination, the patients of the ImRs group and the EMDR group would differ significantly in terms of the degree of perceived personal control in the present. No difference was found from post-treatment to follow-up 8 weeks between the patients of the ImRs and the
0 1 2 3 4 5 6 Pre-treatment Post-treatment Per ceived P er so na l C on tr ol in th e Pr esen t Time Waiting list ImRs EMDR
EMDR groups in terms of the degree of perceived personal control in the present, F(1, 44.31) = .20, p = .66. This, too, was contrary to expectation, as it was hypothesised that the patients in the ImRs group would experience a higher degree of perceived personal control in the present than would the patients in the EMDR group. The means for both groups decreased from post-treatment to follow-up 8 weeks, but the decrease was not significant, F(1, 44.31) = 3.77, p = .059 (see Fig. 2). The two treatments, then, are comparable in terms of the duration of their effect on patients’ feelings of perceived personal control in the present.
Fig. 2. Means and standard deviations for perceived personal control in the present for ImRs
and EMDR at post-treatment and follow-up 8 weeks assessment.
Table 2
Means (M) and Standard Deviations (SD) of Perceived Personal Control in the Present for ImRs and EMDR at Post-treatment and Follow-up 8 Weeks Assessment.
ImRs EMDR
M (SD) M (SD) Post-treatment
Perceived personal control in the present 1.89(.58) 2.19(.79) Follow-up 8 weeks
Perceived personal control in the present 1.81(.67) 2.05(.79) 0 0,5 1 1,5 2 2,5 Post-treatment Follow-up 8 weeks Per ceived p er osn al c on tr ol in th e pr esen t Time ImRs EMDR
3.4 Difference over time in degree of perceived helplessness during confrontation with past
trauma imagery between ImRs, EMDR, and waiting list
See Table 3 for means and standard deviations at pre-treatment and post-treatment assessment. The difference over time in degree of perceived helplessness during confrontation with past trauma imagery between the ImRs group, on the one hand, and the EMDR and waiting list groups, on the other, was significant, F(2, 68.29) = 12.84, p< .001. There is a difference between the patients in the three groups in terms of the degree to which they feel helpless when confronted with past trauma imagery. The means indicate that whereas for the patients in the waiting list group, the feeling of helplessness decreases very little, there is a large decrease in feelings of helplessness for the patients in the ImRs and EMDR groups (see Fig. 3)
The difference between the patients in the ImRs and EMDR groups, leaving out the waiting list group, in terms of perceived helplessness during confrontation with past trauma imagery, was non-significant, F(1, 44.82) = .128, p = .722. When leaving out the waiting list group, the ImRs and EMDR groups did not differ to the degree in which they felt helpless when
confronted with past trauma imagery (see Fig. 3). This is contrary to expectation, as it was hypothesised that the patients in the ImRs group would feel less helpless when confronted with past trauma imagery than would the patients in the EMDR group. For both groups, the perceived helplessness during confrontation with past trauma imagery had decreased
significantly from pre-treatment to post-treatment assessment, F(1, 44.82) = 70.29, p < .001. It is therefore possible to conclude that whereas being assigned to the waiting list group did not significantly affect the perceived helplessness during confrontation with past trauma imagery, this feeling decreased significantly in the ImRs and EMDR groups during the time of the treatment process. Also, the results indicate ImRs and EMDR are comparable in terms
of their ability to lower patients’ feelings of helplessness during confrontation with past trauma.
Fig. 3. Means and standard deviations for perceived helplessness during confrontation with
past trauma imagery for waiting list, ImRs, and EMDR at pre-treatment and post-treatment assessment.
Table 3
Means (M) and Standard Deviations (SD) of Perceived Helplessness During Confrontation With Past Trauma Imagery for ImRs, EMDR, and Waiting list at Pre-treatment and Post-treatment Assessment.
Waiting list ImRs EMDR M (SD) M (SD) M (SD) Pre-treatment
Imagery Interview 4.26(1.14) 4.25(.80) 4.33(1.01) Post-treatment
Imagery Interview 4.21(1.10) 2.46 (1.38) 2.36(1.43)
3.5 Difference in perceived helplessness during confrontation with past trauma imagery from
post-treatment to follow-up 8 weeks between ImRs and EMDR 0 0,5 1 1,5 2 2,5 3 3,5 4 4,5 5 Pre-treatment Post-treatment Per ceived h el pl essn ess d ur in g co nfr on ta tio n w it h p ast tr au m a im ag er y Time Waiting list ImRs EMDR
See Table 4 for means and standard deviations. It was tested whether from post-treatment to the follow-up, 8 weeks after post-treatment termination, the patients of the ImRs group and the EMDR group would differ significantly in terms of the degree of perceived helplessness during confrontation with past trauma imagery. No difference was found from post-treatment to follow-up 8 weeks between the patients of the ImRs and the EMDR groups, F(1, 43.37) = .064, p = .801 (see Fig. 4). This is contrary to expectation, as it was
hypothesised that patients in the ImRs group would feel less helpless when confronted with past trauma imagery than would the patients in the EMDR group. For both groups, the means decreased somewhat from post-treatment to follow-up 8 weeks, but the decrease was not significant, F(1, 43.37) = .426, p = .517. It is possible to conclude, then, that the two
treatments are comparable with regards to the duration of their effect on patients’ feelings of helplessness during confrontation with past trauma imagery.
Fig. 4. Means and standard deviations for perceived helplessness during confrontation with
past trauma imagery for ImRs and EMDR at post-treatment and follow-up 8 weeks. 2 2,05 2,1 2,15 2,2 2,25 2,3 2,35 2,4 2,45 2,5 Post-treatment Follow-up 8 weeks Feel in g o f h el pl essn ess d ur in g co nfr on ta tio n w it h p ast tr au m a im ag er y Time ImRs EMDR
Table 4
Means (M) and Standard Deviations (SD) of Perceived Helplessness During Confrontation with Past Trauma Imagery in the Present for ImRs and EMDR at Post-treatment and Follow-up 8 Weeks.
ImRs EMDR M (SD) M (SD) Post-treatment Imagery Interview 2.46(.1.38) 2.36(1.43) Follow-up 8 weeks Imagery Interview 2.35(.982) 2.18(1.53) 4. Discussion
In the present study, trauma patients having received Imagery Rescripting (ImRs), EMDR or having been assigned to a waiting list were compared in terms of their degree of perceived personal control in the present, as well as in terms of their perceived helplessness during confrontation with past trauma imagery.
Firstly, it was tested whether, from pre-treatment to post-treatment, patients having received ImRs, EMDR of having been assigned to a waiting list would differ with regards to their degree of perceived personal control in the present. It was hypothesised that at post-treatment assessment, patients having received ImRs would experience a larger degree of perceived personal control in the present than would patients having received EMDR or having been assigned to a waiting list. The results, however, did not support this hypothesis: the only difference found was with regards to the patients in the waiting list group, who experienced a lower degree of perceived personal control in the present than did the patients in the ImRs and EMDR groups. When leaving out the patients in the waiting list group, there was no difference in perceived personal control in the present between the patients of the
ImRs and EMDR groups from pre-treatment to post-treatment. For both these groups, patients’ degree of perceived personal control in the present rose significantly from pre-treatment to post-pre-treatment. This implies that both pre-treatments effectively increased patients’ feeling of perceived personal control in the present, and in addition, that for both treatments, this effect is of comparable size.
Secondly, it was tested whether, from treatment cessation at post-treatment to the follow-up assessment 8 weeks later, patients having received ImRs or EMDR would differ in terms of their degree of perceived personal control in the present. It was hypothesised that also at this point, patients having received ImRs would experience a higher degree of perceived personal control in the present than would patients receiving EMDR. This hypothesis was not supported by the results, however, since no difference in perceived personal control in the present was found between the patients in the ImRs and EMDR groups. Furthermore, although in both groups, perceived personal control in the present had dropped somewhat from post-treatment to follow-up assessment, this decrease was not significant.
All in all, then, the results of the present study indicate that in terms of increasing patients’ feeling of perceived personal control in the present, ImRs and EMDR seem to be equally effective: during therapy, it increased significantly for both treatment groups. Also, the effects of either treatment on patients’ degree of perceived personal control in the present after treatment cessation appear to be comparable: the feeling of perceived control decreases somewhat for both treatment groups, but not significantly. As mentioned above, these results were contrary to expectation, as it was hypothesised that based on its more active involvement of the client during sessions, ImRs would increase patients’ degree of perceived personal control in the present to a higher degree than would EMDR. The conclusion, then, is that ImRs and EMDR seem to be equally effective, and more effective than waiting list
assignment, when it comes to increasing patients’ degree of perceived personal control in the present.
Next, it was tested whether, from pre-treatment to post-treatment, patients receiving ImRs, EMDR of having been assigned to a waiting list would differ in terms of their feelings of helplessness during confrontation with past trauma imagery. It was hypothesised that due to the ImRs protocol’s more active involvement of patients during treatment, patients receiving ImRs would feel less helpless when confronted with past trauma imagery than would patients receiving EMDR or having been assigned to a waiting list. The results, however, did not support this hypothesis: the difference found concerned the patients in the waiting list group, who experienced a higher degree of helplessness at post-treatment assessment than did the patients in the ImRs and EMDR groups. When leaving out the patients in the waiting list group, there was no difference in perceived helplessness between the patients of the ImRs and EMDR groups from pre-treatment to post-treatment. In both the ImRs and the EMDR groups, patients’ feelings of helplessness when confronted with past trauma imagery decreased significantly from pre-treatment to post-treatment. This implies that both treatments effectively decrease patients’ feelings of helplessness when confronted with past trauma imagery during treatment, and furthermore, that for both treatments, this effect seems to be comparable.
Lastly, it was tested whether, from treatment cessation at post-treatment assessment to the follow-up assessment 8 weeks later, patients receiving ImRs or EMDR would differ in terms of their feelings of helplessness during confrontation with past trauma imagery. It was hypothesised that at this point, too, patients receiving ImRs would experience less
helplessness when confronted with past trauma imagery than would patients receiving EMDR. This hypothesis was not supported by the results, however, since no difference in perceived helplessness was found between the patients in the ImRs and EMDR groups. In
addition, although patients’ feelings of helplessness had increased slightly from post-treatment to follow-up assessment, this increase was not significant.
It is possible to conclude, then, that in terms of decreasing patients’ feelings of helplessness during confrontation with past trauma imagery, ImRs and EMDR seem equally effective: for the patients in both treatment groups, the feelings of helplessness decreased significantly during therapy. Furthermore, the effect of both therapies on patients’ feelings of helplessness when confronted with past trauma imagery after treatment cessation seems to be comparable: in both treatment groups, the feelings increased somewhat, albeit not
significantly. This too was contrary to expectation, as the more active involvement of the client during ImRs sessions was hypothesised to decrease patients’ feelings of helplessness more than would treatment with EMDR. Therefore, ImRs and EMDR can be said to both be effective when it comes to decreasing patients’ feelings of helplessness during confrontation with past trauma imagery.
Until now, no study has compared the two treatments with regards to their efficacy in increasing patients’ sense of perceived control in the present. Furthermore, the study
comparing their effectiveness in terms of treating PTSD has not yet been completed
(Boterhoven et al., 2017), and hence, at this point, conclusions concerning the results of that study are premature. Nevertheless, it is likely that the results of the present study do in fact support research testifying to the efficacy of both ImRs and EMDR as a treatment for PTSD (Arntz et al., 2007; Grunert et al., 2007; Bisson et al., 2007; Arntz et al., 2013; Raabe et al., 2015; Brockman & Calvert, 2016, Seidler & Wagner, 2006, Shapiro et al., 2012, Watts et al., 2013), since according to research, a sense of perceived personal control in the present, has been seen to decrease PTSD symptoms (Frazier et al, 2002; Frazier et al., 2004; Pietrzak et al., 2009; Ullman et al., 2009; Najdowski & Ullman, 2009; Larsen & Fitzgerald, 2011). Due to the fact that the study by Boterhoven et al. (2017), on which this study is based, has not yet
been completed, it was not possible to study directly the relationship between the increase in perceived personal control in the present and recovery from PTSD, but it is important that future research consider whether the significant increase in perceived personal control in the present, noted by patients in both treatment groups, is related to a decrease in PTSD
symptoms.
As with the comparison between ImRs and EMDR in terms of perceived personal control, no study until now has compared the two treatments concerning their effect on patients’ perceived helplessness during confrontation with trauma imagery. The decrease in patients’ feelings of helplessness during confrontation with past trauma imagery, which is visible in both treatments from pre-treatment to post-treatment assessment, may very likely support the efficacy of either treatment (Arntz et al., 2007; Grunert et al., 2007; Bisson, 2007; Arntz et al., 2013; Raabe et al., 2015; Brockman & Calvert, 2016, Seidler & Wagner, 2006, Shapiro et al., 2012, Watts et al., 2013). Research shows that a feeling of being in control of the treatment process is particularly beneficial to the treatment of PTSD (Frazier et al., 2002; Frazier et al., 2004; Najdowski & Ullman, 2009; Larsen & Fitzgerald, 2011), and if
helplessness during confrontation with past trauma imagery is viewed as a proximal measure of this form of control, it is interesting for future research to consider whether the decrease in feelings of helplessness during confrontation with past trauma imagery, visible in patients from both treatment groups, is related to a decrease in PTSD symptoms.
An alternative explanation for the unexpected results found in this study may be that the questionnaires applied to study the degree of perceived personal control and helplessness in the present may not have contained sufficient content validity with regards to this
construct. As mentioned above, the present study was based on a larger study by Boterhoven et al. (2017), and hence, it was not possible to include questionnaires specifically designed to study the constructs of perceived personal control in the present and helplessness during
confrontation with past trauma imagery. As a result, the questionnaires may have been too general to uncover possible differences between ImRs and EMDR in terms of their effect on patients’ feelings of control and helplessness. Furthermore, due to the relatively small sample sizes of the present study, it would be difficult to detect any small effect sizes in the
comparison between the two treatment forms. It is important for future research on this subject, then, to apply questionnaires designed specifically to measure these particular constructs, and to ensure a sample size sufficiently large to detect small sample sizes.
In addition to the aforementioned possible non-specificity of the questionnaires, there are a number of limitations to the present study. Firstly, it is in any case difficult to discern the degree to which the answers given by participants were concerned purely with the degree of perceived control or with feelings of helplessness due to the confrontation with past trauma imagery. Many of the participants suffered from comorbidity, often in the form of depression or anxiety. It is not impossible to imagine that negative feelings as a result of comorbidity may have affected participants’ answers, and that their answers may have been more of a reflection of their general state of mind than merely of their feelings of control of
helplessness. In the study by Boterhoven et al. (2017), questions concerning the mental state of patients were included in the battery of questionnaires, and future research might use these measures as a way of specifying the answers.
Secondly, the questionnaires were part of a large battery, which participants were asked to fill out during assessments. It is not unthinkable that the validity of the answers may have been affected by fatigue on the part of the patients; for instance through a tendency to settle for the average score, which may feel as the easiest position to take. Future research may avoid this risk by presenting patients with shorter assessments, and to schedule sufficient breaks during assessment.
Thirdly, the positive effects on perceived personal control and feelings of helplessness in the present found in patients in either treatment group may not be specific to the methods of ImRs or EMDR, but may simply be indirect effects of being treated at all. It is necessary to counter this problem in order to properly understand the effects of a treatment. A way for future research to do this may be to include placebo groups for either treatment, as well as to look closer at the active elements of the treatments.
Lastly, the patients in the waiting list group were not selected randomly, as assignment to the waiting list depended on the time before a patient could begin treatment with ImRs or EMDR. It is possible that assignment to a waiting list may have increased patients’ feelings of loss of control and helplessness, as many of them had already waited a long time for treatment before being included in the study. Furthermore, although patients were assigned randomly to either treatment group, only treatment completers were used for the present study. It is
therefore conceivable that patients in the present study may have differed qualitatively from each other, as well as from the rest of the sample for Boterhoven et al. (2017). Future research may avoid this concern by comparing patients at pre-treatment in order to avoid great
differences in patient characteristics.
Looking at the results of the present study, it seems that in terms of increasing patients’ sense of perceived control, ImRs and EMDR are both effective and beneficial. Hence, there seems to be no reason to fear that the difference in protocols in terms of active patient participation is cause for a discrepancy in feelings of control on the part of the patient. Therefore, there seems to be no need to adjust or align protocols on this point. On the
contrary, it is important to broaden the range of treatment options, simply because of the fact that no single treatment is suitable for every patient (Bradley et al., 2005; Arntz et al., 2007; Cloitre, 2009). It is positive that ImRs and EMDR both seem to be effective in terms of
improving patients’ sense of perceived control, and it is interesting to consider the link with their effectiveness in reducing PTSD symptoms.
Another important conclusion concerning the results found in this study is that
whereas for ImRs, an important rationale consists of the treatment empowering the victim and thereby increasing their sense of control (Smucker et al., 1995; Arntz & Weertman, 1999; Holmes et al., 2007; Arntz et al., 2007; Brockman & Calvert, 2016), EMDR must contain elements which increase a patient’s sense of empowerment and personal control to a similar degree. Although we do not yet fully understand the working mechanisms of either therapy, and although it is therefore necessary to keep studying them, it is good to know that similar goals may apparently be met by treatments quite different in terms of their internal processes. This justifies experimentation with regards to discovering new ways of trauma treatment and inspires hope that ever more people suffering from PTSD may find a kind of therapy which is suitable to them.
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