Martin Page is a Level 1 trained EMDR Psychotherapist at The Sheldon Institute for Psychotherapeutic Studies (LN3 5TZ UK). He is Senior Lecturer in Health Studies at the University of Lincoln (United Kingdom) where he is Programme Leader for M.Sc Trauma and Disaster Management Studies and Masters/PhD supervisor for the Universitys School of Health and Social Care. He can be reached at: martin.g.page@googlemail.com. 

Abstract:

This study shows how three changes (one addition to the EMDR protocol, plus two alterations) were used in the treatment of anxiety disorders. The addition to the EMDR protocol was:

1) The use of Galvanic Skin Response (GSR) monitors to provide a constant flow of objective, testable and measurable data specific to the experience of suffering or disturbance, exclusively to the clinician (and not to the patient) throughout the therapy process,

The two other alterations were:

2) Incorporating specifically targeted verbal prompts at various points in the process, thus serving to maintain the patients emotional and intellectual focus on the experience of suffering the presenting disorder.

3) Allowing the patient to close his or her eyes and using tactile desensitization and reprocessing rather than eye movements, thereby allowing the patient to maintain the mental imagery specific to the suffering. 

The study group achieved beneficial outcomes sooner and more effectively than the control group who were given standard EMDR therapy. 

Introduction

Eye Movement Desensitization and Reprocessing (EMDR) was discovered and developed by Francine Shapiro in 1987 (Shapiro, 1995) and used as a treatment for posttraumatic stress disorder (PTSD) (Shapiro, 1989). Following Shapiros publication of the protocol EMDR has met with a lively but mixed reception. Some practitioners argued that it was methodologically flawed (e.g., Herbert & Mueser, 1993) whilst others found it to be useful (e.g., Lipke & Botkin, 1993). Since those early days, several thousand therapists and clinicians have been trained and are practicing EMDR.  

Practitioners who use EMDR are experienced in other treatment modalities before qualifying as EMDR therapists. The counselor, psychotherapist, clinical/counseling psychologist and psychiatrist will all have a range of psychotherapeutic skills, instruments and approaches that are designed to address the essential needs of clinical practice. Assessments sometimes involve objective psychometric testing, although an assessment might be based on clinically focused interpretations of the clients own subjective descriptions. Where a specific disorder is identified, it is common for a treatment method to be clearly defined, and that method (or the choice of methods) will be supported by a clear literature base drawn from clinical practice and research.  At present, and even after more than a decade of use, the writer believes that EMDR has yet to convince many practitioners of the flexibility and appropriateness of its application in general psychotherapy practice.  

In some respects this might be because the measures of outcome are based on a subjective interpretation made by the patient. Subjective assessments involve phenomenological rationale that dwells on the lived experience (e.g., Banister, P., Burman, E., Parker, I., Taylor, M., & Tindall, C. , 1995), and perhaps because of this the reliability and objectivity of judgmental probability is open to challenge (Jeffrey, 2004). This means the assessments are based on a narrative that fails to provide convincing measure and test potential for the therapist, and therefore offer little in the way of objective accuracy and reliability. Unless other psychometric tests or other psychophysiological instrumentation has been used, the clinician has no objective measure to support the notion of the success or the failure of the treatment method.  

This study was designed as a direct result of the observation that EMDR lacked objectivity in the critical assessments at the start of, and during therapy programmes. Moreover, and in common with other psychotherapy models, EMDR was observed to lack objective outcomes that were measurable and testable.  

The Aim of the study: 

The Aim of the study was to investigate the notion that a cessation of symptoms of Chronic Anxiety Disorder could be brought about sooner by the use of an altered version of EMDR than by the standard EMDR model. The description of the presenting disorder was the clients, and the diagnosis was confirmed at assessment by the psychotherapist / clinical psychologist as General Anxiety Disorder (GAD) or Anxiety Disorder Not Otherwise Specified (ADNOS) (APA 2000). 

Method: 

The study used two different EMDR treatment styles:

Design

• The first treatment style conformed to the standard model of EMDR, as published by Shapiro (1995). This style was used with the control group without alteration.
• The second treatment style differed from the standard EMDR procedures. The alterations were:
  1. The additional use of Galvanic Skin Response (GSR) monitors.
  2. The use of synchronized verbal prompts, which is a modification of the original protocol.
  3. The use of tactile (rather that eye movement) desensitization and reprocessing, which is also a modification of the original protocol. 

Sample identification rules

It is important to say here that each patient of the clinic (private sector) is asked if they would allow their case notes to be used for research purposes. There are no penalties or direct benefits associated with the decision, and examples of previous studies are shown, if requested. Assurances of anonymity and confidentiality are given, which in practical terms means that an informed person would not know who had taken part in the study. All participants in this study agreed that their case notes could go forward for research and the clinics rules of anonymity and confidentiality were automatically applied. 

Sample

A convenience sample of twelve (n = 12) self referred patients (who agreed to allow their case notes to be put forward for research purposes) all reporting with chronic anxiety disorders (GAD or ADNOS) were assigned alternatively (by first appointment date) to either the study group (n = 6) or the control group (n = 6).  

Inclusions and exclusions

The studys main entry criterion was that subjects would only be drawn from those whose description of their disorder was consistent with the diagnoses of chronic anxiety disorder or chronic anxiety and stress, and only where the clinician had diagnosed GAD or ADNOS (APA 2000).  

Group selection

The 12 clients were divided into two groups on an alternate entry basis until two groups comprised six (n = 6) clients each.  

The study group comprised 3 males (ages 33, 35, & 36 years) and 3 females (ages 31, 36, & 37 years).  

The control group comprised 4 males (ages 28, 35, 41 & 47 years) and 2 females (36 & 37 years).  

Instrumentation

Portable GSR monitors were used:

Galvanic skin responses are changes in the electrical conductivity of the skin (Boucsein, 1992; Backs & Boucsein, 2000). The changes are specifically associated with psychophysiological stress symptoms (Roy, Boucsein & Fowles, 1993; Backs & Boucsein, 2000) and a simple GSR monitor will show the live fluctuations of anxiety and stress levels in the patient. In this regard the monitors indicate emotional arousal of the individual (Boucsein, 1992; Backs & Boucsein, 2000) by means of a digital reading presented on a liquid crystal display (LCD).  

A patients GSR reading will reflect the emotional arousal (Boucsein 1992; Roy et al., 1993; Backs & Boucsein, 2000) quickly and accurately. The GSR monitor allows the therapist to see exactly when the patient is fully engaged with the memory of the anxiety cue or trigger, and most importantly, how emotionally challenging that memory is in terms of a GSR reading. The GSR readings indicate the severity of suffering when calibrated against Backs & Boucsein (2000) findings for heart rate, indicating physical strain, and finger temperature, indicative of emotional strain (Backs & Boucsein, 2000, p. 9).  

Use of monitors: 

The equipment model, training and practical use: 

This study used low cost hand held battery operated GSR machines known as Bio Feedback Monitors: Professional Series. They comprise minimal GSR detector electronics, a small LCD screen and a usefully long lightweight lead or cable, separating to two copper terminals, each with a small Velcro/copper finger pad. At 2 meters in length, the lead allows the patient to sit some distance away from the monitor. The monitors are the size of a bulky cigarette packet. 

The equipment is unobtrusive. The lead terminals are held lightly against the third phalange finger pads of two fingers of one hand by a small Velcro fixing. The machine is switched on, and a digital reading is available immediately. The patient feels only that a small copper disc, similar in size to a low denomination coin is lightly placed against the skin of two fingers. There is no risk of electrical discharge at all because the monitors receive data from the skin rather than transmit signals to the skin. Batteries are known to last more than one year in daily clinical use. 

The GSR monitor is as easy to read as a digital clock. No special training is required for the use of the GSR equipment. However, it is important that the therapist practices recording the data in note form because there are no electronic data storage facilities on this model. It is common practice for the therapists to log readings as they make the usual notes during the sessions. The clinics therapists have used these models for a number of years and have found that adding a reading ( a three digit number) in the left hand margin of the case notes whenever they are making a note and whenever a difficult emotional episode occurs for the patient, are routines which are easily established into the sessions.  
 
The common experience: 

Both the study group and the control group had GSR monitor finger pads attached to two fingers of one hand throughout the therapy sessions. The control group monitors had the batteries removed, and so did not work. This meant that the therapist would not be able to record data, and would not be influenced by the GSR reading at all.  

The study group GSR monitors had working batteries and were therefore able to provide live data showing galvanic skin responses throughout the therapy sessions. This meant that the patient experience of having the GSR monitor attached to two fingers of one hand for the duration of each therapy session was the same for both groups.  

Each GSR monitor was placed before the therapist in such a way that neither patient group could see the LCD screen at any time. This maintained the integrity of the control and study groups as each participant remained oblivious to their role in the study. The only bio-technical information required prior to each session was that when scoring or noting the readings the therapists knew that a heightened emotional response resulted immediately in an increased GSR reading. Likewise where the emotional response eased, so the reading reduced to a lower digital reading. The GSR monitors were therefore used only as assessment tools and not as part of the therapy. 

Details of Therapy Procedures

The Control group

Shapiro (1995) gives a step by step detailed description of the process of EMDR therapy. Instructions for the therapist are also given in the training manuals produced by the EMDR Association. It is not the intention to explain the standard EMDR therapy process in this paper. The procedures in therapy followed the published format and were delivered in accordance with the EMDR taught model of practice. This model relies upon the patient re-engaging with the memory and experience of the emotion that is bound up with the trigger(s) of the presenting disorder response (Shapiro, 1995). Typically, the patient is asked to recall the original emotional response and to score that feeling against their own scale of Subjective Units of Disturbance (SUDs) which commonly ranges between zero and 10, with zero being no disturbance, and 10 being the most extreme disturbance.  

The Study group

The study group was also treated using the Shapiro model of EMDR, but there were some important differences or alterations. The first difference was that the GSR monitors were live for the study group and gave an instantaneous digital reading to the therapist of galvanic skin responses indicating variations in emotional stress arousal. 

The second alteration was the introduction of verbal prompts. Standard EMDR protocol implies that the therapist does not probe with questions about specific aspects of a presenting disorder, but keeps to general and nondescript instructive prompts such as OK, just hold that thought for a moment, and follow my fingers with your eyes now. However, in other modalities, it is not only acceptable, but often required that a therapist should ask the patient to respond to specific questions, or to questions about specific aspects of the disorder (see, for example, Yalom, 1995; Lockley, 1999; Fransella & Dalton, 2000; Mahoney, 2003; McWilliams, 2004).  

Experience shows that a patient in EMDR therapy might say that they are reliving the anxiety, but the GSR reading could indicate a moderate or low emotional engagement, rather than a full engagement. This might be because the patient has brought the idea, but perhaps not the full physical experience of the anxiety to mind. In such cases a verbal prompt tends to be useful for triggering the arousal of emotional expression of the anxiety episode. Therefore, it was accepted that new prompts (examples given below) would be incorporated into the methodology that were specific and targeted to encourage the patient to get more deeply involved in the emotional aspects of the presenting disorder.  

The third alteration was to allow the patient to close his or her eyes. In some situations it can be worthwhile asking the patient to close his or her eyes and to then talk through the affront or the cause of the anxiety or stress (Battino & South 2000; Dowd, 2000), much the same as with some approaches in cognitive behaviour therapy (Beck, 1991; Hawton, Salkovskis, Kirk, & Clark, 1995). The patients own narrative is argued to be effective in achieving a heightened state of emotional arousal (e.g., Armstrong, OCallahan & Marmar, 1991; van der Kolk; McFarlane & Weisaeth, 1996), and is a useful device for ensuring full emotional engagement during the therapy session. In other examples of clinical practice it has been observed with some patients that where full engagement with the feelings of the presenting disorder is not achieved, the situation can be enhanced if the patient closes his or her eyes. Then, without talking, the patient brings the emotional response to mind together with the physiological experiences. The altered EMDR model in this experiment also allowed the patient to close his or her eyes. 

Because the patients eyes were closed, tactile desensitization and reprocessing (TDR) rather than eye movements was used with the study group.  

Establishing baseline GSR readings 

At the start of the first appointment of therapy, each patient was encouraged to relax physically, so that a baseline GSR reading could be logged. Once that was done, and after a pause, the patient was asked to recall the internal feelings of the presenting anxiety and to say where on the SUDs scale their anxiety would be. This recollection was in accord with the standard EMDR routine of establishing the parameters of the suffering. The patient was then asked to close his or her eyes and to recall and re-experience those feelings of anxiety. Apart from the eyes being closed, this instruction would be similar in the standard EMDR model.  

The therapist then noted the increased GSR monitor reading. The therapist could also see the GSR point at which that higher reading reached a plateau. The higher reading would be recorded as being the extreme suffering point, and that would be the point at which the TDR routines would begin.  

Measurable and testable factors

At this point the therapist had two readings logged:  

1. The first was the patients own baseline GSR reading relating to that patient in a sedentary position and breathing normally.
2. The second GSR reading was logged as the extreme suffering point for that patient at the time of the presenting disorder symptoms being recalled. The extreme suffering point was a GSR measure of emotional arousal.

These became the first measurable data in EMDR therapy and as such, could be tested at a later date. It was also standard practice for a mid point to be calculated between both extremes. The mid point gave the direction to the therapist of what to do next. If the GSR reading was above the mid point, the TDR would continue. If the GSR reading fell below the mid point a verbal prompt (see below) would be issued to try to raise the reading. If the verbal prompt did not raise the GSR reading and it continued to drop below the mid point, the TDR routine would be brought to a close for a few minutes. 

A fictitious example of how the data were shown:

These GSR numbers differ between patients and are not standardized at all. The example given in this table is used for explanation purposes only. 

It was observed that the first TDR routine would end quickly. Possibly because the tapping was a new and unfamiliar sensation and could have caused the patients concentration to lapse as the two different aspects (recalling the anxiety, and feeling the tapping) were in process.  

The therapist would allow a pause, in the same way that the standard EMDR model includes pauses between hand passes. When the GSR monitor showed a reading quite close to the baseline reading, and having established that the patient was relaxed and breathing normally, the patient would be instructed to close his or her eyes and recall the full experience of the anxiety. The next TDR routine would begin when the GSR monitor showed an increase as far above the mid point as possible. This would be enhanced by a verbal prompt, for example: 

Close your eyes; bring to mind those feelings of anxiety, allow yourself to re-experience those deep feelings of anxiety now or, Bring it to mind now, feel that anxiety now, let it build up and feel it again. 

If appropriate, the therapist might also mention the site of the feeling in line with EMDR standard practice of establishing where in the body the client felt the disorder resided. Feel it now, deep in your stomach, for example. 

Also if appropriate, the therapist might ensure that other senses were used, but only those senses which the patient had mentioned as being associated in some way with the anxiety. For example, if a particular taste or an odour had been said to play a part in the anxiety (Doty, 2003), the therapists could suggest the patient include these. 

And then more generally;

Re-experience the anxiety now, feel the anxiety and sense it as deeply as you can. Hold that thought as you feel the tapping. 

The ad hoc prompts served to maintain the heightened GSR reading for longer, indicating that the anxiety was present and was able to be processed over longer periods of time. 

As a practical guide, the pause between each TDR routine was extended to at least three minutes and sometimes up to five minutes. It was observed that by extending the pause between TDR routines in this way the patient was able to achieve his or her baseline GSR reading and spend a short while relaxing between TDR routines.  

It was also common for the second and subsequent GSR readings of the extreme suffering point to be different from the original reading. This was not a concern as long as an increase in GSR reading as far beyond the mid-point as possible had been achieved.  

Closing the appointment

The first EMDR / TDR therapy appointment was considered right for closing when the GSR mid point was difficult to achieve, or the revised extreme suffering point readings showed a plateau at a much lower level than the first readings. The appointment was closed after the revised extreme suffering point could not be increased with verbal prompts on two consecutive routines, and the mid point was not exceeded.    

These changes to the EMDR protocols were employed for each person in the study group. One other instruction was given at the close of each therapy appointment, and before the client left the chair. It is known that a degree of hypnosis will have inadvertently applied when a patient is taking instructions with their eyes closed (see, for example, Ousby, 1990; Battino & South, 2000; Dowd, 2000). It was therefore necessary to dissolve the hypnotic element by finally saying something like: 

Thats fine, Let your anxiety leave you, relax now. In a moment I will count backwards from three to zero, and when I say zero you will be fully awake and fully alert, and ready for the rest of a good day. Three, Two, One, Zero (slight pause). Then, You can open your eyes now. Thats fine, take a moment or two to stretch and settle.  

This procedure was repeated at subsequent appointments. The GSR extreme suffering point was revised downwards on numerous occasions and a new GSR mid point was found and recorded.  

Results:

The control group results were based on standard EMDR session procedures. The process as detailed in the training manual and in Shapiro (1995) was followed and with the exception of one patient, appropriate outcomes were achieved. One patient in the control group attended for five EMDR sessions and no sustained cessation of symptoms was reported. One patient attended for five sessions and reported a cessation of most symptoms. Two patients attended for four sessions and reported a cessation of symptoms. Two patients attended for three sessions and reported a cessation of symptoms.

Table 1: The Control Group (Presented in order of outcome starting with least beneficial self reported outcome)

It could be argued that the control group conformed to a standard that indicates each patient case will be different. Indeed, as Shapiro (1995) states in her Preface: EMDR is not a cure-all; treatment failures occur, as they do with any method (Shapiro, 1995, p. vii). 

Results for the study group showed a different range of outcomes, based in part on a newly informed and therefore altered process of treatment. This alteration included the patient having his or her eyes closed, the use of GSR monitors, and the use of verbal prompts at appropriate times to ensure the patients full engagement with the feelings that were linked with the triggers for the presenting anxiety disorder. 
 
 

Table 2: The Study Group (Outcomes were uniformly successful. This table is presented by gender and age in sequence from male to female and from youngest to oldest)

The table shows that the study group completed EMDR therapy in 3 clinical appointments. Each patient in the study group stated that the first session had achieved an appropriate outcome in that the symptoms of anxiety were reported to have ceased, and therefore were no longer of concern.  

Table 2 shows that at appointment 2, the study group patients stated that the symptoms of anxiety had ceased. The Patient Case Notes suggested that following the first appointment, the study group patients were more relaxed at their second and subsequent appointments than the control group.  

Discussion:

EMDR was the preferred treatment regime for GAD, ADNOS (APA 2000) and stress related anxiety which each subject attributed to an event, circumstance or situation in their past. The outcomes for the study group indicate a shorter treatment time and an improved benefit over the results from the control group. The outcome for the control group was more difficult to establish because there were no concrete data against which an assessment might be made.  

This was fundamentally important in that the therapist was able to note the patients individual baseline reading that represented him or her in a relaxed and sedentary position. From this point the therapist could note the increased reading that was achieved when the patient made his or her first attempt to recall the emotional response of the triggers associated with the presenting disorder. This gave two poles, or extremes of emotional response that could be used as the primary benchmark range for future reference. It also provided a mid point between these extremes that proved to be a useful measure of when to conclude the TDR sessions, and when to conclude the first appointment.  

The practical application of this information meant that once having noted the benchmarks (two poles, one at either end of the continuum of emotional response, with sedentary and relaxed at one end, and severely anxious at the other end), thereafter, the therapist was able to encourage and prompt the patient to engage fully with the recollection of the feelings of anxiety. The verbal prompts facilitated the achievement of a heightened state of emotional arousal in the patient. Each time this event occurred, the GSR readings were noted, and measured against previous readings. These were formally noted at three points in each appointment so that a record could be maintained of the GSR results. During the TDR routines, where a GSR reading dropped to below the mid point, the therapist was able to continue tapping, and incorporate verbal prompts to re-engage the patient with the feelings of the anxiety and therefore raise the GSR monitor reading.  

Where it was observed that regardless of verbal prompts the GSR reading fell below the mid point, the therapist would allow that particular routine to cease with another verbal prompt such as OK, we will pause for a few minutes to relax. You might like to open your eyes for a while. The appointment would carry on until the GSR readings would plateau at a level less than the level first observed.  

At the second appointment for the study group the GSR readings showed a lower top line (heightened arousal) reading, and when the revised heightened state was achieved the GSR readings dropped quicker than during the first appointment. This indicated a lessening of the emotional response, and a subdued or moderate (rather than severe) experience of anxiety. This view was supported by the lower GSR readings at the second appointment. 

At the study groups third appointments each patient stated that the symptoms had ceased mainly following the first appointment, but almost completely after the second appointment. TDR was conducted and the GSR readings at the third appointment showed (in all patients of the study group) that the original presenting disorder was not triggering the original mid point GSR readings.  

Follow up appointments

Follow up appointments were conducted at between 26 and 27 weeks after the third appointment. One patient in the control group had left the project. Five patients in the control group indicated no further symptoms, but one patient asked for another top up EMDR session. GSR monitors could not be used at follow up with the control group because they had not been used with this group during the study period. The follow up for the study group included the use of GSR monitors and they gave no indication of symptoms.  

Limitations of the study

The main limitation is that the study group comprised only six patients. Whilst the results are encouraging, there remain some questions about general applicability to all patients with similar presenting disorders. It is worth noting that the patients in both groups were middle and senior managers in public sector or commercial/industrial professions and all were self sponsoring. In this regard they were not a broadly based representative sample of the general public. 

Also the possibility of using standard EMDR visual passes rather than TDR was not explored. The reason was that of practicalities: the therapist was not able to record data from the GSR monitors at the same time as conduct the visual hand passes. The use of a metronome or other device was not investigated. It is likely that another therapist would be able to overcome this situation and stick to the traditional hand or finger passes.  

However, the protocol in standard EMDR therapy is for the patient to bring to mind and to relive the feelings and sensations of the presenting disorder, and to hold that thought as the hand passes occur. The writer suggests that by visually following the hand passes, the patient might risk diverting or dividing their concentration. This might be because they would be following verbal instructions to imagine, following verbal instructions to watch the hand passes, and concentrate on eye movement and not head movements. It must also be noted that the EMDR psychotherapy session is an unusual and unpracticed environment for the patient. The writer suggests that if the patient is allowed to close his or her eyes, then the psychotherapeutic potency of the mental imagery of bringing to mind and of holding that thought is enhanced rather than reduced.    

Clinical Implications

If the findings of this study are corroborated elsewhere, it is argued that the procedures for EMDR, and possibly other psychotherapy models, will develop to include the routine use of instruments that provide objective measures of patient suffering. If the suffering can be specified (for example, the suffering associated with PTSD, and with anxiety disorders), monitored and tested, it might make a contribution to a decision about treatment approaches.  

The writer would argue that with some presenting disorders (typically anxiety and stress related disorders) there exists an ethical imperative to ensure that accurate and objective data are gathered immediately to define the parameters of a patients suffering. The clinical implications of this study include the notion that the use of a simple and low cost instrument might facilitate a tighter focused therapy style and a speedier recovery time for a range of psychological problems.  

Conclusion

As it stands, EMDR in general terms depends on a number of subjective critical points. The first is that the patient must make a numeric assessment of the suffering. This is followed by the therapist asking the patient for news of a change to that subjective score. Such a process does not take into account the various opportunities to get the assessment wrong by either understating or overstating the lived experience. Also, given that ones mood is sensitive to external influences (such as humour, for example) it can be argued that anxiety disorders are fluid and very difficult to score.  

The uniformed results from the study group indicate that the model described above achieved an appropriate result in the case of six patients who suffered chronic anxiety disorders. It might be argued by some practitioners that EMDR is not the most appropriate approach to treating anxiety disorders. It might also be argued that the altered version presented here appears to borrow some important elements from other modalities.  However, regardless of the acquisition of key components from other models, it has been demonstrated that the use of GSR monitors linked with the use of targeted verbal prompts can provide beneficial, objective and testable outcomes for some patients suffering a chronic anxiety disorder. 

Clearly, if an accurate, objective, testable and recordable method of scoring exists, then it is in the patients best interest to use it. Not only do the GSR monitors relieve the clients of having to make the critical clinical assessments for themselves (by scoring the emotional feelings on a SUDs scale), they also inform the therapist of the current live situation in a way that facilitates better targeting of psychotherapy. 

Suggestions for further research

Electrodermal conductivity or galvanic skin responses have been the subject of research in various contexts for a number of years (Boucsein, 1992; Roy, Boucsein & Fowles, 1993; Backs & Boucsein, 2000). Page & Robson (2007) carried out a calibration of GSR monitors against heart rate (physical strain) and finger temperature (emotional strain) monitors. They found synergy between the devices and concluded that the GSR monitor detected physical strain as well as emotional strain, indicative of anxiety and stress.  

It is suggested that more research is conducted by clinicians to establish the efficacy of GSR monitors in psychotherapeutic clinical practice. Moreover, it is suggested that clinicians look to establishing objective and measurable parameters for other psychological disorders by following a regime of Evidence Based Practice, and by contributing through published research.      
 
 

References

Armstrong, K., OCallahan, W., & Marmar, C. (1991). Debriefing Red Cross disaster personnel: The Multiple Stressor Debriefing Model. Journal of Traumatic Stress, 4, 581  593.

Backs, R. W., & Boucsein, W. (2000). Engineering Psychophysiology: Issues and Applications. New Jersey: Lawrence Erlbaum Associates.

Banister, P., Burman, E., Parker, I., Taylor, M., & Tindall, C. (1995). Qualitative Methods in Psychology: A Research Guide. Buckingham, Philadelphia: Open University Press

Beck, A. T. (1991). Cognitive Therapy and the Emotional Disorders. London: Penguin Books.

Battino, R., & South, T. L. (2000) Ericksonian Approaches; A comprehensive manual. Carmarthen: Crown House Publishing Limited.

Boucsein, W. (1992). Electrodermal Activity. New York: Kluwer Academic Publishers

Doty, R. I. (2003). Handbook of Olfaction and Gustation: Neurological Disease and Therapy (2^nd Ed). New York: Marcel Dekker.

Dowd, E. T., (2000). Cognitive Hypnotherapy New Jersey: Jason Aronson, Inc.

Fransella, F., & Dalton. P. (2000). Personal Construct Counselling in Action (2^nd Edition). London: SAGE Publications.

Hawton, K., Salkovskis, P.M., Kirk, J., & Clark, D. M. (1995). Cognitive Behaviour Therapy for Psychiatric Problems: A practical guide. New York: Oxford University Press.

Herbert, J. D., & Mueser, K. T. (1992). Eye movement desensitization: A critique of evidence. Journal of Behaviour Therapy and Experimental Psychiatry, 23(3), 169-174.

Jeffrey, R. (2004). Subjective Probability: The Real Thing. Cambridge University Press

Lipke, H. J., & Botkin, A. L. (1993). Case Studies of Eye Movement Desensitization and Reprocessing (EMD/R) with Chronic Posttraumatic Stress Disorder. Psychotherapy. 29, 591-595.

Lockley, P. (1999). Counselling Women in Violent Relationships. London: Free Association Books.

Mahoney, M. J. (2003). Constructive Psychotherapy: A Practical Guide. New York: The Guilford Press

McWilliams, N. (2004). Psychoanalytic Psychotherapy: A Practitioners Guide. New York: The Guilford Press.

Ousby, W. J. (1990). The Theory and Practice of Hypnotism. London: Thorsons

Page, M., & Robson, A. (2007) Galvanic Skin Responses from asking stressful questions. British Journal of Nursing, Vol. 16,No. 10. pp 622  627. 

Roy, J.C., Boucsein, W., & Fowles, D.C. (1993). Progress in Electrodermal Research. New York: Plenum Publishing Corporation.

Shapiro, F. (1987). Eye Movement Desensitization and Reprocessing: A new treatment for posttraumatic stress disorder. Journal of Behaviour Therapy and Experimental Psychiatry. 20, 211-217.

Shapiro, F. (1995). Eye Movement Desensitization and Reprocessing: Basic principles, protocols and procedures. London New York: The Guilford Press

Yalom, I. D. (1995). The Theory and Practice of Group Psychotherapy (4^th Edition). New York: Basic Books. 

The Study Group findings: 

The data gathered by GSR monitors and given in the tables 3 to 8 below show the downward trajectory of anxiety in all of the study group appointments. The GSR readings were logged at three points per appointment. The first TDR routine was used to establish the first baseline for that client and the corresponding extreme suffering point and mid point. The next recording of data was at the third or fourth TDR routine. The third reading was taken at the last routine prior to the close of that particular appointment 

Key to table numbers 3 to 8 inclusive:

Client = Client details by age and gender

Appointment = The therapy completed in one appointment 

Base = Baseline (relaxed) GSR reading for that client at that point in the process

Mid = Mid Point between the baseline and the ESP GSR reading at that point in the therapy process

ESP = Extreme Suffering Point or highest GSR reading at that point in the therapy process

1^st = first readings in this appointment

2^nd = second readings logged in this appointment

3^rd = 3^rd reading for TDR routine prior to close of appointment 

Table 3

Table 3: Follow up shows an ESP slightly lower than the original baseline at the first appointment. This reading is almost the same as the ESP reading at the close of the third appointment. The readings per appointment show a decline in every recorded TDR routine. Follow up data indicate no symptoms. 
    

Table 4

Table 4: Follow up shows a lower ESP than the original base line reading at appointment 1; however, the ESP at the close of appointment 3 is lower than the ESP at follow up. This was not a concern mainly because the ESP at follow up was very much lower than the original baseline reading that showed a relaxed GSR. Follow up data indicate no symptoms, but a slight increase in ESP is shown. This might be because of other unspecified issues within the client that were unrelated.  

Table 5

Table 5 shows the first appointment to have concluded with an ESP higher than the starting baseline reading. However the closing ESP reading for appointment 3 shows a lower GSR than the baselines for all three appointments. This might indicate that the period between appointments carries some importance in the therapy process. Follow up data indicate no symptoms. 
   

Table 6

Table 6 shows a high ESP at the first appointment that is reduced to a reading (in appointment 3) that is lower that the baseline at the close of the first appointment. Other information is also evident that relates to a continuous downward trajectory of all GSR readings across the three therapy appointments. Follow up data indicate no symptoms. 

Table 7

Table 7 shows the data for this client were consistently lower than for other clients in the study group. This indicates that each GSR reading is specific to the individual and that it is difficult to standardize the GSR readings because electrodermal responses are typically within a broad range (rather than a narrow range like a pulse rate or body temperature) for the species. The difference between the baseline and the ESP still showed an increased psychophysiological response to the instructions and verbal prompts. Follow up data indicate no symptoms. 
   

Table 8

Table 8 shows a decline of GSR readings across the appointments in line with the rest of the study group outcomes. The ESP at follow up is very much lower than the baseline at the first appointment, indicating that the relaxed client at the first appointment might actually have been quite anxious, and that the anxiety then became very intense to achieve the ESP score of 96. on the GSR monitor. The second appointment shows that the anxiety was assuaged at least in part at the start of that appointment. By the close of the third appointment the ESP was lower than the closing Baseline for the first appointment. Follow up data indicate no symptoms, but a slight increase in ESP over the final GSR record from appointment 3.