The British Journal of Psychiatry (2016)

209, 311–318. doi: 10.1192/bjp.bp.115.167775

Eye movement desensitisation and reprocessing

therapy v. stabilisation as usual for refugees:
randomised controlled trial
F. Jackie June ter Heide, Trudy M. Mooren, Rens van de Schoot, Ad de Jongh and Rolf J. Kleber

Background Results
Eye movement desensitisation and reprocessing (EMDR) Intention-to-treat analyses found no differences in safety (one
therapy is a first-line treatment for adults with post-traumatic severe adverse event in the stabilisation condition only) or
stress disorder (PTSD). Some clinicians argue that with efficacy (effect sizes: CAPS –0.04 and HTQ 0.20) between the
refugees, directly targeting traumatic memories through two conditions.
EMDR may be harmful or ineffective.
Conclusions
Aims Directly targeting traumatic memories through 12 h of EMDR
To determine the safety and efficacy of EMDR in adult in refugee patients needing specialised treatment is safe, but
refugees with PTSD (trial registration: ISRCTN20310201). is only of limited efficacy.

Declaration of interest
Method A.d.J. reports receiving personal fees from teaching activities
In total, 72 refugees referred for specialised treatment were and from books about trauma and its treatment (including
randomly assigned to 12 h of EMDR (3660 min planning/ EMDR). He is a board member of the Dutch EMDR
preparation followed by 6690 min desensitisation/ Association and the EMDR Europe Association.
reprocessing) or 12 h (12660 min) of stabilisation. The
Clinician-Administered PTSD Scale (CAPS) and Harvard Trauma Copyright and usage
Questionnaire (HTQ) were primary outcome measures. B The Royal College of Psychiatrists 2016.

Experiences of war and organised violence in combination with

Method
post-migration stressors1 leave asylum seekers and refugees in
Western countries at relatively high risk of developing post-
The trial was performed at Foundation Centrum ’45, a highly
traumatic stress disorder (PTSD).2,3 PTSD in adult refugees has
specialised Dutch centre for diagnostics and treatment of
been shown to pose a burden not only for individuals and their
psychotrauma resulting from persecution, war and violence.
families,4 but also for communities at large.5 Psychological treatment
Centrum ’45 receives national referrals of patients considered
for refugees with chronic PTSD, although imperative, is a great
too complex to be treated in their own municipalities. Participants
clinical challenge.6 According to evidence-based guidelines for
were enrolled at two out-patient teams for refugees (in the
the treatment of adults with chronic PTSD, trauma-focused
towns of Oegstgeest and Diemen). Patients judged eligible for
cognitive–behavioural therapy (TFCBT) and eye movement
participation were asked by their intake therapists if they wished
desensitisation and reprocessing (EMDR) therapy should be
to receive any information about the study and, upon consent,
offered to all patients with this disorder.7,8 With refugee patients
were informed about the study by a research associate. Both
the experience-based recommendation is often made that
treatments were presented as aimed at diminishing PTSD
trauma-focused treatment should be preceded or even replaced
symptoms: EMDR through desensitisation of traumatic
by stabilisation.7,9 Trauma-focused therapy per se, especially for
memories, stabilisation through enhancement of coping with
refugees living in unstable conditions, has been suggested to cause
PTSD symptoms and stressful circumstances in the here-and-
unmanageable distress10 and to be inappropriate and ineffective.7
now. Those willing to participate signed an informed consent
Nevertheless, systematic reviews of the psychological treatment of
form and were then interviewed with the MINI International
refugees have shown TFCBT and narrative exposure therapy
Neuropsychiatric Interview (MINI)14 to formally check inclusion
(NET) to be safe and efficacious with refugees in various social
and exclusion criteria. Data collection took place from September
conditions.10–12 However, no full, high-quality randomised trials
2009 until August 2012. The trial was approved by the medical
of EMDR therapy with refugees have yet been conducted. To
ethics committee of the University of Leiden. Trial registration:
determine the safety and efficacy of EMDR therapy in traumatised
NARCIS (Dutch National Academic Research and Collaborations
refugees, we designed a trial in which adult asylum seekers and
Information System) OND1324839; ISRCTN20310201.
refugees with chronic PTSD were randomly assigned to either
EMDR therapy or stabilisation. In line with a pilot study13 and
evidence-based guidelines, our first hypothesis was that EMDR
therapy would not differ from stabilisation in the occurrence of Study entry criteria
harms (defined as symptom increase and drop-out related to Refugees who applied for treatment at Centrum ’45 were eligible
symptom increase). Our second hypothesis was that EMDR for participation if they were at least 18 years of age, met the
therapy would be more efficacious than stabilisation in reducing criteria for a PTSD diagnosis according to the DSM-IV-TR,2
trauma-related symptoms (PTSD, anxiety and depression) and and asked for individual therapy to diminish their PTSD
improving quality of life. symptoms. Patients who had at some point claimed asylum in

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The Netherlands – irrespective of whether their claim had been course and use of interpreters, discussing the patient’s explanatory
met or rejected or was still under consideration – were defined model and subsequently providing psychoeducation on PTSD and
as ‘refugee’. Patients were excluded if they had disorders that EMDR, and making a timeline of traumatic experiences and
acutely threatened their mental or physical health (i.e. depression symptoms). Traumatic memories that were expected to lead to
with high suicidal intent or psychotic features, psychotic disorder, the greatest remission of PTSD symptoms were selected for
bipolar disorder and severe self-harm or eating disorders) or that desensitisation. The preparatory sessions were followed by six
interfered with their ability to participate (i.e. alcohol or substance 90 min desensitisation sessions, using the Dutch version of the
dependence and cognitive disorders). No restrictions were placed EMDR protocol.21 Stabilising interventions were proscribed. The
on either refugee status or language proficiency. No other EMDR condition was performed by seven clinical psychologists,
psychotherapeutic treatment could take place during the study, one physician/psychotherapist and two psychotherapists. Only
and psychotropic medication had to be kept stable from 2 months therapists who had earlier in their career completed an accredited
before treatment until the post-treatment assessment. For those advanced EMDR course participated. Their average experience in
participants who developed high suicidal intent, a psychotic EMDR therapy was 5.3 years (s.d. = 2.9). They received monthly
disorder or another serious psychiatric disorder during the study, supervision by a licensed EMDR supervisor.
a psychiatric consultation was prescribed during which the The stabilisation condition consisted of 12 sessions of 60 min
necessity of prescribing or changing psychotropic medication stabilisation as usual. In phase-oriented treatment for PTSD, the
(using a medication protocol) and of discontinuation of the first phase or stabilisation phase is aimed at enhancing safety,
intervention were to be evaluated. control over symptoms and socio-psychological competencies
through interventions such as emotion regulation and relational
Trial design skills building, stress management and cognitive restructuring;
processing of traumatic memories is left until the second phase.9
A two-arm design was used in which participants were randomly
Stabilisation as usual, rather than a structured form of
assigned to either 12 h (9 sessions) of EMDR therapy or 12 h (12
stabilisation, was chosen as a control condition to reflect the
sessions) of stabilisation as usual. To create maximum ecological
regular non-structured stabilisation offered in European mental
validity, the recommended session length of EMDR and stabilisation
healthcare centres for refugees.22,23 Therapists were asked to select
was preserved,7 and conditions were equated on number of treat-
stabilising interventions to match their patient’s needs. Exposure
ment hours rather than number of sessions. Twelve treatment
to traumatic memories was proscribed. Stabilisation was
hours is considered a minimum to reach improvement in multiply
performed by three clinical psychologists, five psychotherapists,
traumatised patients.7
one physician/systemic therapist, one psychiatrist, one social
Blocked, simple randomisation was conducted with the latest
psychiatric nurse, two psychiatrists in training and one
two participants who had satisfied the inclusion criteria at the
psychotherapist in training. Those therapists participated who
same study site forming a block. Participants were assigned to
regularly conducted stabilising interventions in their usual care.
their experimental group through flipping a coin: the outcome
Their mean number of years of experience in working with
(EMDR therapy for heads, stabilisation for tails) was assigned to
traumatised refugees was 9.9 (s.d. = 5.5), which did not differ
the participant lowest in the alphabet. An independent research
from EMDR therapists’ experience (mean 9.00, s.d. = 5.5;
associate who was not otherwise involved in the inclusion process
t(22) = 70.41, P = 0.75). Stabilisation therapists received monthly
performed randomisation. As both the EMDR condition and the
supervision from a registered cognitive–behavioural and family
stabilisation condition contained active treatment elements, the
therapy supervisor/trainer with a specialisation in trauma therapy.
design was complemented with a naturalistic waitlist condition
For both conditions, therapist manuals were designed with
to control for time (see online supplement DS1). Primary
information on the study methods (such as study design and rules
outcome measures consisted of the change in PTSD symptom
for drop-out), study treatment (such as pre- and proscribed
severity and diagnosis, both clinician-rated (Clinician-Administered
elements), the medication protocol and camera use (manuals
PTSD Scale, CAPS)15 and self-administered (Harvard Trauma
available from the authors on request). To assess treatment
Questionnaire, HTQ).16 Secondary outcome measures were
integrity, treatment sessions were videotaped. For the EMDR
changes in anxiety and depression (Hopkins Symptom Checklist,
condition, a detailed treatment fidelity scale was put together
HSCL-25)17 and quality of life (World Health Organization
consisting of the scale used in a Dutch EMDR trial24 and
Quality of Life Assessment, WHOQOL-BREF).18 Harms were
additional prescribed, proscribed and non-specific elements. For
defined as an increase in PTSD symptoms of at least ten points
the stabilisation condition, a brief treatment fidelity scale was
on the CAPS19 and premature termination of the study treatment
designed containing prescribed, proscribed and non-specific
because of symptom increase. All instruments were administered
elements. All interventions were delivered in Dutch when possible
before treatment (T1), 2 weeks post-treatment (T2) and at a
and translated by registered interpreters (physically present or by
3-month follow-up (T3). After T2, participants converted to care
telephone) when necessary.
as usual.

Interventions Measures
EMDR therapy is a trauma-focused treatment that consists of PTSD severity and diagnosis were measured by the CAPS and
several steps including treatment planning, preparing the patient the HTQ. The CAPS yields frequency and intensity scores (ranging
for trauma-focused treatment, desensitisation and reprocessing, from 0 to 4) for all PTSD symptoms according to the DSM-IV-TR
and evaluation. During desensitisation and reprocessing (which in the past week. A symptom was considered present if its
is considered the main active element) a focus on a traumatic frequency was rated as at least 1 and its intensity as at least 2.25
image and the thoughts, sensations, feelings and memories that To capture full PTSD severity, interviewers referred to clusters of
it elicits, is combined with an attention-demanding task such as war or persecution experiences rather than to one index traumatic
tracking the therapist’s fingers with the eyes.20 The EMDR event. The HTQ consists of three parts: one on traumatic events,
condition started with three 60 min sessions dedicated to one on DSM-IV trauma symptoms, and one on other trauma
treatment planning and preparation (including discussing study symptoms. Scores for the symptom parts range from 1 (not at

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 Eye movement desensitisation and reprocessing therapy for refugees

all) to 4 (extremely). Anxiety and depression were measured using to be present when the credibility interval does not include zero. A
the HSCL-25, which uses the same scale. Quality of life was difference in treatment effect between conditions can be assumed
measured by the WHOQOL-BREF, which measures four domains to be present when credibility intervals between conditions do not
of quality of life (physical, psychological, social relationships, and overlap. As a measure of effect size between conditions we divided
environment) on a scale of 1–5 (a higher score indicating a higher the difference between the linear slopes by the square root of the
quality of life). All of these instruments have good psychometric linear slope’s variance (which is equal for the two conditions).33
properties and are widely used in transcultural research.26–29 Finally, to analyse individual changes in post-traumatic stress
Interpreters were used whenever the participant did not speak scores over time and to identify predictors in the separate
Dutch and the instrument was not available in the participant’s treatment conditions, we applied a multigroup latent growth
native language. To maximise participant understanding of the model to the data. Latent growth modelling (LGM) enables an
questionnaires while minimising dependency on individual examination of individual growth trajectories for each condition,
interpreters’ skills, where possible we used questionnaires in the allowing participants to have a different starting point (i.e. a
participant’s native language that had been carefully translated random intercept model) and a different growth rate (i.e. a
by our institute (HTQ, HSCL)30 or by the WHOQOL Group random slope model). The R-squared statistic provides the
(WHOQOL-BREF).18 Interviews were administered by trained proportion of variance in post-traumatic stress symptoms that is
Master’s students in psychology who were kept masked to explained by the latent growth factors. The posterior predictive
treatment condition by having limited access to participant data P-value was checked as an indication for model fit (outcome files
and by asking participants not to reveal treatment content. They available from the authors on request).
received monthly supervisions of their CAPS ratings using
videotaped interviews. Participants received a gift coupon at T2 Results
and a box of chocolates at T3.
Participants
Participant flow during the trial is depicted in Fig. 1. The flow
Statistical analysis diagram includes all patients who met inclusion criteria at intake,
Sample size was calculated with the power analysis program i.e. before they were informed about the study and formally
G*Power version 2 for Windows (Erdfelder, Faul and Buchner at interviewed.34 Although the inclusion of 72 participants was
the University of Trier, Germany, www.psycho.uni-duesseldorf.de/ planned, 2 participants who terminated their participation
aap/projects/gpower/). Power calculations were based on outcomes before the first treatment session, unaware of which condition
of our pilot study, which resulted in a medium effect size between they had been assigned to, were replaced as it was clear that no
EMDR and stabilisation on the HTQ.13 For the main study, a post-treatment data could be obtained for them.
sample size of 36 patients per condition was needed (using a Chi-squared and t-tests revealed no significant demographic
power of 0.80, a two-sided significance level of 0.05 and three or clinical differences between participants and those who refused
repeated measures) to detect a medium between-treatment effect to participate (data available from the authors on request). Table 1
size at T3. In response to reviews of our pilot study, in the final shows demographic and clinical characteristics for the two groups
analyses we used a statistically more advanced variation of the at baseline (see online Table DS1 for a version of this table that
planned analysis strategy (Bayesian latent growth modelling details a wider range of demographic characteristics). The EMDR
instead of repeated measures analysis), which the sample size group was found to contain significantly fewer female participants
allowed for.31 than the stabilisation group. Types of traumatic experiences most
Treatment fidelity, interrater reliability and demographic and frequently reported in the HTQ were being close to death (60/72,
clinical variables were analysed with SPSS version 20.0 for 83%), murder of family or friend (54/72, 75%) and threatened
Windows. Chi-squared and t-tests were conducted to check for with torture (52/72, 72%). Drop-out numbers for the two groups
demographical and clinical differences between participants and were comparable, with 6 EMDR participants (16.7%) and 8
those who refused to participate as well as between the two treatment stabilisation participants (22.2%) discontinuing the intervention
conditions. Mean scale and subscale scores were computed, allowing (w2(1,n = 72) = 0.36, P = 0.55). One participant, in the stabilisation
for a maximum number of three missing values in the HTQ and group, terminated treatment prematurely because of symptom
HSCL and following the questionnaire manual rules for missing increase (attempted suicide). In both groups, asylum seekers and
values for the WHOQOL-BREF. Chi-squared tests (for treatment those in the country illegally were no more likely to drop out of
condition, gender, refugee status, drop-out, use of an interpreter treatment than participants with a refugee status (EMDR therapy:
and work status) and t-tests (for age, distance from home to w2(1,n = 36) = 0.05, P = 0.83; stabilisation: w2(1,n = 36) = 0.05,
treatment centre, and CAPS score at baseline) were conducted P = 0.83).
to explore relationships between missing values and demographic
and clinical variables. Treatment integrity and content
Data were then converted to Mplus version 7 (Muthén and Treatment integrity was rated by four trained graduate-level
Muthén at University of California, www.statmodel.com/). Bayesian research assistants. We randomly selected 12.5% of all treatment
estimation was used in all analyses with the default settings in sessions for rating of treatment fidelity. Interrater agreement was
Mplus with regard to prior specifications.32 Bayesian analysis determined for the first three ratings for both conditions. As this
enables full intent-to-treat analysis as missing data are was consistently high (Cronbach’s a = 0.95 for EMDR and 1.0 for
automatically imputed. For the burn-in and convergence criteria stabilisation), interrater agreement was deemed to be satisfactory
we used a minimum of 20 000 iterations after which the and was not monitored thereafter.
Gelman-Rubin convergence criterion32 was used to monitor For the EMDR group, 36 out of 291 sessions were rated, a
convergence with a cut-off value of 0.01. Additionally, to ensure third of which were taken from the preliminary sessions and
convergence was reached, we checked the trace-plots manually. two-thirds of which from the EMDR protocol sessions. The mean
In Bayesian statistics, credibility intervals are used to indicate treatment fidelity score for the preliminary sessions was 97.0
the 95% probability that the estimate will lie between the lower (s.d. = 3.0) and for the protocol sessions 87.8 (s.d. = 9.2) on a scale
and upper value of the interval. A treatment effect can be assumed of 0–100. For EMDR treatment completers (n = 30), subjective

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Enrolment: 224 Met inclusion criteria

patients at intake

81 Excluded at intake and/or screening:

– 5 no full diagnosis of PTSD
7 – 76 interfering comorbid disordersa
69 Declined to participateb

74 Randomised

6
6 6
Allocation:
37 Allocated to EMDR therapy patients 37 Allocated to stabilisation as usual
– 36 started intervention – 36 started intervention
– 6 discontinued interventionc – 8 discontinued interventiond
– 1 did not start intervention – 1 did not start intervention

6 6
Allocation:
10 care providers; 2 teams care providers 14 care providers; 2 teams
Patients treated by each care provider: Patients treated by each care provider:
– median 3 (IQR 1, range 1–4) – median 3 (IQR 2.25, range 2–5)
Patients treated by each team: Patients treated by each team:
– 15 and 21 patients per team – 16 and 20 patients per team

6 6
Follow-up:
5 Lost to follow-up assessment patients 5 Lost to follow-up assessment
– 4 refused to complete assessment – 4 refused to complete assessment
– 1 was not approached for assessment – 1 was not approached for assessment

6 6
Analysis:
36 Analysed patients 36 Analysed
1 Excluded from analysis because of not 1 Excluded from analysis because of not
receiving any treatment receiving any treatment

Fig. 1 CONSORT flow diagram.

EMDR, eye movement desensitisation and reprocessing; IQR, interquartile range.
a. 34 substance or alcohol dependence, 7 self-harm, 3 cognitive disorder, 5 eating disorder, 10 serious suicidal ideations, 16 psychotic disorder, 1 bipolar disorder.
b.10 did not want any help at the institute, 30 found participation too much hassle, 18 did not want trauma-focused treatment, 3 did not want stabilisation, 2 did not want treatment
for post-traumatic stress disorder (PTSD), 6 refused for various study-related reasons.
c. 3 did not show up for 4 consecutive appointments; 1 thought the travel distance too great; 2 did not want to continue trauma-focused therapy.
d. 6 did not show up for 4 consecutive appointments; 1 developed high suicidal intent; 1 wanted to change to trauma-focused therapy.

unit of distress (SUD) scores decreased significantly from the start negative emotions, and active problem-solving by participant
of treatment to the end of treatment (from a mean of 8.3, s.d. = 1.7 and therapist.
to a mean of 3.9, s.d. = 3.7, t(29) = 7.5, P50.001), with only 11 For three EMDR participants and three stabilisation participants
participants reaching the desired SUD of 0–1. Mean number a change of medication took place during the study. In most cases
of targets treated was 1.6 (s.d. = 1.0, range 1–5), with most this entailed a new or changed prescription for antidepressants.
participants (19/30, 63%) staying with one target.
For the stabilisation group, 48 out of 387 sessions were rated.
The mean treatment fidelity for the stabilisation condition was Reliability
88.7 (s.d. = 8.9) on a scale of 0–100. For these 48 sessions the main To assess interrater reliability, 12.5% of all interviews (MINI and
interventions were registered using an intervention menu.13 The CAPS) were randomly selected, using stratification for time of
most frequently registered interventions were discussing and assessment. Interrater reliability for the decision whether or not to
teaching of coping strategies, identification and validation of include a patient in the study (using the MINI; 12.5%, 12/94) was

Table 1 Demographic and clinical characteristics before treatment a

EMDR group Stabilisation group
(n = 36) (n = 36) w2 (d.f.) t-test (d.f) P

Age, years: mean (s.d.) 43.1(10.7) 39.8 (11.9) 1.26 (70) 0.21
Women, n (%) 6 (16.7) 14 (38.9) 4.43 (1) 0.04
Types of traumatic experiences, HTQ: mean (s.d.) 13.8 (5.5) 13.7 (5.6) 0.85 (70) 0.93
Years with PTSD, mean (s.d.) 7.9 (7.2) 8.0 (6.5) 70.41 (59) 0.97
Comorbid depression, n (%) 28 (77.8) 28 (77.8) 0.00 (1) 1.00
On psychotropic medication, n (%) 21 (58.3) 21 (58.3) 0.00 (1) 1.00
CAPS symptom severity, mean (s.d.) 74.7 (18.0) 78.3 (18.3) 70.83 (70) 0.41
Use of interpreter during study treatment, n (%) 20 (55.6) 20 (55.6) 0.00 (1) 1.00

EMDR, eye movement desensitisation and reprocessing; HTQ, Harvard Trauma Questionnaire; PTSD, post-traumatic stress disorder; CAPS, Clinician-Administered PTSD Scale.
a. See online Table DS1 for a table that details a wider range of demographic and clinical characteristics.

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 Eye movement desensitisation and reprocessing therapy for refugees

excellent (a Cronbach’s a of 1). Interrater reliability for the CAPS LGM model. This, however, led to a decreased model fit. We therefore
(12.5%, 25/198) was excellent for PTSD symptom severity analysed the effect of gender on the slopes of the primary outcome
(Cronbach’s a = 0.95) and good for PTSD diagnosis (Cohen’s measures. Low R squares for all measures and conditions showed that
k = 0.78). Internal consistency for all scales was excellent, with a gender had little influence on treatment effect (online Table DS3).
Cronbach’s a of 0.86 for the CAPS; 0.88 for HTQ symptoms;
0.90 for the HSCL; and 0.85 for the WHOQOL-BREF.
Refugee status
Missing data As some clinicians argue that EMDR therapy with asylum seekers
Out of a total database of 1944 total or mean scores (i.e. nine is not possible because of their insecure living conditions, we also
outcome measures administered three times with 72 participants), analysed the effect of refugee status on the primary outcome
186 scores (9.6%) were missing and automatically imputed for measures. We divided the groups into participants with no refugee
each Bayesian analysis. ‘Missingness’ was significantly related to status (i.e. asylum seekers and those staying in the country
drop-out, with those who ended participation prematurely being illegally) and those with temporary or permanent refugee status.
more likely to have missing data than those who completed the The direction of the effect was that participants without a refugee
study (w2(1,n = 72) = 12.85, P50.001). status, regardless of treatment group, showed more PTSD
symptom reduction than participants with a refugee status.
Outcomes Although not statistically significant, in the stabilisation group
the effect size was medium (online Table DS3).
Primary outcomes
Table 2 describes PTSD diagnoses for the two groups at each
assessment. Discussion
Numbers indicate that outcomes displayed a slightly quadratic
development over time for both groups. Between T1 and T3, the Main findings
majority of assessment completers in both groups achieved a In this study, no differences in safety or efficacy were found
clinically significant improvement in PTSD severity (defined as between EMDR therapy and stabilisation as usual. As previously
improving at least ten points on the CAPS, Table 2).19 stated, some clinicians argue that trauma-focused treatment in
In the LGM analyses, best model fit was obtained when refugees, especially those living in unstable circumstances, may
including a quadratic slope. Table 3 shows the results of the be harmful.10 However, in this study, the EMDR and stabilisation
intent-to-treat analyses for primary outcomes. Participants in groups had comparable numbers of participants who dropped out
both groups initially achieved a clinically significant improvement of treatment and participants reporting symptom increase. In fact,
in clinician-rated PTSD severity, which was partly lost after T2. drop-out numbers were relatively low compared with other PTSD
The EMDR group significantly improved in self-reported PTSD outcome studies.36 Additionally, in the EMDR as well as the
symptoms according to DSM-IV. No significant differences stabilisation group asylum seekers showed an improvement at
between the two groups were found in either linear or quadratic least equal to that of refugees. Results are in line with an increasing
slopes and effect sizes between the groups were small (for within- body of evidence suggesting that trauma-focused therapy carries
and between-treatment effect sizes based on unimputed data, see no risk of psychologically overwhelming refugee patients, even
online Table DS2). those in unstable conditions.10 However, conclusions may not
generalise to refugee patients who meet our exclusion criteria –
Secondary outcomes notably those with psychotic disorders, substance dependence or
No significant differences were found between the EMDR therapy severe suicidal ideations – although the justifiability of using these
and stabilisation group on any of the secondary outcome measures exclusion criteria in patients who are treated for these disorders
(Table 3). Neither intervention had a significant effect on anxiety, has been called into question.37
depression or quality of life. Quality of life, in fact, in both groups Comparison with a non-randomised waitlist condition
did not show uniform improvement. suggested that treating refugees with EMDR therapy is more
effective than not treating them. However, contrary to expectation,
EMDR therapy was found to be no more effective than stabilisation.
Post hoc analyses
The effect of stabilisation was similar to effects found for
Gender unstructured stabilisation in other refugee samples in Western
As the EMDR group contained significantly fewer female participants countries.22,23 However, the effect of EMDR therapy was lower
than the stabilisation group, we added gender as a covariate to the than expected, with effect sizes for other trauma-focused therapies

Table 2 Post-traumatic stress disorder (PTSD) diagnosis and clinically significant change in PTSD severity in the eye movement
desensitisation and reprocessing (EMDR) therapy and stabilisation groups
n/N (%)
EMDR group Stabilisation group w2 (d.f.) P

CAPS diagnosis 30/36 (83) 32/36 (89)

T1 21/33 (64) 20/29 (69) 0.47 (1) 0.50
T2 26/32 (81) 22/31 (71) 0.08 (1) 0.78
T3 0.92 (1) 0.34
CAPS severity change T1–T3 0.23 (2) 0.89
Deterioration (5–10 points) 7/32 (21.9) 8/31 (25.8)
No change (510 points to 4710 points) 12/32 (37.5) 10/31 (32.3)
Improvement (510 points) 13/32 (40.6) 13/31 (41.9)

CAPS, Clinician-Administered PTSD Scale.

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Table 3 Intent-to-treat analyses of the effects of treatment on post-traumatic stress disorder (PTSD), anxiety, depression and
quality of life in the eye movement desensitisation and reprocessing therapy (EMDR) and stabilisation group
Credibility interval Credibility interval
Intercept Slope Lower 2.5% Upper 2.5% Effect sizea Q slope Lower 2.5% Upper 2.5% Effect sizea

Primary outcomes
CAPS, severity
EMDR therapy group 74.71 711.68 724.91 1.12 70.04 4.66 71.70 10.50 70.03
Stabilisation group 78.30 712.75 727.26 1.61 4.33 72.55 10.98
HTQ, DSM-IV
EMDR therapy group 3.06 70.40* 70.74 70.04 0.20 0.15 70.01 0.30 70.29
Stabilisation group 3.19 70.25 70.57 0.06 0.06 70.08 0.20
HTQ, total
EMDR therapy group 2.85 70.31 70.63 0.02 0.29 0.12 70.02 0.27 70.38
Stabilisation group 2.90 70.11 70.41 0.18 0.02 70.11 0.14
Secondary outcomes
HSCL, anxiety
EMDR therapy group 2.86 70.09 70.43 0.25 0.09 0.02 70.13 0.16 70.15
Stabilisation group 3.04 70.01 70.45 0.43 70.03 70.23 0.17
HSCL, depression
EMDR therapy group 2.95 70.20 70.55 0.16 70.03 0.06 70.09 0.21 0.03
Stabilisation group 2.97 70.22 70.59 0.18 0.07 70.09 0.23
WHOQOL-BREF, physical
EMDR therapy group 2.35 0.07 70.36 0.49 0.07 70.03 70.23 0.16 70.10
Stabilisation group 2.34 70.01 70.44 0.43 0.01 70.18 0.21
WHOQOL-BREF, psychological
EMDR therapy group 2.34 0.00 70.47 0.47 0.07 70.03 70.22 0.17 70.15
Stabilisation group 2.35 70.09 70.61 0.44 0.04 70.19 0.27
WHOQOL-BREF, social relationships
EMDR therapy group 2.71 0.05 70.48 0.58 70.28 70.09 70.33 0.15 0.22
Stabilisation group 2.56 0.38 70.18 0.95 70.20 70.46 0.05
WHOQOL-BREF, environment
EMDR therapy group 2.99 70.24 70.61 0.14 70.52 0.06 70.11 0.24 0.38
Stabilisation group 2.68 0.22 70.17 0.63 70.08 70.26 0.10

CAPS, Clinician-Administered PTSD Scale; HTQ, Harvard Trauma Questionnaire; HSCL, Hopkins Symptom Checklist; WHOQOL-BREF, World Health Organization Quality of Life
Assessment.
a. Cohen’s d: 0.20 small, 0.50 medium, 0.80 large.35
*P<0.05.

in refugee samples in Western countries ranging from 0.93 to 1.6 up to do in those respects. A randomised controlled trial is needed
for NET22,23 and from 2.4 to 2.6 for exposure.10,38 A primary to clarify this issue.
explanation is that the number of trauma-focused sessions was
lower in this study (i.e. 6 sessions of desensitisation and Strengths and limitations
reprocessing) than in comparable studies (9 for NET22,23 and 20
This study is the first full trial that meets all CONSORT criteria to
for TFCBT38). Considering the high number of types of traumatic
test the safety and efficacy of EMDR therapy in refugees with
experiences (14 in both conditions), six sessions appear to have
chronic PTSD. A broad range of refugee patients were engaged
been insufficient to process all memories driving PTSD symptom
in this study, including patients who needed interpreters and
severity. Additionally, it is possible that equalisation of number of
highly vulnerable patients who were homeless, stayed in the
treatment sessions rather than number of treatment hours would
country illegally or were listed for forced return. Both groups were
have resulted in differences in efficacy between the two groups, as
treated by highly experienced therapists. Bayesian estimation
it did in our pilot study.13 A second explanation is that the study
allowed for full intention-to-treat analysis.
sample consisted of refugee patients who are relatively difficult to
The study also has several limitations. Although all
treat. Centrum ’45 is a specialised institute that receives national
instruments used have been extensively validated in refugee or
referrals of patients who have insufficiently benefited from, or
transcultural samples, not all language versions were validated,
are expected to insufficiently benefit from, treatment within
which may have compromised measurement validity. In addition,
primary mental healthcare. This may be related to the complexity
a measure of positive expectancy for both therapists and patients
of their traumatic experiences (i.e. multiple, prolonged, inter-
would have been useful to explore the influence of treatment
personal traumatic events often involving intentional and extreme
preference on treatment outcome. Asking refugees which treat-
cruelty) as well as the complexity of their present-day lives (such
ment would be preferable under which circumstances would have
as being threatened with expulsion, having no financial means,
yielded valuable information and would have enabled refugees to
being socially isolated, fearing the effects of ongoing conflict in
contribute as experts as well as participants. Finally, inequality in
the country of origin).39 Comparable studies included only
number of treatment sessions between the two groups may have
participants who were fluent in the language of their resettlement
led to a greater risk of treatment drop-out in the stabilisation
country38 or who could be treated within general healthcare.23 A
condition than in the EMDR condition.
third possible explanation is that TFCBT (including NET) is
indeed more effective than EMDR therapy in treating refugees
with chronic PTSD. The culturally sensitive rationale40 and Clinical implications
relatively simple protocol of NET might make this therapy easier On the basis of our study it may be concluded that therapists need
to grasp for refugees and EMDR therapy may have some catching not refrain from offering EMDR therapy to asylum seekers or

316
 Eye movement desensitisation and reprocessing therapy for refugees

refugees with chronic PTSD for fear of deterioration, although ISTSS, 2012 (http://www.istss.org/ISTSS_Main/media/Documents/ISTSS-
Expert-Concesnsus-Guidelines-for-Complex-PTSD-Updated-060315.pdf).
this conclusion may not necessarily generalise to refugees with
10 Nickerson A, Bryant RA, Silove D, Steel Z. A critical review of psychological
comorbid untreated psychosis, substance dependence and high
treatments of posttraumatic stress disorder in refugees. Clin Psychol Rev
suicidal intent. Offering only a limited number of EMDR sessions, 2011; 31: 399–417.
as was the case in this study, may not result in a satisfactory 11 Palic S, Elklit A. Psychosocial treatment of posttraumatic stress disorder in
reduction of PTSD and comorbid symptoms. Whether EMDR adult refugees: a systematic review of prospective treatment outcome
therapy would show greater efficacy with refugees after a larger studies and a critique. J Affect Disord 2011; 131: 8–23.
number of sessions, or with refugee patients who are referred to 12 Robjant K, Fazel M. The emerging evidence for narrative exposure therapy:
general rather than specialised mental healthcare, or when a review. Clin Psychol Rev 2010; 30: 1030–9.

preceded by or combined with stabilising interventions, remains 13 Ter Heide FJJ, Mooren TM, Kleijn W, De Jongh A, Kleber RJ. EMDR versus
stabilisation in traumatised asylum seekers and refugees: results of a pilot
to be tested in future trials. This study adds to an increasing body study. Eur J Psychotraumatol 2011; 2: 5881.
of evidence that directly targeting traumatic memories of refugees 14 Sheehan DV, Lecrubier Y, Harnett-Sheehan KH, Amorim P, Janavs J, Weiller E,
carries no harm. et al. The MINI International Neuropsychiatric Interview (M.I.N.I.): the
development and validation of a structured diagnostic psychiatric interview
for DSM-IV and ICD-10. J Clin Psychiatry 1998; 59: 22–33.
F. Jackie June ter Heide, PhD, MPhil (Cantab), Trudy M. Mooren, PhD, Foundation
Centrum ’45 – partner in Arq Psychotrauma Expert Group, Oegstgeest and Diemen, 15 Blake DD, Weathers FW, Nagy LM, Kaloupek DG, Gusman FD, Charney DS,
The Netherlands; Rens van de Schoot, PhD, Department of Methods and Statistics, et al. The development of a clinician-administered PTSD Scale. J Trauma
Utrecht University, Utrecht, The Netherlands and Optentia Research Program, Faculty Stress 1995; 8: 75–90.
of Humanities, North-West University, Vanderbijlpark, South Africa; Ad de Jongh,
PhD, Department of Behavioural Sciences, Academic Centre for Dentistry 16 Mollica RF, Caspi-Yavin Y, Lavelle J, Tor S, Yang T, Chan S, et al. The Harvard
Amsterdam, University of Amsterdam, Vrije University, Amsterdam, The Netherlands, trauma questionnaire (HTQ): manual; Cambodian, Laotian and Vietnamese
and School of Health Sciences, Salford University, Manchester, UK; Rolf J. Kleber, versions. Torture 1996; 1 (suppl): 19–34.
PhD, Foundation Centrum ’45 – partner in Arq Psychotrauma Expert Group, Diemen
and Department of Clinical & Health Psychology, Utrecht University, Utrecht, The 17 Mollica RF, Wyshak G, de Marnette D, Tu B, Yang T, Khuon F, et al.
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Correspondence: F. J. J. ter Heide, PhD, MPhil (Cantab), Foundation Centrum’45
– partner in Arq Psychotrauma Expert Group, Nienoord 5, 1112 XE Diemen, 18 The WHOQOL Group. Development of the World Health Organization
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19 Schnurr PP, Friedman MJ, Foy DW, Shea MT, Hsieh FY, Lavori PW.
Randomized trial of trauma-focused group therapy for posttraumatic stress
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Arch Gen Psychiatry 2003; 60: 481–9.
Funding 20 Shapiro F. Eye Movement Desensitization and Reprocessing: Basic Principles,
Protocols and Procedures. Guilford Press, 2001.
This study was jointly funded by ZonMW, The Netherlands organisation for health research
and development, and Foundation Centrum ’45, partner in Arq Psychotrauma Expert 21 De Jongh A, Ten Broeke E. Handboek EMDR [EMDR Handbook]. Swets &
Group. R.v.d.S. was supported by a grant from The Netherlands organization for scientific Zeitlinger, 2003.
research: NWO-VENI-451-11-008.
22 Neuner F, Kurreck S, Ruf M, Odenwald M, Elbert T, Schauer M.
Can asylum-seekers with posttraumatic stress disorder be successfully
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The authors thank all participants and colleagues at Foundation Centrum ’45 who 23 Stenmark H, Catani C, Neuner F, Elbert T, Holen A. Treating PTSD in
contributed to this study; Berthold Gersons, Jeroen Knipscheer and Geert Smid who served refugees and asylum seekers within the general health care system:
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Nise da Silveira (1905–1999),

extra Brazilian psychiatrist and pioneer
of rehabilitation psychiatry

Christopher Kowalski

‘To navigate against the current, these rare qualities are

needed: a spirit of adventure, courage, perseverance
and passion’
– Nise da Silveira

In a time when lobotomies, electroshock and insulin therapies

were still the norm in Brazilian psychiatry, Nise da Silveira stood
out as a singular voice advocating for a kinder and more
relational approach to the treatment of people with mental
health conditions. Despite working in an arena dominated by
men, she fought passionately against the status quo and was
instrumental in establishing occupational therapies as a valid
treatment in schizophrenia and other chronic psychiatric
conditions in Brazil, changing the way in which rehabilitation
was viewed and practised in her native land.

Ever the revolutionary, da Silveira found inspiration in many counter-cultural ideas and ways of thinking, both in the field of psychiatry
and outside of it. In 1934, she was imprisoned for 18 months for possessing ‘subversive’ Marxist literature, having been denounced
to the Vargas dictatorship by a nurse with whom she worked. Upon her return to psychiatric practice, da Silveira became increasingly
disillusioned with the application of what she saw as aggressive and inhumane treatments in mental health. Inspired by the work of
R.D. Laing, David Cooper and Maxwell Jones, she set out to develop new and more compassionate ways of working with those
suffering with chronic illness. This led to her establishing the Seção de Terapêutica Ocupacional e Rehabilitação (Department of
Occupational Therapy and Rehabilitation) in the Centro Psiquiátrico de Pedro II, Rio de Janeiro, in 1946. Here, she organised
workshops for painting and sculpting where patients were encouraged to experiment with new means of emotional expression.
A devotee of Carl Gustav Jung, da Silveira applied Jungian ideas to the interpretation of her patients’ works in an attempt to develop
a deeper and more personal understanding of the individuals in her care and the psychotic processes underpinning their symptoms.
The success of this approach was evident early on and many of da Silveira’s patients were able to successfully reintegrate back into
society.

The works of these patients eventually came to be celebrated in the Museu de Imagens do Inconsciente (Museum of Images of the
Unconscious) which da Silveira founded in 1952. The museum has remained in operation to this day and now holds over 350 000
works by patients from the 1940s to today.

da Silveira went on to establish the Casa das Palmeiras in 1956, a clinic devoted to the rehabilitation of former patients of psychiatric
hospitals which eschewed the institutionalisation and restriction of liberty of its attendees. She pioneered research into the
therapeutic potential of animals in recovery, naming them her ‘co-therapists’, and her work inspired the creation of cultural centres
and therapeutic institutions both in Brazil and abroad. She died at the age of 94, leaving behind a truly unique legacy. Her passion and
devotion to the value of emotional connection, creativity and compassion are reminders of the importance of these qualities in both
the treatment and rehabilitation of people with mental illness.
The British Journal of Psychiatry (2016)
209, 318. doi: 10.1192/bjp.bp.116.190199

318
Data supplement to ter Heide et al. Eye movement desensitisation and
reprocessing therapy v. stabilisation as usual for refugees: randomised controlled
trial. Br J Psychiatry doi: 10.1192/bjp.bp.115.167775

Online supplement DS1

The research design did not include a randomised waitlist condition as we considered it
unethical to randomly ask patients to refrain from having any psychiatric or
psychotherapeutic interventions for a set period of time, and as we expected that such a
request would increase refusal to participate. Instead, to control for time we chose to
compare the effects of the two treatment conditions with a naturalistic waitlist condition
consisting of patients who for various practical reasons did not participate in the main study
(mainly because inclusion for the main study had already closed). Those patients were
eligible for participation who (a) were refugees of at least 18 years old, (b) had a PTSD
diagnosis, (c) had been waiting to start treatment for at least 11 weeks (i.e. equal to the time
between T1 and T2 for the EMDR condition) and had not had any psychiatric or
psychotherapeutic intervention during that time, (d) had completed a regular psycho-
diagnostic assessment (consisting of the HTQ events and DSM-IV subscales and the HSCL-
25) at intake and had granted permission to use this assessment for scientific purposes, and
(e) did not meet the exclusion criteria for the main study. The files of patients who had been
placed on the regular waitlist after intake were screened for these criteria by a research
associate. Potential participants were contacted by telephone to ask if they were willing to
complete an additional assessment before their first therapy session. Upon consent, the HTQ
events and DSM-IV symptom subscales, as well as the HSCL-25 were administered before
starting treatment. In total, 36 patients were enrolled in the waitlist condition. At the second
assessment, significant differences in PTSD severity (EMDR n=32, mean 2.79, s.d.=0.54 v.
waitlist, n=36, mean 3.17, s.d.=0.43, P = 0.002) and in anxiety (EMDR n=32, mean 2.77,
s.d.=0.69 v. waitlist, n=36, mean 3.16, s.d.=0.66, P=0.021) were found between EMDR and
waitlist, with medium effect sizes (0.77, 95% CI 0.28–1.27, and 0.57, 95% CI 0.09–1.06,
respectively, calculated in SPSS). In the LGM model, medium effect sizes (ESs) for PTSD
severity were also found between EMDR and waitlist (ES=0.71), and stabilisation and waitlist
(ES=0.54), but these did not reach statistical significance (see online Table DS4).
Table DS1 Demographic and clinical characteristics before treatment
EMDR
therapy Stabilisation Analysis
2
( n =36) ( n =36) χ t -test d.f. P
Demographic characteristics
Age in years, mean (s.d.) 43.1(10.7) 39.8(11.9) 1.26 70 0.21
Female, n (%) 6(16.7) 14(38.9) 4.43 1 0.04
Education, n (%) 3.44 2 0.18
No education/primary school only 7(19.4) 13(36.1)
Secondary school/vocational training 15(41.7) 15(41.7)
University/academy 14(38.9) 8(22.2)
Married, n (%) 21(58.3) 15(41.7) 2.00 1 0.16
Employment, n (%) 0.60 2 0.74
Unemployed/sickness leave 21(58.3) 24(66.7)
Volunteer work/school 8(22.2) 7(19.4)
Employed 7(19.4) 5(13.9)
Country of origin, n (%) 2.78 5 0.73
Iraq 9(25.0) 8(22.2)
Afghanistan 9(25.0) 6(16.7)
Former Yugoslavia 3(8.3) 5(13.9)
Other Middle Eastern countries 6(16.7) 4(11.1)
African countries 8(22.2) 10(27.8)
Other 1(2.8) 3(8.3)
Refugee background, n (%) 1.74 5 0.88
Political activist 14(38.9) 16(44.4)
Civilian victim of war/organised violence 10(27.8) 7(19.4)
Veteran 3(8.3) 4(11.1)
Child soldier 1(2.8) 2(5.6)
Persecution for various reasons 2(5.6) 3(8.3)
Combination of factors 6(16.7) 4(11.1)
Refugee status, n (%) 0.85 1 0.36
Asylum seeker/illegal 5(13.9) 8(22.2)
Temporary/permanent refugee status 31(86.1) 28(77.8)
Years in the Netherlands, mean (s.d.) 10.0(5.3) 8.9(5.1) 0.88 69 0.38
Clinical characteristics
Types of traumatic experiences (HTQ), mean (s.d.) 13.8(5.5) 13.7(5.6) 0.85 70 0.93
Years of having PTSD, mean (s.d.) 7.9(7.2) 8.0(6.5) -0.41 59 0.97
Comorbid depression, n (%) 28(77.8) 28(77.8) 0.00 1 1.00
On psychotropic medication, n (%) 21(58.3) 21(58.3) 0.00 1 1.00
CAPS symptom severity, mean (s.d.) 74.7(18.0) 78.3(18.3) -.83 70 0.41
Use of interpreter during study treatment, n (%) 20(55.6) 20(55.6) 0.00 1 1.00
EMDR, eye movement desensitisation and reprocessing; PTSD, post-traumatic stress disorder;
HTQ, Harvard Trauma Questionnaire
Table DS2 shows unimputed outcomes as calculated by SPSS. We used pre- and post-
treatment means, sample sizes and paired groups t-values calculated by SPSS to calculate
effect-sizes within conditions, and means, standard deviations and sample sizes at follow-up
calculated by SPSS to calculate effect-sizes between conditions. Effect-sizes and 95%
confidence intervals were calculated using Comprehensive Meta-Analysis version 2 for
Windows (Biostat, Englewood NJ; see http://www.meta-analysis.com/index.php).

Table DS3 shows the effects of gender and refugee status on treatment outcome for
both conditions.

Table DS4 shows changes in symptom severity for the two treatment conditions and
the non-randomised waitlist condition.
Table DS2
Unimputed analyses of the effects of treatment on PTSD, anxiety, depression and quality of life for EMDR therapy and stabilisation
Measure Condition T1 T2 T3 ESa T1-T3 ESa EMDR - stabilisation
n Mean (s.d.) n Mean (s.d.) n Mean (s.d.) (95% CI) (95% CI) at T3
Primary outcomes
CAPS severity EMDR therapy 36 74.69(18.01) 32 67.38(23.16) 32 69.94(25.07) 0.19(-0.16 to 0.54) -0.02(-0.51 to 0.63)
Stabilisation 36 78.25(18.34) 29 68.86(26.93) 31 69.55(25.05) 0.30 (-0.06 to 0.66)
HTQ DSM-IV EMDR therapy 36 3.05(0.49) 32 2.79(0.54) 31 2.86(0.58) 0.38(0.02 to 0.73)* 0.13(-0.36 to 0.63)
Stabilisation 36 3.19(0.43) 30 2.98(0.62) 32 2.94(0.59) 0.39(0.03 to 0.75)*
HTQ total EMDR therapy 34 2.86(0.45) 32 2.63(0.57) 31 2.73(0.63) 0.20(-0.17 to 0.57) 0.04(-0.45 to 0.54)
Stabilisation 34 2.90(0.51) 30 2.79(0.62) 32 2.76(0.62) 0.25(-0.11 to 0.61)
Secondary outcomes
HSCL anxiety EMDR therapy 35 2.86(0.57) 32 2.77(0.69) 31 2.75(0.71) 0.02(-0.34 to 0.37) 0.10(-0.39 to 0.59)
Stabilisation 36 3.04(0.66) 30 2.98(0.66) 32 2.89(0.69) 0.17(-0.18 to 0.52)
HSCL depression EMDR therapy 35 2.94(0.52) 32 2.79(0.61) 31 2.81(0.61) 0.30(-0.07 to 0.66) -0.01(-0.50 to 0.49)
Stabilisation 36 2.97(0.61) 30 2.80(0.66) 32 2.80(0.64) 0.26(-0.09 to 0.61)
WHOQOL-BREF EMDR therapy 36 2.35(0.60) 31 2.39(0.60) 31 2.34(0.58) -0.10(-0.45 to 0.26) -0.06(-0.55 to 0.44)
physical Stabilisation 36 2.34(0.53) 29 2.36(0.72) 32 2.37(0.62) 0.03(-0.32 to 0.37)
WHOQOL-BREF EMDR therapy 36 2.34(0.65) 31 2.34(0.71) 31 2.21(0.65) -0.18(-0.53 to 0.18) -0.17(-0.66 to 0.33)
psychological Stabilisation 36 2.35(0.70) 29 2.30(0.91) 32 2.33(0.77) -0.01(-0.36 to 0.33)
WHOQOL-BREF EMDR therapy 36 2.71(0.80) 31 2.72(0.80) 31 2.49(0.86) -0.32(-0.69 to 0.04) 0.04(-0.46 to 0.53)
social relationships Stabilisation 36 2.55(0.98) 29 2.65(0.88) 32 2.46(0.87) 0.00(n.a.)
WHOQOL-BREF EMDR therapy 36 2.99(0.70) 31 2.81(0.60) 31 2.77(0.57) -0.32(-0.68 to 0.04) -0.06(-0.56 to 0.43)
environment Stabilisation 35 2.65(0.66) 29 2.84(0.80) 32 2.81(0.65) 0.15(-0.21 to 0.50)
EMDR, eye movement desensitisation and reprocessing; TAU, treatment as usual; CI, credibility interval; ES, effect size; CAPS,
Clinician Administered PTSD Scale; HTQ, Harvard Trauma Questionnaire; DSM-IV, Diagnostic and Statistical Manual of Mental
Disorders, 4th edition; HSCL, Hopkins Symptom Checklist; WHOQOL, World Health Organization Quality of Life
a
Cohen's d: 0.20 small, 0.50 medium, 0.80 large 35
*P<0.05, **P<0.01
Table DS3
Effects of gender and refugee status on treatment outcome for EMDR and stabilisation
beta SE CI
Measure Condition lower 2.5% upper 2.5% R2 a 95% CI 0 to
Gender CAPS total EMDR therapy 3.36 6.95 -10.08 17.27 0.05 0.38
Stabilisation -1.94 4.33 -10.43 6.49 0.03 0.28
HTQ DSM-IV EMDR therapy -0.06 0.17 -0.40 0.27 0.04 0.32
Stabilisation -0.03 0.10 -0.23 0.17 0.03 0.23
HTQ total EMDR therapy -0.07 0.18 -0.43 0.28 0.04 0.29
Stabilisation -0.03 0.11 -0.24 0.19 0.02 0.20
Refugee status CAPS total EMDR therapy 0.17 6.31 -12.19 12.67 0.03 0.28
Stabilisation 7.98 5.05 -1.74 17.98 0.14 0.55
HTQ DSM-IV EMDR therapy 0.13 0.15 -0.17 0.42 0.06 0.38
Stabilisation 0.19 0.12 -0.05 0.42 0.14 0.51
HTQ total EMDR therapy 0.11 0.16 -0.20 0.42 0.04 0.23
Stabilisation 0.19 0.13 -0.06 0.44 0.11 0.43
EMDR, eye movement desensitisation and reprocessing; SE, standard error; CI, credibility interval;
CAPS, Clinician Administered PTSD Scale; HTQ, Harvard Trauma Questionnaire;
DSM-IV, Diagnostic and Statistical Manual for Mental Disorders, 4th edition
a
0.02 small, 0.13 medium, 0.26 large 35
*P<0.05, **P<0.01
Table DS4 Intent-to-treat analyses of change in symptom severity for EMDR therapy, stabilisation and
non-randomised waitlist
Measure Condition Intercept Slope CI ESa
lower 2.5% upper 2.5%
Primary outcomes
HTQ DSM-IV EMDR therapy 3.05 -0.26* -0.46 -0.06 EMDR - stabilisation 0.17
Stabilisation 3.19 -0.21* -0.41 -0.01 EMDR - waitlist 0.71
Waitlist 3.20 -0.03 -0.18 0.12 Stabilisation - waitlist 0.54
Secondary outcomes
HSCL anxiety EMDR therapy 2.86 -0.08 -0.28 0.13 EMDR - stabilisation 0.05
Stabilisation 3.04 -0.06 -0.36 0.24 EMDR - waitlist 0.40
Waitlist 3.09 0.08 -0.14 0.28 Stabilisation - waitlist 0.35
HSCL depression EMDR therapy 2.94 -0.15 -0.38 0.07 EMDR - stabilisation 0.00
Stabilisation 2.97 -0.15 -0.38 0.09 EMDR - waitlist 0.23
Waitlist 2.99 -0.06 -0.24 0.13 Stabilisation - waitlist 0.23
EMDR, eye movement desensitisation and reprocessing; HTQ, Harvard Trauma Questionnaire;
DSM-IV, Diagnostic and Statistical Manual of Mental Disorders, 4th edition; HSCL, Hopkins Symptom Checklist;
ES, effect size
a
Cohen's d: 0.20 small, 0.50 medium, 0.80 large 35
*P<0.05, **P<0.01
Eye movement desensitisation and reprocessing therapy v.
stabilisation as usual for refugees: randomised controlled trial
F. Jackie June ter Heide, Trudy M. Mooren, Rens van de Schoot, Ad de Jongh and Rolf J. Kleber
BJP 2016, 209:311-318.
Access the most recent version at DOI: 10.1192/bjp.bp.115.167775

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