Objective: This study aims at determining the efficacy of the new
therapy approach Brainspotting (BSP) in comparison to the established
Eye Movement Desensitization and Reprocessing (EMDR) approach for
the treatment of Posttraumatic Stress Disorder (PTSD). Method: The
sample consisted of 76 adults seeking professional help after they have
been affected by a traumatic event. Clients were either treated with three
60-minute sessions of EMDR (n=23) or BSP (n=53) according to a
standard protocol. Primary outcomes assessed were self-reports of the
severity of PTSD symptoms. Secondary outcomes included selfreported
symptoms of depression and anxiety. Assessments were
conducted at pretreatment, posttreatment and 6 month after the
treatment. Results: Participants in both conditions showed significant
reductions in PTSD symptoms. Effect sizes (Cohen’s d) from baseline
to posttreatment concerning PTSD related symptoms were between 1.19
– 1.76 for clients treated with EMDR and 0.74 – 1.04 for clients treated
with BSP. Conclusion: Our results indicate that Brainspotting seems to
be an effective alternative therapeutic approach for clients who
experienced a traumatic event and/or with PTSD.
Posttraumatic Stress Disorder (PTSD) is defined as “a delayed or
protracted response to a stressful event or situation (of either brief or
long duration) of an exceptionally threatening or catastrophic nature,
which is likely to cause pervasive distress in almost anyone” (World
Health Organization, 1992, p. 147). In general, the range for lifetime
PTSD lies between a low of 0.3% in China to 6.1% in New Zealand
(Kessler & Üstün, 2008). Current past year PTSD prevalence was
estimated at 3.5% (Kessler, Chiu, Demler, Merikangas, & Walters,
2005), with 1.8% among men and 5.2% among women (National
Comorbidity Survey, 2005). The prevalence of full or partial PTSD in
the primary care medical setting is reported with 12% of the primary
care attendees (Stein, McQuaid, Pedrelli, Lenox, & McCahill, 2000).
The presence of PTSD is positively correlated with higher levels of
health-related problems (Schnurr & Green, 2004) and lower levels of
functioning (Thorp & Stein, 2005). Moreover, PTSD is often a
persistent and chronic disorder (Perkonigg et al., 2005). Thus, effective
treatments for PTSD are needed.
There are different treatment approaches to reduce the symptoms of
PTSD. Some already existing approaches were specially modified for
the treatment of traumatic experiences, e.g., trauma-focused cognitivebehavioral
therapy (Benkert, Hautzinger, & Graf-Morgenstern, 2008).
Others are developed primarily for the treatment of PTSD, e.g., Eye
Movement Desensitization and Reprocessing (EMDR, Shapiro, 2001),
Narrative Exposure Therapy (NET, Schauer, Neuner, & Elbert, 2011) or
Brainspotting (BSP, Grand, 2013).
In an early meta-analysis by van Etten and Taylor (1998), the most
effective drug therapies as well as the best psychological therapies,
namely EMDR and behavior therapy, were found equally effective.
Later, at least four other meta-analyses confirmed that EMDR is
empirically proven to be the best treatment for PTSD in addition to the
cognitive-behavioral therapies (Bisson & Andrew, 2007; Bisson,
Roberts, Andrew, Cooper, & Lewis, 2013; Bradley, Greene, Russ,
Dutra, & Westen, 2005; Maxfield & Hyer, 2002; Seidler & Wagner,
Primary aims of the present study were to compare the efficacy of
Brainspotting with the established EMDR-therapy and to detect areas of
significant change or lack of change (program evaluation). Outcomes
BRAINSPOTTING assessed were the severity of PTSD symptoms as well as the symptoms of
depression and anxiety.
Design and Sample
The data for this multicenter longitudinal study were collected by
independent psychotherapists in Germany, the United States of
America, Austria, Switzerland and Italy. The therapists were previously
informed about the study by mail or during EMDR and BSP trainings. If
the therapists were interested in participating, they were instructed by
mail and/or phone and then received a package with all study material.
The treatment and data collection was carried out by 27 experienced
trauma therapists. There was a pre-determined standard protocol for
both EMDR and BSP, which the therapists had to follow during their
treatment. Therapists were licensed therapists who were fully educated
in EMDR through an accredited training facility and they had at least
completed the Phase I training in Brainspotting. Thus, clients were able
to choose whether they would be treated with the established therapy
approach EMDR or the new therapy approach BSP. In case the client
chose BSP and the therapy outcome was not satisfactory, he/she had the
right to receive additional EMDR sessions. None of the clients have
taken up this offer.
Data was collected before the first therapy session, after one week after
the third therapy session and after about half a year (M=6 month; range:
2-12 month, with 69% were conducted after 5, 6 or 7 month). The
sample is composed of 76 consecutive clients (79% female; mean age
42.0 years) starting their therapy between 2009 and 2015. The inclusion
criteria were: a) adult clients aged 18 and over; b) the client have either
experienced a traumatic situation and / or suffer from a posttraumatic
stress disorder or acute stress disorder; and c) the client gives his written
consent to participate in the study. The client was deemed not eligible
for the study when the treatment already included more than the
preparatory sessions. Between the posttest and the follow-up assessment
no treatment of the trauma under focus was applied. Only counseling or
supportive sessions were possible and if needed another trauma might
be treated. Finally we collected data of 53 clients treated with BSP and
23 clients treated with EMDR. The study was reviewed and approved
by an ethics committee of the University of Bielefeld. Informed consent
was obtained from all research participants being involved in this
research after the study and the procedures were explained.
The Therapy Approach Eye Movement Desensitization and
Reprocessing (EMDR). EMDR was developed by Francine Shapiro
(2001). It is a well-established therapy for the treatment of PTSD or other
trauma associated diseases. EMDR consists of eight phases, from which
phases three to six are original EMDR stages. After establishing a good
therapist-client relationship and after the introduction of relaxation
techniques or other stabilization techniques, the client is asked to reexperience
the traumatic situation while focusing on the therapist’s
finger tips which are moving on a horizontal axis in front of his or her
eyes. In a safe environment and as part of a good therapeutic
relationship, the client relives the traumatic situation and reprocesses the
feelings, emotions, cognitions and body sensations connected to the
trauma (Schubbe, 2006).
The Therapy Approach Brainspotting (BSP). BSP is a
psychotherapeutic model discovered in 2003 by David Grand, Ph.D..
Grand has conceptualized BSP as brain-wise and body-aware relational
attunement process. In this context he has developed the model of the
Dual Attunement Frame. The foundation of this model is the
articulation of the attuned, relational presence of the therapist with the
client. This relational attunement is seen as being both focused and
deepened by the neurological attunement derived from observing and
harnessing different aspects of the visual orienting reflexes of the client
(Corrigan & Grand, 2013).
By slow eye tracking, either with one eye or with two eyes, locations for
BSP are identified. To find these locations, the techniques of either
“Inside Window“ or “Outside Window” can be used. The “Inside
Window” utilizes the client’s felt sense, the “Outside Window” helps to
locate this location by observation of clients’ reflexive response such as
blinks, eye twitches or wobbles or quick inhalation, by the therapist.
Once the therapist and client determine together the Brainspot, the client
is directed to maintain their fixed visual attention on the position and
mindfully observe their internal process. In BSP this is called Focused
Mindfulness as the mindfulness that ensues occurs in a state of Focused
Activation. The Focused Mindfulness ensues, with the therapist closely
and openly following along until the client comes to a state of
BSP is a focused treatment method that works by identifying,
processing and releasing core neurophysiological sources of
emotional/body pain, trauma, dissociation and a variety of other
challenging symptoms (Grand, 2011). In BSP, the therapist is
encouraged to openly follow the client’s process with no assumptions.
The therapist is guided to trust the innate human neurological capacity
for self-regulation given optimal conditions. In this context, the BSP
therapist also guides the client to become brain-aware through ongoing
opportunities for psycho-education. For a more detailed description of
BSP, the reader may consult Grand (2013). The standardized protocol
determines the usage of “two eyes” and the “Inside Window”.
First results indicate that Brainspotting could be an effective therapy
approach for the treatment of clients having experienced traumatic
experiences and clients with generalized anxiety disorder (Anderegg,
2016; Hildebrand, Stemmler, & Grand, 2015; NSHCF, 2016).
Measures PTSD and symptom severity. To screen the clients for the presence of
PTSD and to assess the symptom severity and functioning of the clients
the Posttraumatic Diagnostic Scale (PDS; Ehlers, Steil, Winter, & Foa,
1996; Foa, Cashman, Jaycox, & Perry, 1997) was administered. The
PDS has 49 items. It includes a 12 item checklist identifying potentially
traumatizing events experienced by the respondent. Respondents then
indicate which of these events has troubled them most in the last month.
To determine whether the DSM-IV stressor criteria are met, the
response to this event at the time of its occurrence should be rated.
Clients then rate 17 items representing the cardinal symptoms of PTSD
experienced in the past 30 days on a four-point scale (0-3). In the last
part respondents indicate the level of impairment caused by their
symptoms across nine areas of life functioning. By adding up the scores
of the corresponding items, the symptom severity for the three subscales
re-experiencing (5 items), avoidance/numbing (7 items) and
hyperarousal (5 items) is calculated. The total symptom severity score is
obtained by adding up the responses of selected items and ranges from 0
to 51 (1-10 = mild, 1-20 = moderate, 21-35 = moderate to severe, > 36 =
Additional mental impairment. Additional mental impairment was
investigated through the Hospital Anxiety and Depression Scale
(HADS; Zigmond & Snaith, 1983). This self-rating scale measures
states of depression and anxiety and features seven questions for anxiety
(HADS-A) and seven for depression (HADS-D). The respondent rates
each item on a four-point scale. The scores for the subscales range from
0 to 21.
Demographic data. Data included sex, date of birth, marital status, place
of residence, socioeconomic status (0=low, 1=average, 2=high),
traumatic experience (item “How would you describe the client’s
trauma?”) with a five point rating scale with the response categories
from 1 (minor) to 5 (major) and ICD-10/DSM-IV diagnosis of the
Analyses were conducted using SPSS 23. Independent samples t-tests
and χ2-analyses were conducted to determine whether there were statistically
significant differences between the means of those treated with
BSP and those treated with EMDR on the demographic variables. We used
univariate two factor analysis of variance (ANOVA) with repeated measures
and χ2-tests to assess treatment effects. Effect sizes were calculated according
to Cohen’s (1988) d statistic. For each scale of the PDS and HADS and for
each treatment group the magnitude of change from pre-to posttest, from preto
follow-up and from posttest to follow-up was defined as (M1-
M2)/SDpooled, where SDpooled = [(SD12+SD22)/2]1/2. Positive effect sizes
represent improvements in PTSD and other symptoms (depression, anxiety).
Negative effect sizes indicate a worsening of symptoms. The sample sizes for
the different items vary slightly due to missing data.
Demographic Data and Traumatic Experiences
Demographic data. Results of χ2- and t-test analyses comparing those treated
with BSP and those treated with
EMDR indicated no statistically significant differences regarding gender, age,
family status and PTBS diagnosis –
except place of residence (Table 1).
– Table 1 – Appendix 1
Traumatic experiences. Both groups of clients most frequently listed as the
worst traumatic experience an event that is not explicitly mentioned in the PDS
(EMDR: 48%, BSP: 37%, examples: working with death bodies, psychological
abuse). Accidents were marked by 17% of the clients treated with EMDR and
23% treated with BSP. Sexual assault by someone known was listed by 22% of
the EMDR clients and 18% of the BSP clients. The other traumatic events were
each marked by less than 10% of the client group. Differences between groups
concerning the worst traumatic event were not statistically significant (χ2 [9, N =
75] = 5.11, p = .825).
PDS. Table 2 summarizes the means and standard deviations of the PDS for the
pretest, posttest and follow-up for both treatment groups. The results of the
univariate two factor analysis of variance (ANOVA) with repeated measures and
the effect sizes are also listed. We found a significant time effect in all four scales
of the PDS, showing a decrease in the reported symptoms for both treatment
groups. We did not find a significant interaction effect, revealing no significant
differences between the groups concerning the decrease of symptoms. Pre-followup
effect sizes for the measures of PTSD symptoms for both EMDR (d = 1.11 –
2.12) and BSP treatment (d = 1.06 – 1.36) were high. The same applies to pre-post
effect sizes for EMDR (d = 1.19 – 1.76) and BSP (d = 0.74 – 1.04).
– Table 2 – Appendix 2
HADS. Results for the HADS are presented in table 3. Clients treated with
EMDR as well as clients treated with BSP reported a significant decline in
symptoms of anxiety and depression. The between groups tests indicate that the
variable treatment group is not significant for both scales. Moreover, the
interaction of time and group is not significant which means that the groups are
not changing in different ways over time.
Pre-follow-up effect sizes for the HADS were high.
– Table 3 – Appendix 3
We aimed to investigate a comparison between treatment outcomes in clients
treated with EMDR and BSP. The latter is a new psychotherapy approach which
theorizes that the field of vision can be used to locate eye positions that correlate
with relevance to inner neural and emotional experience (Grand, 2011). With a
growing recognition of BSP as an alternative treatment approach for PTSD, this
study helps to support the need for the evaluation of treatment efficacy.
We found that clients treated with BSP weren‘t more impaired than clients
treated with EMDR in the variables under consideration. Brainspotting seems to
be an effective therapeutic approach for clients who experienced a traumatic event
and/or with PTSD. Additionally, BSP seems to be as effective as EMDR in many
areas under examination (cardinal symptoms of PTSD, anxiety and depression).
In this vein, our study supports the results of Sack et al. (2016) who compared
dual attention, eye movements, and exposure only during EMDR in a randomized
clinical trial. The use of eye movements as a dual-attention task had no additional
treatment effects compared to visual fixation on a nonmoving hand. The pre-post
effect sizes for the EMDR treatment group in our study are comparable to other
findings (Bradley et al., 2005; Maxfield & Hyer, 2002; van Etten & Taylor,
1998), where effect sizes for pre- versus post-treatment comparisons range
between -.50 and 2.22. Even though the pre-post effect sizes for BSP were
apparently a bit smaller, there was no significant difference between groups
concerning the treatment outcome in either of the scales.
Our study had a longitudinal and quasi-experimental design with two
equivalent comparison groups. According to the Maryland Scientific Method
Scale (SMS; Sherman et al., 1997), which evaluates the methodological quality of
studies, our study is positioned at level 3 on a 5-point scale. The authors
indicate that confidence in the results is highest at level 5 and level 3 is required
to achieve reasonably accurate results. As differences between groups were
analyzed and not statistically significant, threats to internal validity were
minimized. For example, regression towards the mean (Stigler, 1997) could be
precluded, as there were no group differences for example in the trauma severity
score at pretest.
Limitations of the Present Study
Although improvements in symptoms of PTSD have been observed with BSP,
we can only state preliminary conclusions on the benefits of this intervention due
to the relatively small sample size. Thus, more research with larger samples is
needed to replicate our results.
Another limitation of this paper is that we did not use a randomized trial. As
randomized controlled trial is often considered the gold standard in evaluating
treatment efficacy (Misra, 2012), we also thought about using this design. Due to
organizational and ethical issues (Edwards et al., 1998; Sullivan, 2011), we
decided that clients should have the possibility to choose whether they are treated
with EMDR or BSP.
Both, EMDR and BSP were successful in treating clients with traumatic
experiences. Therefore, the common factors in the two treatment approaches and,
in general, for all effective trauma therapies should be taken into consideration
(Wampold, 2015). Both treatments start with the anamnesis and therapy planning
(Schubbe, 2014). In both treatments, the personality and particular attributes of
the therapist, the therapeutic relationship, the need of establishing personal safety
and stability, and the reprocessing of the traumatic experience could have for
example affected treatment outcome. In our study we did not focus on these
moderators of treatment outcome. In sum, the development of trauma treatment
methods include more and more resource orientation, and BSP follows this
overall direction (Schubbe, 2016).
Conclusions and Future Prospects
To conclude, our study supports the use of BSP to treat subjects who show
symptoms of PTSD. Thus, BSP seems to be an alternative treatment approach for
clients with PTSD. More research is needed to replicate our results and to
evaluate effects in different samples, e.g., clients with substance use disorders and
comorbid PTSD. Moderator analyses are necessary to further evaluate the
contribution of BSP to the treatment of PTSD. Further studies should also analyze
the potential usefulness of BSP with other diagnostic measures like the Clinician-
Administered PTSD Scale for DSM-5 (CAPS-5, Weathers et al., 2013).
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Tab. 1. – Comparisons of Demographic information of treatment groups.
Tab. 2. – PDS. Univariate two factor analysis of variance (ANOVA) with repeated
measures and effect sizes
Tab. 3. – HADS. Univariate two factor analysis of variance (ANOVA) with
repeated measures and effect sizes