Posttraumatic stress disorder occurs when individuals experience intrusive effects of a disturbing event that they have experienced for more than one month. PTSD is also marked by an individual’s determined avoidance of any stimuli that might remind them of the aforementioned event, along with a marked shift in mood and behavior which is distressing to the people around them. Over the years, a number of therapeutic techniques have been used to treat PTSD. Due to their effectiveness, exposure therapies and eye movement desensitization and reprocessing (EMDR) are two of the most widely used of these techniques. These have been utilized to treat soldiers as well as civilians who have experienced trauma. However, the nuances of their application, in terms of their effectiveness against specific demographics have yet to be determined. This paper will critically evaluate a number of different studies conducted using exposure techniques, EMDR, or both and determine their effectiveness in treating individuals with PTSD. Even though EMDR has its roots in exposure therapy, for the purposes of this study, EMDR and exposure therapies will be regarded as two distinctive therapeutic techniques (CITE).
One of the biggest issues faced by PTSD treatment research is a large number of studies with subpar methodologies. Due to this, Foa and Meadows (1997) published seven standards that should be present in any research that deals with treatment outcomes of PTSD. They are known as the “Gold Standards” for treatment outcome studies. According to Foa and Meadows, every suitable PTSD research should have clearly defined symptoms; reliable and valid measures; use of independent evaluators; trained assessors; manualized, replicable, specific treatment programs; treatment adherence; and an unbiased assignment to treatment.
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Ready et al. (2012) provides an effective utilization of group-based exposure therapy which sets the precedent in favor of exposure techniques among veteran soldiers. Their decision to divide the participants into three groups of ten ensures that every individual can form personal connections with other members of the group given the limited time of the treatment program. The small group size also allows the participants, who would typically avoid social situations, to not feel overwhelmed when asked to share their experiences. On the other hand, the lack of any gender diversity within the sample group reduces external validity and adds to the stereotype that only men who have been in combat suffer from PTSD. Given the comorbidity of PTSD and substance abuse (CITE), using drug abuse as exclusion criteria further decreases its external validity.
Allocating the first part of the program to forming support groups among participants is an effective use of the small sample size. It also helps in prolonging the social and emotional support that participants get during the program so that they will continue to support each other after its conclusion. Using each individual’s presentations as a form of exposure allows for a highly personalized exposure treatment while allowing them to understand that others have faced the same situations that they have. However, since they are required to listen to it as homework, it can only be effective with highly motivated participants. Seeing the long-term effectiveness of this type of exposure technique, Ready et al. (2012) proposed that the number of times that participants are required to listen to the presentations be increased from 10 to 20, which would theoretically increase the rate at which symptoms of PTSD would disappear. Overall, group based exposure therapy (GBET) is shown to be an effective short-term and long-term treatment for PTSD.
Through research conducted in a Ugandan refugee camp, Neuner et al. (2008) demonstrated that, even with laypersons with minimal training in psychotherapy, exposure techniques such as narrative exposure therapy (NET) can be used to treat PTSD. Just nine research assistants, all laypersons, were employed to conduct this study among a sample size of 277 individuals. While they were given a 6 week crash course on therapeutic techniques and communication skills, the use of unqualified personal to treat psychological disorders is unethical and could have negatively affected the participants being treated. Furthermore, it would have been better to use research assistants who weren’t from the camps that the study was being conducted on; this would have decreased threats to the validity of the study such as demand characteristics and participant expectations. However, the subject of PTSD wasn’t alien to the laypersons since all of them had been diagnosed with it at one point or another, meaning that they could empathize with the participants via personal experience. Since follow-up assessments showed that 70% of the participants who underwent NET can no longer be diagnosed with PTSD, this type of psychotherapy can be used in war-torn regions where professional help isn’t readily available. But the validity of the final results can be questioned due to the large number of participants who could not be located for the post-test and follow-up sessions, even though the study had adjusted for attrition during participant selection.
Another exposure technique, known as imagery rescripting and exposure therapy (IRET), was used by Long et al. (2011) to treat nightmares associated with PTSD. Like in the aforementioned case of Ready et al. (2012), this program also suffered from the issue of being all male. Furthermore, the temporal relevance of the study can be questioned since the participants were primarily veterans of the Vietnam War and none of the participants had participated in active combat since the early 1990s. While IRET had great success in decreasing the frequency of nightmares and increasing the quality of sleep, it wasn’t shown to have any effect on other symptoms associated with PTSD. The validity of these findings can be further questioned by the fact that the mean age for the participants were 62.1 years; meaning that their sleep disturbances may be the result of factors other than PTSD. Despite all of this, the self-employed and individualized exposure techniques used in this study, along with the extensive psychoeducation that preceded it, makes it a highly effective tool to treat nightmares associated with PTSD, even in individuals who have been suffering from it for decades.
Rothbaum, Astin, and Marstellar (2005) attempted to compare the efficacy of prolonged exposure therapy (PE) to EMDR with respect to the treatment of rape victims. One of the things that stood out from this study was the fact that every assessment and evaluation that is required during the course of the study was conducted by independent, blind evaluators. In addition to that the integrity of the specific therapies was measured by assessors who rated them highly. The sample size used was appropriate but a high dropout rate, combined with a few peculiar additions to the sample groups negatively affects the validity and reliability of the study; three participants who would not have otherwise been able to pass the exclusion criteria were allowed to participate in the study. It also used the participant’s subjective opinion on the most significant events in their lives, on which the treatments were focused on, which stands out due to the lengths they went to make the results of this study independent and objective. Furthermore, the remarkable success at which both PE and EMDR was able to treat the participants, raises questions on the reliability of the treatment process; 95% of the PE group and 75% of the EMDR group of patients who have been suffering from PTSD for over a decade, were no longer diagnosable as PTSD patients after a treatment process that lasted a few weeks. Despite all that, the efficacy of both exposure techniques and EMDR in treatment compared to no treatment cannot be questioned.
Ahmad, Larsson, and Sundlein-Wahlsten’s (2006) study, which was conducted using participants between the ages of 6 to 16, demonstrated that PTSD is prevalent even among children. The randomized controlled nature of the study along with the independent assessments makes it high in internal validity. Participants on the control group of this also showed improvements; they however, improved in non PTSD related symptoms. Moreover, the inventory that was administered had been modified in such a way that it can be understood and used easily with children. Furthermore, a more extensive evaluation can be carried out in the form of longitudinal studies or case studies regarding the relationship between PTSD in children and the history of mental illness in their family. Like many other programs which tested different treatments of PTSD, this study lacked a larger sample size, and utilized extensive exclusion criteria; this could affect its generalizability. In addition to this, they failed to make independent assessments of their follow-up evaluations, affecting its claim of having blind assessments.
Similar to Rothbaum, Astin, and Marstellar’s (2005) study which used the victim’s subjective opinion of their worst experience in order to conduct their PTSD assessment, this study also decided to focus on one single incident that the young participants or their guardians deemed significant. This is an effective method of administering EMDR, since it is more efficient in treating specific memories that are distressing to the participants. However, in a broader perspective, while a case can be made to the point that subjective opinions of individuals’ most distressing events are relevant to treating PTSD since it’s the individuals themselves who are experiencing them, it should also be pointed out that what an individual considers to be the most significant event in his/her life need not be the most significant event in terms of psychological and emotional trauma. Therefore, it should be best to conduct extensive background checks before any kind of decision is made regarding the significance of any life events.
In a study published by Taylor et al. (2003), a side by side comparison of prolonged exposure therapy and EMDR with respect to specific symptoms of PTSD was conducted to determine which technique was more effective against each of them. Compared to most other studies conducted regarding PTSD, this study had a fairly large sample size (n=60) with the majority of them being Caucasian and women. While the study employed an impressive sample size, since the participants were primarily diagnosed with chronic and severe forms of PTSD, the external validity of the results can be brought into question. However, since most of the participants of the study had chronic PTSD, it reduces the possibility that the changes that were observed in the pretests and posttests are purely due to temporal changes. The validity can be further questioned due to the difference in educational qualifications of the two therapists who administered these therapeutics techniques. However, independent expert assessment of their interrater reliability produced high scores, disproving these doubts. Moreover, the treatments were administered using standardized manuals which increased the validity of the study by ensuring that all participants received near as similar treatments as possible. This study is the first study to have achieved the aforementioned “gold Standard” for PTSD outcome treatment research (CITE). This study’s observed reductions in PTSD symptoms for all three subject groups were determined by the authors as a result of the effect of unintended exposure during relaxation training and EMDR techniques. This contradicts with the belief that in EMDR, eye movement “enhances the retrieval of episodic memory and increases cognitive flexibility” (CITE).
While exposure techniques and eye movement desensitizing and reprocessing (EMDR) are similar to each other in many ways and are efficacious in their treatment of PTSD, their approaches, implementations, and goals are quite different from one another. EMDR treats PTSD by asking the patients to subjectively choose the memory or experience that they think is causing them the most distress and treating them so that they are desensitized to this particular experience. The root of their PTSD is determined to be their most distressing memory and by desensitizing them to that experience and the re-experiencing that follows it, they are shown to have significant decrease in symptoms of PTSD. While some specialized exposure therapies employ similar approaches, others such as the NET and GBET explores an individual’s whole life or a particular period in which they were susceptible to distressing experiences respectively. This method allows the therapist to play a part in determining the most significant event in an individual’s life and adjusting the treatment process accordingly. In addition to that, since Taylor et al. (2003) showed that prolonged exposure therapy was more effective than EMDR in reducing the levels of re-experiencing and avoidance, the authors of the study concluded that it is the superior therapeutic technique. All in all, both exposure techniques and EMDR are very good at what they are supposed to do; but exposure techniques are better at it. Therefore, a hypothesis can be derived from the above discussed studies which states that specialized exposure techniques are more efficacious in the treatment of PTSD than EMDR across social and temporal demographics.
