Paper One.

Critical Literature Review – Published in the Counselling Psychology Quarterly. Distinguishing between treatment efficacy and effectiveness in Post-traumatic Stress Disorder (PTSD): Implications for contentious therapies. Mills, S., & Hulbert-Willaims, L. (2012). Distinguishing between treatment efficacy and effectiveness in Post-traumatic Stress Disorder (PTSD): Implications for contentious therapies. Counselling Psychology Quarterly, 25 (3), 319-330.

Abstract. Research psychologists often complain that practitioners disregard research evidence whilst practitioners sometimes accuse researchers of failing to produce evidence with sufficient ecological validity. We discuss the tension that thus arises, using the specific illustrative examples of two treatment methods for post-traumatic disorder (PTSD): Eye-Movement Desensitisation and Reprocessing (EMDR) and exposure based interventions. Contextual reasons for the success or failure of particular treatment models that are often only tangentially related to the theoretical underpinnings of the models are discussed. Suggestions regarding what might be learnt from these debates are put forward and implications for future research are discussed. KEYWORDS: Eye-Movement Desensitisation and Re-processing (EMDR), Post-Traumatic Stress Disorder (PTSD), Treatment Efficacy, Treatment Effectiveness, Qualitative. Introduction. In general terms, the term theory is defined as “a set of principles on which the practice of an activity is based” (Oxford English Dictionary, 2011). For Counselling Psychologists, who value inter-subjectivity, psychological theories are used to inform a practitioner’s therapeutic practice and provide “tools” that can be utilised in therapy (Moller & Hanley, 2011). Although the importance of theory in our profession is plain to see—it dominates our

language, informs therapeutic practice, and is a core component of any psychological training programme—it is not the only element that influences psychological therapy. Therapist factors such as competence have been highlighted as having an impact on therapeutic variance (Wampold, 2004) as have client factors such as personality and motivation (Onwuegbuzie & Leech, 2005). Other psychologists such as Rosenzweig (1936) and later Luborsky et al (2002), with the idea of the “Dodo Bird Effect”, have also sought to highlight the importance of commonalities in therapies such as a therapeutic alliance and allegiance. If one were to accept the “Dodo Bird Effect” as a valid description of the relative merits of different treatment models, one would have to conclude that other general factors such as a strong therapeutic alliance and allegiance are just as important as specific psychological models in determining treatment success (Wampold, 2004). Despite the regular resurgence of this idea, and regular repetition of Rosenzweig’s (1936) phrase, “All have won so all must have prizes”, applied psychology has accepted, to a great extent, the notion of evidence based practice (EBP; Newnham & Page, 2010). Derived from the medical model (Hemsley, 2010), EBP emphasises the need to find the most successful treatment method for a particular disorder as determined by the highest forms of evidence, the randomised control trial (RCT) and the meta-analysis. Such acceptance leads the National Institute of Clinical Excellence to expend effort in ensuring practitioners have up-to-date evidence on which to base their practice (Hemsley, 2010). Despite a great deal of rhetoric in applied psychology regarding the importance of evidence- based practice models, in real-world therapy settings not all practitioners rely on such evidence when choosing and delivering treatments (Newnham & Page, 2010). The current

trend for the adoption of EMDR as a treatment for PTSD is illustrative and will be taken up in this paper as an example used to demonstrate a set of more general points. Post-Traumatic Stress Disorder. Within the treatment arena of Post-Traumatic Stress Disorder (PTSD), there is a wealth of evidence that supports the use of exposure-based CBT for reducing the symptoms of PTSD and its sub-groups which include combat-related PTSD (Power et al., 2002). Such work remains topical today not least because of the recent wars in Iraq and Afghanistan. Exposure based interventions enjoy a sound theoretical grounding, having developed initially from behavioural movements with the more traditional techniques of flooding and implosion (Groves & Thompson, 1970), and later having developed alongside both cognitive and behavioural paradigms with the treatment protocol involving exposure to the feared stimuli combined with cognitive restructuring (e.g. Foa & Kozak, 1986). As well as general support for the broad theoretical orientation, which is at root an application of basic behavioural psychological principles, exposure based interventions for the treatment of PTSD also enjoy sound evidence of efficacy in the form of trial data (Foa, Dancu, Hembree, Jaycox, Meadows & Street, 1999; Foa et al 2005; Schnurr et al., 2007). In fact the research base which supports the use of exposure based interventions in the treatment of PTSD is so vast that some professionals are now terming it the zeitgeist of the disorder (Russell, 2008). Exposure based CBT: The zeitgeist of the disorder.

Studies examining the efficacy of this form of treatment go back to the early 1980s and include Frank and Stewart’s (1984) investigation into the desensitisation of female rape victims. More up to date research has reported on the success of exposure therapy when compared to other independent methods of treatment such as stress inoculation training (see Foa et al., 2005). For combat-related PTSD specifically, a number of studies report a similar trend. Research conducted by Cooper and Clum (1989) examined the effectiveness of imaginal flooding, a form of exposure therapy, over standard psychotherapeutic and pharmacologic approaches in the treatment of combat-related PTSD. The evidence from this study supported imaginal flooding in the reduction of symptoms relating to the traumatic event, including traumatic stimuli-related anxiety (F=5.58, p<.05), sleep disturbance (F=11.1, p<.01) and self-monitored nightmares (F=6.08, p<.05). Exposure therapy has also been reported as more successful in eradicating PTSD symptoms in female war veterans specifically when compared to person centred therapy. Schnurr et al. (2007) studied 277 female veterans and 7 active duty personnel with combat-related PTSD. Participants were randomly assigned to either a prolonged exposure or person-centred condition. Women who received prolonged exposure experienced a greater reduction in their symptoms than those assigned to the person-centred condition directly after treatment (d=0.29, p<.01) and this difference was maintained at 3 month follow up (d=0.24, p<.047). Despite the ascent of CBT and exposure-based therapies, and the solid evidence base they enjoy, a range of other treatment methods for PTSD have become popular during recent years. Several of these therapies have been grouped together under the title of “Power Therapies”. The Power Therapies, of which Eye Movement Desensitisation and Reprocessing (EMDR) is an example, share one thing in common: they claim to work more efficiently than the existing interventions for anxiety disorders (Herbert et al., 2000). These therapies have

been derided for a lack of adequate trial data, and for lacking theoretical substance (Devilly, 2005). EMDR: Theoretical substance. In 1989, EMDR was introduced into the therapeutic arena as a new treatment method for psychological trauma (Shapiro, 1989). Shapiro’s account of its discovery describes a happy accident, and a flash of insight. It was not based on pre-existing psychological theory (Muris & Merckelbach, 1999), and in this respect differs considerably from exposure therapy and CBT. The theoretical basis of EMDR has been challenged by component break-down studies which look to identify those mechanisms within a treatment protocol that are necessary and sufficient to achieve the established aims (Rogers & Silver, 2002). It would appear that where EMDR starts to become unstuck is in its suggestion that the dual stimulation e.g. eye movements, or finger tapping, are what makes the treatment unique and efficacious (see Herbert et al., 2000). Most studies, when testing this claim, have found that outcome is not dependent on the presence of this unique aspect of the treatment protocol though these findings are not universal (Rogers & Silver, 2002). For example, Wilson, Silver, Covi and Foster (1996) conducted a study which sought to identify the contribution of eye movements in the EMDR protocol. They compared EMDR to two identical procedures which omitted the eye movement component. The results of which indicated that the dual attention aspect of EMDR does contribute to treatment outcome as desensitisation rates were higher in the full

EMDR treatment condition than the other two conditions which omitted the use of dual stimulation. EMDR: Weaker evidence of efficacy. When comparing EMDR to the front-runner in PTSD treatment, that of exposure intervention, only a few studies have compared the efficacy of these two treatments directly. For reasons of space, it is not possible to document the results from all these comparison studies however a few will be discussed. Ironson, Freund, Strauss and Williams (2002) compared EMDR to prolonged exposure therapy in a sample of 22 traumatised out-patients. Both treatments appeared successful in reducing the symptoms of PTSD, with a larger pre- post effect size for prolonged exposure (d = 2.18, t = 5.27, p = .002) than for EMDR (d = 1.53, t = 3.36, p = .008, ds calculated by the current author). Ironson et al. (2002) compared the treatments by way of a multifactorial ANOVA which showed neither treatment to be statistically superior to the other (F=0.6, p<.82). Lee, Gavriel, Drummond, Richards and Greenwald (2002) found similar results. In their study of 24 participants, the EMDR group improved slightly more (d = 1.87) than the stress inoculation plus prolonged exposure group (d= 1.73), but the difference between the two active treatment groups did not reach statistical significance cut-offs (F =1.37, p=.29). Devilly and Spence (1999), in their comparison study, found exposure techniques when delivered through a CBT package, were superior to EMDR in reducing PTSD symptomatology, and in this case the difference reached statistical significance criteria [Λ(6,16)=.37, p < .007].

The Effectiveness—Efficacy Distinction Applied to EMDR.

Whilst there is some promise in terms of EMDR’s efficacy from the research noted above, even a charitable interpretation would have to acknowledge that the evidence base for EMDR is weaker than that for exposure therapy, with respect to PTSD. Some psychologists go much further and describe EMDR as “pseudoscience” (Herbert et al., 2000) and urge the abandonment of research on EMDR and similar therapies categorised as such. We feel that such a position fails to take into account an important distinction between treatment efficacy and treatment effectiveness in psychological therapy. Taking physical medicine, where the terms efficacy and effectiveness are derived, as an accessible example: Drugs and procedures can often be efficacious, bringing about desired outcomes due to the nature of their chemical or mechanical properties, and yet lack effectiveness because they are not well adopted by doctors and patients. The classic example is poor treatment adherence due, for instance, to undesirable side effects. In medical research, it is widely accepted that an intervention might be highly efficacious, and yet have poor effectiveness in practice, whilst treatments of lesser efficacy might produce moderately successful outcomes in terms of practical efficacy (Marchand, Stice, Rohde & Becker, 2010). EMDR enjoys high client satisfaction with regard to dropout figures and treatment side effects (Marcus, Marquis & Sakal, 1997; Wilson, Becker & Tinker, 1995) and has seen a meteoric rise in the number of therapists trained to deliver EMDR. With this in mind, we suggest that EMDR might offer some advantages over exposure based therapies in regard of various contextual factors. A number of these contextual factors could be hypothesised to be

associated with the high acceptability of, and considerable therapist loyalty to, EMDR in light of the erstwhile acceptance of exposure-based treatments. The client experience. It is not a new suggestion that prolonged exposure is thought to be distressing and so is poorly tolerated by many clients (Scott & Stradling, 1997). Exposure therapies, particularly the more traditional methods of flooding, involve the client repeatedly re-visiting the memory that they find traumatic in an attempt to desensitise them to the feared stimulus. Pitman and colleagues (1991) in their study which examined six case vignettes found re-occurring complications which they believe to be “under-recognised” in flooding therapy for PTSD. For instance they document how this type of therapy can produce adverse consequences such as an exacerbation of feelings relating to guilt, self-blame and failure. Whilst some researchers such as Feeny and colleagues (2003) disagree, arguing instead that most clients can tolerate and do benefit from exposure based interventions, there is a good deal of commentary in the literature on how exposure therapy is not suitable for all PTSD sufferers (e.g. Litz et al., 2010). Client factors have been discussed in terms of treatment success for exposure based interventions. It has been suggested that clients presenting with anger (Jaycox & Foa, 1996), alcohol abuse (Pitman et al., 1991), suicidal ideation and avoidance, as measured through session attendance, (Tarrier, Liversidge & Gregg, 2006) may affect treatment outcome. Worryingly, Axis I disorders such as depression are often associated with PTSD (Strachan, Gros, Ruggiero, Lejuez & Acierno, 2011) and dysfunctional readjustment traits such as alcohol abuse are notably high in veterans returning from war in both the US and UK (Rona, Jones, Fear, Hull, Hotopf & Wessely, 2010; King’s Centre for Military Health Research, 2010).

Comparatively, within the United States at least, EMDR has been recognised by The Department of Veterans’ Affairs and Department of Defence (2004) as being less distressing than exposure therapy and suitable for those PTSD sufferers who might not benefit from exposure therapy (Russell, 2008). EMDR is considered more associative in nature compared to the directive aspects of exposure therapy and it focuses on brief rather than prolonged exposure to the traumatic memory (Rogers & Silver, 2002). Evidence supplied by Wilson et al (1996) found that the dual attention component of EMDR treatment is associated with relaxation in clients and as such is useful in regulating the level of distress caused by the exposure component of the EMDR protocol. The current evidence does not permit a strong conclusion, but it appears that EMDR may be less distressing than prolonged exposure, either because of the nature of the treatment or because a specific element of the treatment has a relaxing effect. The therapist experience. By most measures, the evidence base for exposure-based therapies, especially exposure-based CBT is stronger, but data suggest that only about twenty percent of practitioners who specialise in the treatment of anxiety disorders use this type of therapy to treat PTSD (Tarrier et al., 2006). For combat-related PTSD specifically, Fontana, Rosenheck and Spencer (1993) in their study of 4000 Veterans with PTSD, found that exposure therapy was used to treat fewer than 20% of this population and was the primary treatment in only 1% of cases. Therapist fears of addressing the trauma directly, a concern that the treatment will exacerbate the symptoms in sufferers, and the distressing nature of the treatment are highlighted as the main reasons for therapist reluctance in utilizing this type of treatment (Becker, Zayfret & Anderson, 2004).

Whilst there appear to be notable difficulties in matching the acceptance of exposure therapy from research into practice, it has been shown that when exposure therapy is used in real- world therapy settings it is successful in reducing PTSD symptomatology. A recent study by Tuerk et al. (2011) recruited 65 veterans of the recent Afghanistan and Iraq wars receiving care in a Veterans Administered (VA) Healthcare context to examine this point. Whilst they did not use a control group, Tuerk and colleagues did successfully manage to demonstrate that exposure therapy can be applied to real-world therapy settings by showing that prolonged exposure was as successful in reducing the symptoms of combat-related PTSD in this type of setting as in Randomised Control Trails (RCTs). Whilst this is the case, the aforementioned utilisation rates for exposure based interventions are concerning. Comparatively, it would appear that EMDR is warmly received by a substantial proportion of therapists. There is currently an international association, conference and journal devoted to EMDR for example (Becker, Darius & Schaumberg, 2007). For combat–related PTSD specifically, EMDR is now being recommended as a treatment option for combat-related PTSD in the US (EMDR Institute; Department of Veterans’ Affairs and Department of Defence, 2004) and is frequently offered in local Military Community Mental Health departments in the UK (Wesson & Gould, 2009). Numerous studies have compared the dropout rates in exposure based conditions with the dropout rates in other therapy conditions. Some of these studies have found increased dropout rates in exposure therapy when compared to supportive therapies for PTSD (Schnurr et al., 2007), with others finding no association between treatment method and dropout rates (Feeny, Hembree and Zoellner, 2003). Factors affecting dropout have also been researched.

Demographic factors (Tarrier, Sommerfield, Pilgrim & Faragher, 2000), pre-treatment symptom severity (Minnen, Arntz & Keijsers, 2002) and feelings of shame, anger and guilt (Jaycox & Foa, 1996) are just some of the variables thought to influence dropout rates in PTSD treatment. For EMDR, dropout rates have not been studied as extensively as they have for exposure therapy. A cursory cross-study comparison suggests 10% dropout rates can be expected from EMDR (Marcus et al., 1997; Wilson et al., 1995), compared to rates above 25% for exposure therapy (e.g. Foa, Rothbaum, Riggs and Murdoch, 1991). On the one occasion where dropout rates for these two therapies were compared within the same study, tentative evidence of higher dropout rates in exposure therapy is reported (Ironson et al., 2002). The EMDR Movement. Shapiro (2002) has claimed that approximately 25,000 therapists are now fully trained in delivering EMDR as a treatment method to clients. Anecdotal evidence and a cursory perusal of any psychological training bulletin board would support such a number. It has been accepted into the National Institute of Clinical Excellence guidelines (NICE, 2012) as a recommended treatment method for PTSD alongside exposure therapy and is quickly gaining recognition in US and UK military settings (Russell, 2008). Alongside its recommendations for PTSD and combat-related PTSD, it is also being more widely used in the treatment of other common psychological disorders such as Phobias (Muris & Merckelbach, 1997) and Panic (Feske & Goldstein, 1997), although it has not yet gained acceptance by NICE for these disorders (Nowill, 2010). With these points in mind, few psychologists would argue the point made by McInally (1999) that EMDR “has grown quicker than the psychoanalytic and behavioural movements”.

Despite the contentious issues which surround EMDR in terms of theoretical grounding and efficacy, there is evidence to show that the therapy is gaining quick momentum, as highlighted above. In addition to the aforementioned intrinsic factors relating to the therapy’s processes, some professionals have also posited a sociological explanation for its rapid growth. In his article entitled “Power Therapies and possible threats to the science of psychology and psychiatry”, Devilly (2005) refers to some common social factors deployed by certain pseudoscientific therapies, of which he includes EMDR, to explain the adherence of clients and therapists to these therapies. With reference to these factors, Devilly (2005) refers to the hard hitting article made by Pratkanis (1995) that puts forward nine necessary qualities that a pseudoscience must possess so that people can “buy into the concept”. The factors highlighted by Pratkanis (1995) include such terms as “creating a phantom”, by which he describes developing a concept that brings hope to something that appears hopeless. In the context of EMDR Devilly (2004) connects this to Shapiro’s claim that the therapy was 100% successful after one session. Something which gave other professionals hope in the otherwise hopeless domain of treatment for such a complex disorder. Whilst the likely existence of contextual and social factors such as those identified by Pratkanis (1995) and their relevance to the adoption of EMDR as described by Devilly (2005) should be acknowledged, labelling EMDR mere ‘pseudoscience’ may in fact exacerbate the in-group out-group thinking of therapists trained in this tradition and further alienate them from a discourse on the evidence for and against the EMDR model. For applied psychologists who place high value on the scientist–practitioner model of research and therapy (Moller & Hanley, 2011), these strong social concepts cannot be ignored if we want to retain our professional standing. The question of whether a therapy is adopted for purely

pseudoscientific reasons, for contextual reasons to do with the distinction between efficacy and effectiveness, or because of experimental evidence, goes to the very heart of whether psychologists can truly describe themselves as scientist-practitioners. It is crucial that EMDR and other power therapies be studied for what they are, for what they might offer, and for how they have achieved such popularity in such a short time, though this is no reason to dispense with inquiry. Other researchers too (e.g. Sikes and Sikes, 2003) have contrasted exposure based interventions and EMDR in terms of efficacy, theoretical grounding and effectiveness, suggesting that this relative mismatch needs to be explained. The “wagging finger” need not be pointed at new and innovative ideas but instead be pointed at the way in which psychological research is conducted in general. With this in mind, it has been suggested that therapies such as EMDR, might be better suited to a practice-based evidence (PBE) mode of enquiry rather than from the traditional evidence based practice (EBP) perspective (Nowill, 2010). The transition from EBP to PBE is thought to be a worthy one as ever increasingly EBP is being criticised for being compatible with certain modes of treatment akin to the medical model such as CBT, and not with others (Newnes, 2007; Hemsley, 2010). Alongside the suggestions made for a change in how psychological research is conducted with respect to PBE, it is also argued here that there is a need for client-centred research to be more widely adopted in the PTSD treatment arena. Client-Centred Research. For some time, a number of practitioners have been calling for an enhanced place for the client perspective in the science of psychological intervention (Stewart and Chambless,

2010). Such research would help us answer the question we have posed: why are theoretically sound and efficacious treatment methods in PTSD sometimes not terribly effective in practice? To date, very little is known about the client experience of trauma therapy. Becker et al. (2007) examined client preferences for exposure versus alternative treatments for PTSD, including EMDR, in individuals with varying degrees of trauma history. Their participants were asked to imagine undergoing a trauma, developing PTSD and seeking treatment. Participants showed a preference for exposure therapy over EMDR, though Becker and colleagues acknowledge the lack of ecological validity of their findings since their sample did not include participants suffering from PTSD, and relied instead on participants imagining themselves in the situation. Qualitative psychological methods, especially phenomenological ones, offer tools to examine the client experience and generate insights into the efficacy-effectiveness question in an inductive manner (see Hanson, 2004). Whilst this is the case, qualitative methods are underutilised in research. This is demonstrated by a lack of available qualitative research published (Rennie, Watson & Monteiro, 2002). It is suggested that this bias is due to the traditional views that “good” research is based on falsifiable theories and outcome measures that can be generalised to the wider population, all of which sit comfortably within an EBP framework (Fairfax, 2008). For the treatment of PTSD, it would appear that the research base has followed this trend. Whilst there is a wealth of quantitative research documenting the efficacy of treatment protocols, there is little evidence aimed at un-picking the reasons for the

efficacy/effectiveness anomalies presented in this article. By drawing upon other research which has documented the usefulness of qualitative enquiry by allowing a more intricate understanding of the ingredients and processes within therapy (see Berry & Hayward, 2004), it is suggested that this might be a worthy transition in the field of PTSD research. This seems even more relevant when we look at the growing appreciation, within psychology at least, that generalised findings from RCTs are inhibited because of individual differences found in both therapist and client (Fairfax, 2008). Conclusion. The importance of finding appropriate treatment methods that can be used to help clients presenting with the symptoms of PTSD is considerable. The evidence base is currently dominated by RCTs where client satisfaction, therapist burden, dropout rate and other similar factors are far from the primary outcome measures, and are often considered extraneous. In these studies, exposure based interventions have proven to be the gold standard, not only because of their proven efficacy but also because of their strong theoretical underpinnings. It has been proposed that the poorer uptake of these treatments, as compared with EMDR in the current example, reflects a research base which does not adequately take account of the distinction between efficacy in research settings and effectiveness in real-world therapeutic settings. Throughout the current paper it has been suggested that PTSD research would benefit considerably from an increased attention to practical effectiveness. This will require the adoption of a client-centred research model where the client experience is central.

Paper Two. Research Report. How do veterans make sense of their disengagement from traditional exposure therapy and their subsequent engagement in a non-exposure based intervention for Post- traumatic Stress Disorder (PTSD)? An Interpretative Phenomenological Analysis.

Abstract Exposure therapy is a proven efficacious treatment for PTSD however its effectiveness in real world practice is limited by high rates of premature dropout, particularly for veterans of war. The current study aimed to explore this anomaly by qualitatively examining how veterans make sense of their engagement or disengagement from PTSD treatments; Exposure Therapy and Spectrum Therapy. Semi-structured interviews were conducted with seven veterans who had dropped out of exposure therapy and the transcripts were analysed using Interpretative Phenomenological Analysis (IPA). A number of corresponding themes were grouped together into four super-ordinate themes: The Importance of Control, The Importance of Positive Change, The Problem with Emotion and The Importance of Relationships. From these findings we draw a number of suggestions for improving engagement including the importance of explaining the rationales behind the treatment protocols and the importance of teaching techniques to manage, rather than avoid, emotions generated through therapy. The findings may help therapists to further explore the difficult matter of improving therapy for this client group so that drop-out rates can be reduced and engagement increased. KEYWORDS: Posttraumatic Stress Disorder (PTSD), Combat, dropout, engagement, efficacy, effectiveness, Interpretative Phenomenological Analysis (IPA). It remains evident that, as a profession, we have at our disposal a highly successful treatment method for reducing the symptoms of PTSD; exposure therapy (see Bradley et al, 2005; Bisson and Andrew, 2005; Schnurr et al, 2007). Specifically, in the domain of combat-related

PTSD, exposure-based interventions have proven useful for soldiers presenting with the symptoms of PTSD in the aftermath of both the Gulf and Vietnam wars (Yoder et al, 2012). Moreover, in relation to veterans returning from the wars in Iraq and Afghanistan, Rauch et al (2009) found traditional exposure therapy to be successful in reducing the symptoms of PTSD in a naturalistic setting, albeit through a modest sample size (N=10). Owing to successful trial data and meta analyses of such data, exposure therapy has been accepted by the National Institute of Clinical Excellence guidelines (NICE, 2008), as an evidence-based treatment for PTSD in general populations and is recommended by the Department of Veterans Affairs for use within the military (Garcia, Kelley, Rentz & Lee, 2011). Exposure Therapy might not be the whole answer. Despite the supportive trial data regarding the efficacy of exposure techniques in reducing PTSD symptoms, there is some evidence that this type of therapy is not as successful when applied to real world clinical populations (see Cook, Schnurr & Foa, 2004). It has been reported for combat-related PTSD specifically that therapists are reluctant to apply this therapy in military settings (Fontana, Rosenheck and Spencer, 1993). Therapist fears of addressing the trauma directly, a concern that the treatment will exacerbate the symptoms in sufferers, and the distressing nature of the treatment are highlighted as the main reasons for therapist reluctance in utilizing this type of treatment (Becker, Zayfret & Anderson, 2004). In addition, dropout rates from exposure therapy have been reported as higher than those from supportive therapy in female war veterans (Schnurr et al, 2007). Dropout figures and reduced session attendance from exposure therapy are reported as higher for veterans returning from the recent wars in Iraq and Afghanistan than for those veterans returning from the Vietnam War (Erbes, Curry & Leskela, 2009).

How can future research help address the efficacy-effectiveness distinction in the treatment of PTSD? There appears to be a clear disconnect between what is accepted in clinical practice in the treatment of PTSD by both clinician and client, and what is supported through research trials. On the other side of this debate are those therapies that have been shown to be less scientifically coherent or even less efficacious than exposure therapy but are more widely accepted by both clinician and client in the treatment of PTSD. EMDR for example is acknowledged as having a less solid evidence base than exposure therapy (see Devilly & Spence, 1999) and its mode of action i.e. the dual stimulation aspect of therapy, has been critiqued (see Herbert et al, 2000). Regardless of these scientific problems, EMDR enjoys higher client satisfaction as determined by dropout rates and rapid therapist adherence in real- world practice (Marcus, Marquis & Sakal, 1997; Wilson, Becker & Tinker,