3    Research on EMDR and War Stress Injury

Psychotherapy research is concerned with essentially three broad questions: (1) determining whether a therapy works in strictly controlled settings (efficacy)—especially in comparison with other viable treatments and control groups; (2) determining whether rigidly controlled treatment effects from the laboratory generalize to actual clinical practice (effectiveness); and (3) determining whether a therapy works for the hypothesized reasons (proving theoretical mechanism of action).

1993–1999: EMDR RESEARCH IN THE DEPARTMENT OF VETERANS AFFAIRS

Until as late as 2005, there were no known randomized clinical trials (RCT), either funded or conducted by the Department of Defense (DoD) on psychotherapies for Acute Stress Disorder (ASD) or PTSD with active-duty military personnel (e.g., Creamer & Forbes, 2004). All clinical research on military-related PTSD treatment had been done primarily through the Department of Veterans Affairs (DVA) and almost exclusively with Vietnam War veterans, decades after their military careers had ended. From 1993 to 1999, the DVA conducted a total of four RCT on EMDR treatment for Vietnam Veterans with combat-PTSD. A number of critical reviews and meta-analyses have been conducted on the handful of controlled and semi-controlled research with EMDR treatment of war veterans (e.g., Maxfield & Hyer, 2002). As noted earlier, Shapiro’s (1989) inaugural EMD(R) study included several Vietnam War veterans who reported marked PTSD symptom reduction after a single session. Shortly afterwards, in 1991, the esteemed behaviorist Joseph Wolpe, innovator of exposure-based therapies like systematic desensitization, published his own single-case study of EMD treatment of sexual assault trauma (Wolpe, & Abrams, 1991). Then, in 1992 there was a multiple-case study from DVA clinician-researchers Howard Lipke and Al Botkin reporting significant symptom reduction using EMDR with several clients in a DVA PTSD program (Lipke & Botkin, 1992).

In regards to DVA-sponsored uncontrolled and controlled EMDR research, varying levels of improvement were reported ranging from little to none (Boudweyns, Stwertka, Hyer, Albrecht, & Sperre, 1993) to significant (Carlson, Chemtob, Rusnack, Hedlund, & Muraoka, 1998; cited in Russell & Friedberg, 2009). It should be noted that similar patterns of mixed outcomes were reported by DVA researchers for other PTSD therapies, including heavily favored cognitive-behavioral and exposure-based therapies (e.g., Creamer & Forbes, 2004). Moreover, concerns over treatment fidelity and the manner in which EMDR was tested by DVA researchers were raised (e.g., Shapiro, 2001) that surely did not sit well with DVA experts—especially coming from a person without professional standing. But Shapiro and other advocates of EMDR appear to have a point. For example, RCT with Vietnam War veterans receiving only two EMDR sessions (Boudewyns et al., 1993; Jensen, 1994, cited in Russell, Lipke, & Figley, 2011) or treatment of a single memory (Boudewyns & Hyer, 1996; Pitman et al., 1996, cited in Russell et al., 2011) reduced subjective distress in relation to the memory but achieved no significant or sustained difference between control groups or at 15-month follow-up (e.g., Macklin, Metzger, Lasko, Berry, Orr, & Pitman, 2000, cited in Russell et al., 2011).

A subsequent meta-analysis of all RCT conducted with EMDR, in and outside of the DVA, revealed that the degree of positive EMDR treatment effects obtained was significantly correlated to the number of EMDR sessions and level of treatment fidelity and adherence to the basic EMDR trauma-focused protocol (e.g., Maxfield & Hyer, 2002). The importance of treatment fidelity was perhaps evident when DVA clinician-researchers outside of the National Center for PTSD found significantly more robust findings when adequate treatment fidelity was demonstrated, using a more realistic, 12-session format for treating chronic combat-PTSD. That research team was led by Dr. Steven Silver at VAMC Coatesville, Pennsylvania. Silver, Rogers, Knipe, and Colelli’s (1995) large, non-randomized investigation of EMDR treatment with multiple memories from 83 Vietnam War veterans diagnosed with combat-PTSD was found to be superior in comparison to biofeedback and relaxation training on seven of eight dependent measures; impressive, but not scientifically rigorous enough for DVA executives to take notice.

Besides, by 1996, institutional military medicine’s leaders had already made up their minds about EMDR. Once it was obvious that EMDR was not the single-session wonder that the media and some overzealous EMDR therapists were making it out to be, it was time to pull the plug (Russell, 2008a). It would be understandable, though, if even the harshest skeptics might have secretly hoped for the breakthrough that could possibly help thousands of broken war veterans who spend years or decades drifting in and out of the DVA’s wards—but it didn’t happen. It was 1996, and the results from three clinical trials by the DVA were generally mixed and unspectacular. However, not everyone in the DVA was willing to quit on something that might yet prove helpful to veterans. Seasoned clinicians like Howard Lipke who ran DVA’s PTSD programs at North Chicago VA and Steven M. Silver and Susan Rogers, the Director and co-Director for PTSD Program, VAMC Coatesville—who, despite the nay-saying by DVA leadership, were still obtaining positive clinical results on the ground floor with EMDR that were not achieved with the existing cognitive-behavioral tools.

1998: DVA EMDR RCT ON COMBAT-PTSD WITH TREATMENT FIDELITY

Then, in 1998, Dr. John Carlson and his research group at the DVA Medical Center, Honolulu, Hawaii, entered the fray. Carlson noted that the main purpose of his team’s study was to address the contradictory findings from the DVA’s previous RCT on EMDR (Boudewyns et al., 1993; Pitman et al., 1993; Jensen, 1994, cited in Russell et al., 2011), as compared to highly supportive reports from the civilian sector. Specifically at issue were concerns over treatment fidelity of the DVA studies and an unrealistic design to study a treatment for chronic combat-PTSD, whereby EMDR was being tested after 2–3 sessions, as compared to 9–28 sessions from DVA RCT on exposure therapy (Carlson et al., 1998). Carlson and his team cited a 1995 civilian EMDR RCT within a managed care setting, not unlike the DVA or DoD, that found significant EMDR treatment effects after 12 sessions and by achieving high treatment fidelity (Wilson, Becker, & Tinker, 1995). Given the prevailing controversy and current institutional military medicine resistance toward EMDR research, a more in-depth look at this pivotal DVA study is warranted.

Carlson et al. (1998) carefully designed a research using the “gold standards” for RCT of the time in order to satisfy DVA skeptics and EMDR advocates. His team used a multimodal assessment approach including Clinician Administered PTSD Structured interview (CAPS-1); a host of established standardized psychometric measures: MMPI-2, Impact of Events Scale (IES), Beck Depression Inventory (BDI), Mississippi Scale for Combat Related PTSD (MSCRP), PTSD Symptom Scale (PSS), and the Spielberger State-Trait Anxiety Inventory (STAI); and psychophysiological measures (skin conductance, heart rate, EMG, and temperature). Blind raters were used to assess at pre, post, 3-month, and 9-month follow-up. There were three DVA therapists: one with extensive experience with biofeedback and behavioral therapies, the other a psychodynamic orientation, and the third with extensive experience with biofeedback. All three clinicians received EMDR training and implemented EMDR per the treatment manual (e.g., allowing free association to multiple memories versus 1–2), and treatment fidelity was assessed by an outside consultant (Carlson et al., 1998).

A total of 35 Vietnam War veterans diagnosed with combat-PTSD were randomly assigned to one of three groups: EMDR, a control group receiving routine DVA clinical care for PTSD, and biofeedback-assisted relaxation training. Carlson et al. (1998) explained that their choice of biofeedback was based on (a) the fact that it was active treatment modality in the DVA and could control for attentional effects; (b) the fact that it served as viable treatment for veterans; (c) the implications of physiological arousal in PTSD; and (d) previous biofeedback treatment research of chronic anxiety. There were no meaningful differences across treatment groups. All three groups had overall average combat-PTSD scores (M = 118.3), significantly above the 107 cut-off. After random assignment, there were no drop-outs in the EMDR or control group and one drop-out in biofeedback (Carlson et al., 1998).

Results. Carlson et al.’s (1998) more pragmatic approach to researching EMDR on Vietnam War veterans with chronic, combat-related PTSD revealed that, after 12 EMDR sessions, targeting multiple memories, 77% of combat veterans no longer met criteria for PTSD with results maintained at 3- and 9-month follow-up. Specifically, “very substantial” EMDR treatment effects were found on the majority of psychometrics, with statistically significant differences of EMDR treatment compared to veterans receiving routine clinical care or biofeedback-assisted relaxation therapy as measured by the BDI, MSCRP, PSS, CAPS, and significantly greater improvement and treatment satisfaction as rated by the military patients. Overall, there were lower but not significant decreases on IES and STAI with EMDR, and all groups had significant decreases in physiological arousal (Carlson et al., 1998). So what happened next? Where would the National Center for PTSD go with these results, since it came from one of their component research centers? Scientists adhering to the vaulted scientific method as means to uncover “truths” almost reflexively would opt for replication before deciding whether to accept or reject the findings.

Unfortunately, the Carlson et al. (1998) study has been the last word in the Department of Veterans Affairs National Center for PTSD’s abbreviated flirt with EMDR in fulfillment of its stated mission of “searching for highest quality PTSD care.” Then, on October 1, 2001, the Global War on Terror began, and so, too, the longest war in American history. All eyes went to institutional military medicine to see if, in this war, finally, the Nation would do right by its warrior class.

WHY NO EMDR RESEARCH AND TRAINING IN THE DEPARTMENT OF VETERANS AFFAIRS?

The public explanations provided by the DVA and the National Center for PTSD as for why it does not offer EMDR training or research are multifold: (a) that, while there is evidence of EMDR’s efficacy for treating traumatic stress injuries, there is insufficient RCT with military and veteran’s populations; (b) that dismantling studies have proven that the use of eye movements is superfluous; (c) if the eye movements are not needed for EMDR, then the theory of mechanism of action has been disproven, and therefore the treatment itself is invalid and should not be researched; and (d) there is nothing “new” about EMDR that is not already found in established cognitive and exposure therapies (see Russell, 2008a).

EMDR FUNDED RESEARCH IN THE DEPARTMENT OF DEFENSE

As noted earlier, the extent of EMDR research by military medicine can be summarized in a single word—zero. To be crystal clear, the paucity of EMDR RCT with war veterans in the DVA and the total absence of any EMDR RCT with military personnel in the DoD are an indictment of institutional military medicine for neglecting its responsibilities to the welfare of the warrior class, not the lack of efficacy of EMDR treatment per se. In fact, as we will see shortly, there is already considerable evidence that EMDR is not only an “efficacious” therapy, but, perhaps even more importantly, it is an “effective” treatment for war or traumatic stress injuries in actual real-life military settings.

FUNDED RESEARCH ON WAR STRESS INJURY IN THE DEPARTMENT OF DEFENSE

The reason for the above qualifier “funded” is that, simply put, people (and organizations) tend to invest resources, such as money, into those things they most value and are committed to. The over $400 million spent by the Department of Defense (DoD) since 2005 on researching PTSD treatments has been invested predominantly on those treatments developed and researched by the lead agency of institutional military medicine, the Department of Veterans Affairs, National Center for PTSD: Prolonged Exposure (PE), Cognitive Processing Therapy (CPT), and Virtual Reality Therapy (VRT). To be certain, PE, CPT, and VRT should and must be researched by military medicine within military settings, as they have a proven track record for reducing human suffering from traumatic stress injuries. However, as the war on terror slogged on, it was painfully clear that the hand-selected evidence-based treatments of choice were not sufficient in meeting the mental health needs of returning warriors.

Panicked, military medicine embarked on an “anything but EMDR” shotgun excursion to find any possible effective intervention for war stress injury, funding randomized controlled trials with a broad array of alternative non-evidence-based methods such as yoga, acupuncture, bioenergy (Reiki) massage, journaling, art, horses, fishing, dogs, and a host of other unconventional, yet still possibly valuable adjunctive therapies. When this too did not pan out and the prevalence of war stress injury, suicide, and incidents of mis-conduct stress behavior continued to escalate, military medicine appeared to have reached the conclusion that the effort to discover reliable, effective treatments to stem the tide of chronic anguish, military attrition, and disability had largely failed. Scrambling for an alternative strategy, military medicine elected to devote its scarce resources in a “new” direction—that of “positive psychology” and prevention. In January 2011, the U.S. Army desperately announced a $125 million commitment to civilian academic researchers, uncharacteristically doubling down on the broad implementation of a relatively untested Comprehensive Soldier Fitness (CSF) program—or stress inoculation on steroids—with the glimmer of hope that it might prevent or reduce war stress injury (Casey, 2011).

However since 2008, the Army had already incorporated a well-designed and cost-effective Battlemind resiliency training program for military personnel and family members, for use throughout the deployment cycle. On top of that, the military continues to revise its Combat (Operational) Stress Control (CSC/COSC) protocols employed since 1918. The CSC/COSC mission is “to conserve the fighting force,” which it does by normalizing, stabilizing, and returning military personnel with transient signs of acute stress reactions back to their frontline units—with 90% efficiency (Department of the Army, 2009). While perhaps effective for some military members, none of the military’s previous preventative measures to date have demonstrably reshaped the problem of war stress injury; in fact, the evidence tells the opposite.

No matter how fighting-fit physically, psychologically, spiritually, or socially, there is a limit to human endurance on the modern battlefield. Exponential increase in war-related stressors associated to around the clock, air-land-sea unpredictable, and uncontrollable and inescapable threats of destruction, combined with cumulative effects of stressors related to deployment and combat, provides an abundantly toxic environmental context for acute and chronic psychophysical breakdown. The only certain preventative measure is to not expose human beings to war. Human history dictates that this will never happen; therefore, institutional military medicine is honor bound to fulfill its mission by exhausting all avenues. In sum, the Department of Defense’s current commitment to researching an assortment of treatment and prevention possibilities is not only laudable—it’s the “right thing to do!” There are no panaceas, as the DVA reinforced with its cursory fling with EMDR 14 years ago. Thinking outside of the box is especially critical at this time, because, until 2005, military research on preventing and treating war stress injuries has been shortsightedly “MIA” (missing-in-action). Therefore everyone is desperately playing catch-up during a “hot” war and throwing everything at the problem of war stress injury, including the kitchen sink—except that’s not entirely true. Since the 2004 publication of post-traumatic stress clinical practice guidelines by institutional military medicine and the American Psychiatric Association, the only evidence-based treatment or non-evidence-based alternative not researched by the DVA or DoD is conspicuously EMDR.

Relevant EMDR Efficacy Research on Treating Non-War-Related Trauma

This book covers EMDR treatment for the spectrum of war and traumatic stress injuries, not limited to combat trauma alone. It is similarly for practitioners treating the warrior class to not just focus on assessing for stress injuries related to war. As demonstrated in earlier chapters, inherent to the military occupation is regular exposure to a wide range of potentially traumatic stressors outside of war (e.g., military sexual trauma, training accidents, etc.). In addition, many service members enter the military with a history of adverse childhood experiences, but their difficulties in adjustment to the military environment may or may not be clearly associated with an identifiable trauma-related diagnosis like PTSD (e.g., depression, interpersonal violence). The scientific basis for EMDR’s recognition as evidence-based for treating post-traumatic stress injuries has been well-summarized by any and all of the various domestic (U.S.) and international clinical practice guidelines that have reviewed the meta-analyses and RCT of EMDR (e.g., APA, 2004; Bisson & Andrew, 2007; DVA/DoD, 2010). Therefore, even clinicians wary about using EMDR because of the concerns over the sheer amount of controlled studies with military and veterans should be reassured by the extensive scientific reviews of EMDR’s efficacy on other types of traumatic stress exposure.

Adverse Childhood Experiences: Treating Child-Onset and Adult-Onset Trauma

The second of two NIMH-sponsored studies on EMDR was by Bessel van der Kolk et al. (2007), who conducted a blind-rater, RCT comparison of a placebo-pill control group, EMDR, and medication (Prozac) for the treatment of adults with either childhood-onset PTSD or adult-onset PTSD. After a total of eight sessions (six EMDR treatment sessions), the researchers found that EMDR was superior to Prozac in reducing both PTSD and depression symptoms in adult-onset PTSD. For the majority of adults with child-onset PTSD, most did not achieve complete remission of their PTSD or depression symptoms in either treatment group. However, at the six-month follow-up, 75% of the adult-onset and 33% of the child-onset PTSD cases were asymptomatic after only six EMDR treatment sessions—none were asymptomatic who received Prozac or the placebo control (van der Kolk et al., 2007).

Sexual Trauma

Another pertinent study on EMDR efficacy is Rothbaum, Astin, and Marsteller’s (2005) research on treating female adults with a history of single incident sexual trauma either in childhood or adulthood. The research was funded by the National Institute of Mental Health. This was a randomized, well-controlled study involving 74 female rape victims comparing EMDR, prolonged exposure (PE), and a wait-list control. Structured clinical interviews were conducted (e.g., CAPS, SCID), and a variety of well-established psychometrics used including for depression (BDI), dissociation (DES-II), and PTSD (e.g., IES-R). All participants received nine treatment sessions, and treatment fidelity for PE and EMDR was conducted by experts selected by Edna Foa and Francine Shapiro, respectively (Rothbaum et al., 2005). Results indicated that both EMDR and prolonged exposure produced significant treatment effects with 95% of PE subjects and 75% of EMDR no longer meeting PTSD diagnostic criteria at post-treatment. Symptom improvement was sustained at six months, although more of the PE vs. EMDR group remained completely asymptomatic. This methodologically rigorous, head-to-head comparison met all seven of the RCT “gold standards.” The significant EMDR treatment effects in this well-controlled study were reported to be contrary to other, less rigorous controlled trials that compared EMDR to cognitive-behavioral treatments (e.g., Devilly & Spence, 1999; Taylor et al., 2003, cited in Rothbaum et al., 2005). In conclusion, Rothbaum states, “An interesting potential clinical implication is that EMDR seemed to do equally well in the main despite less exposure and no homework. It will be important for future research to explore these issues” (Rothbaum et al., 2005, p. 614).

Clinical note. Both studies provide evidence of EMDR’s utility with treating military sexual trauma and adverse childhood experiences that are frequent within the military population, as well as other causes of PTSD-related injuries outside of war and combat. The van der Kolk et al. (2007) study is particularly relevant in the military. Many military specialities prohibit military personnel from using psychotropic medications (e.g., pilots, submariners), as well as those with top-secret or higher security clearances, and thus require temporary reassignment until they have been off medication for a specified time or members are discharged from the military. Being temporarily deemed as “unfit for full duty” can result in lower annual performance evaluation marks that may hinder one’s career progression and ultimately end his or her military career. Consequently, there is considerable reluctance for military members to self-disclose stress injuries, usually until a crisis, and, at that point, the career repercussions may be unavoidable. Therefore, van der Kolk et al.’s (2007) study provides support for recommending EMDR to service members in either sensitive jobs, or who are intrinsically against taking psychotropics (and many are). Or, for those deemed temporarily unfit, EMDR may provide clinical benefit in relatively few sessions for some or many individuals—resulting in less “job loss” time and possibly lesser career impact.

Attrition and Treating Military Clients with Child-Onset

The van der Kolk et al. (2007) study and others (e.g., Shapiro, 2001) provide rationale for using EMDR to treat military clients with adverse chilhood experiences that have higher risk for war stress injury and early military separation. For example, 46% of 204 Soldiers surveyed reported a history of childhood physical abuse, and 25% reported both childhood physical and sexual abuse. It bears mentioning that, despite a high prevalence of adverse childhood experiences in the military, most military personnel report functioning as well as those soldiers without such experiences (Seifert, Polusny, & Murdoch, 2011). Nevertheless, during the period 1997–2002, psychiatric conditions were the most common cause of early military discharges reported for Navy (47%) and Marine (36%) enlisted members and the second leading cause of discharge in the Army (15%; National Research Council, 2006). Depending on length in service and military schools attended, on average it costs the government an estimated $52,800 to separate and replace military personnel (e.g., Government Accountability Office, 2011). It is commonplace in the military to inform service members suspected of having a “personality disorder,” but who want to continue their military career, to be administratively separated by saying, “I’m sorry, the military does not provide long-term therapy”—which it doesn’t. If EMDR can get results in as few sessions as in the van der Kolk et al. study (2007), the benefits to service members, military units, the armed services, and greater society when these individuals transition out of the military are substantial.

Terrorism: EMDR for Acute and Chronic Trauma

As noted earlier, military personnel have been targeted, wounded, and killed in acts of terrorism. Early identification and intervention is recommended by the DVA/DoD (2010) clinical practice guidelines to prevent chronic stressinjuries like PTSD. Silver et al. (2005) reported on EMDR treatment provided to 62 direct witnesses to the 9-11 World Trade Center attack. Clients were treated from 2 to 48 weeks (mean was 20 weeks) after the terrorist attack and had either lost a loved one or coworker, were eyewitnesses to the attacks, or were involved in rescue, body recovery, or clean-up efforts at the World Trade Center. Ages ranged from 6 to 65 years. There were no statistically significant differences between women and men on pre- or post-treatment variables. The 62 participants received 1 to 8 EMDR sessions (4.2 sessions on average), by 29 different EMDR therapists. Analysis examined early versus late treatment after the attack. The late group had a statistically significantly higher level of pre-treatment disturbance as measured by the SUD, and lower VOC than the early group. At post-treatment, the early group showed greater positive changes on SUD and VOC than the late group suggesting the passage of time contributed to a worsening of reactions among those requesting treatment (Silver et al., 2005).

Neuro-Scientific Research on EMDR Treatment

The other non-military-related research we want to briefly mention is the neuroimaging and neurobiological studies that can be helpful in phase two of EMDR (client preparation), as well as in educating reluctant military providers and agencies about the neuroscientific data on EMDR. Several EMDR neuroimaging case studies have been published in peer-reviewed journals, describing significant pre-post changes in brain function corresponding to patient self-report on PTSD and other symptom measures. For example, multiple separate case studies utilizing neuroimaging scans before and after EMDR treatment for PTSD have found significant alterations in brain physiology corresponding to reduction in symptom measures. Neuro-physical treatment changes with EMDR have also been found with event-related brain potentials on EEG recordings (e.g., Lamprecht et al., 2004). An exhaustive review was not undertaken, but below is a sampling of relevant studies.

Harper et al. (2009) published the results of qEEG (quantifiable EEG) after EMDR treatment of six subjects with PTSD. After one EMDR session, all participants reported significant reduction of PTSD symptoms. Analysis of qEEG suggests that the neural basis for EMDR is depotentiation of fear memory synapses in the amygdalae during evoked brain state similar to that of slow wave sleep. Results appear consistent with three other reports of brain stimulation during EMDR increasing naturally occurring low-frequency rhythm in memory centers of the brain. Levin et al. (1999) used a within-subject design on a 36-year-old male with complex PTSD from childhood abuse and witnessing severe domestic violence. Standardized symptom measures included CAPS, Hamilton-D, IES, Rorschach, and Single Photon Emission Computed Tomography (SPECT). After three EMDR sessions, significant reduction in self-report of PTSD and depression symptoms coincided with changes during post-treatment recall of the traumatic memory that were now associated with increased activation (as opposed to pre-treatment hypo-activation) of the anterior cingulate gyrus and left frontal lobe. Authors hypothesize the post-treatment hyper-activation in the cingulate and frontal cortex may enhance the ability to differentiate real from imagined threat.

Nardo et al. (2010) used Magnetic Resonance Imaging (MRI) comparisons of 21 subjects exposed to occupational trauma who developed PTSD and 22 subjects exposed to train-accident trauma but did not develop PTSD. In addition, a subset of 15 of the PTSD subjects received five EMDR treatment sessions, resulting in 10 treatment “responders” resulting in significant PTSD symptom reduction and 5 “non-responders” that evidenced little to no PTSD symptom change. Prior to EMDR, the PTSD subjects, compared to no-PTSD, exhibited significantly lower grey matter density in the left posterior cingulate and posterior parahippocampal cortex—which is functionally related to the hippocampus for consolidation and retrieval of declarative memory. After EMDR, the non-responders showed a significantly lower gray matter density as compared to positive EMDR responders, in bilateral posterior cingulate, as well as right amygdala, anterior insula, and anterior parahippocampal gyrus. Nardo et al. concluded that lower gray matter density in limbic and paralimbic cortices were found to be associated with PTSD diagnosis, trauma load, and EMDR treatment outcome, suggesting a view of PTSD as characterized by memory and dissociative disturbances. Lansing et al. (2005) reported using EMDR with six police officers involved with on-duty shootings and diagnosed with delayed-onset PTSD. Pre-and-post treatment changes were measured by standardized psychometric measures (e.g., PTSD Scale Score) and high-resolution SPECT (Single Photon Emission Computed Tomography) imaging. All six police officers self-reported significant symptom reduction that coincided with significant changes in brain functioning. For example, after successful EMDR treatment, SPECT scans revealed significant decreases in the left and right occipital lobe, left parietal lobe, and right precental frontal lobe as well as significant increased activation in the left inferior frontal gyrus. Authors concluded that EMDR appears to be an effective treatment for PTSD in police officers, showing both clinical and brain imaging changes.

Clinical note. The existing neuroimaging studies are promising and reveal visible, measurable neurological changes from EMDR treatment. However, consistent and accurate findings from neuroimaging research on PTSD and psychotherapy are still on the horizon. Case studies do not prove that any specific brain region is implicated in PTSD and after treatment like EMDR. That said, there is mounting evidence, from diverse sources, indicating that successful completion of EMDR therapy is resulting in functional and possibly structural changes in the brain that appear to signify a reversal, if not a “healing,” of the dysfunctional brain changes that occur in PTSD. The ends may not be unique to EMDR therapy, but the means are (e.g., no intense repetitive exposure, cognitive disputation, coping-skill building homework, etc.). Also of particular relevance is Lansing et al.’s (2005) neuroimaging case study with six police officers diagnosed with PTSD after a shooting incident. Although no neuroimaging studies have been conducted yet with EMDR in military populations, there is obviously considerable overlap between paramilitary organizations like police departments and the occasional need to use deadly force.

Unfunded Research on EMDR Effectiveness in the Military

As alluded to in the previous chapter, military medicine has elected to follow versus lead when it comes to the matter of investigating every possible treatment option, including all identifiable “evidence-based” psychotherapies highly recommended by its own clinical practice guidelines since 2004. Moreover, ample small-and-large clinical case studies utilizing EMDR treatment with military personnel have been widely circulated within military medicine and published in peer-reviewed scientific journals, depicting clinically significant treatment effects along a spectrum of war stress injury (e.g., PTSD, depression, phantom limb, medically unexplained conditions) and across a range of actual operational (e.g., military field hospital) and military environments (e.g., military treatment facility). Simultaneously, numerous news media accounts of military practitioners using EMDR successfully in the field add further credence to EMDR’s effectiveness within the United States military, as well as the armed forces of staunch allies like the United Kingdom and Germany.

Of critical importance is a National Institute of Mental Health (NIMH)-funded EMDR study, in which a blind, RCT-compared EMDR to placebo control and Prozac groups in treating adults with childhood-onset PTSD and adult-onset PTSD found EMDR superior to both conditions (van der Kolk et al., 2007). These findings have profound implications for military personnel averse to taking medication, or whose jobs are incompatible with the use of psychotropic medications (e.g., submariners, aviators, special forces, top-secret clearances, etc.), as well as service members experiencing adjustment difficulties upon entering the military due to a history of unresolved child abuse or other early traumatic experiences finding is informative. Other notable non-military-related EMDR research of relevance to the military includes at least five neuroimaging EMDR treatment case studies revealing functional pre-post brain changes, coinciding with self-reported symptom improvement. Consequently, arguments about the efficacy of EMDR therapy with non-combat-related trauma (e.g., sexual assault, accidents, terrorism, adverse childhood events, natural disasters, etc.) have been largely settled, leading to its wide-spread recognition as evidence-based treatment for non-combat-related trauma (e.g., DVA/DoD, 2010). This is of critical importance for clinicians working with military clientele, many of whom may either enter military duty with a personal history of traumatic experiences (e.g., childhood abuse) and/or encounter traumatic events during non-combat-related military service (e.g., training accidents, sexual assault, witnessing atrocities during peace-keeping missions, post-disaster relief). Getting back to EMDR efficacy research, any lingering controversy has now shifted away from disputes over efficacy to a debate over proving its hypothesized mechanism of action (e.g., role of lateral eye movements; see Russell, 2008a).

Bradley et al.’s (2005) meta-analysis on PTSD treatments reaffirmed EMDR’s evidence-based status, but questioned the external validity of all so-called evidence-based treatments for deficient field testing of the effectiveness of these therapies in actuarial contexts, versus artificially controlled laboratory settings that regularly exclude clients with co-morbidity. This is a critical observation in light of PTSD research that routinely identifies high levels of co-morbidity (50–80%) with depression, substance abuse, and medically unexplained condition, to name just a few (e.g., DVA/DoD, 2010). As will be evident in the case-study research below, nearly every therapist is dealing with co-morbidity in their military clientele.

EMDR Treatment of Acute Stress and Trauma in the Military

Elan Shapiro (2009) reviewed civilian research on EMDR as an early intervention following terrorist attacks and natural disasters, revealing its potential efficacy within the military. We will examine evidence of EMDR’s potential effectiveness as an early intervention for acute stress or acute traumatic stress within military populations across national lines.

United States Military

EMDR’s potential effectiveness has been demonstrated at an U.S. Navy field hospital where four American service members were medically evacuated from the Iraq battlefield at the outset of the Iraqi invasion. Each of the military clients was referred to the author (Mark Russell) by medical staff, due to a high level of disturbance and medical instability, to be transported to a stateside treatment facility. Two military clients were diagnosed with combat-related Acute Stress Disorder (ASD), and two with acute combat PTSD. The first client was a 23-year-old, Marine Lance Corporal whose armored vehicle was hit by an IED, resulting in his witnessing the grotesque death of a close friend. The second client was a 22-year-old Marine Corporal with shrapnel wounds following an Iraqi ambush, the third client was a 25-year-old Army Specialist reporting traumatic grief and over the intentional killing of non-combatants who did not heed warnings to stop their vehicle at a military checkpoint, and the fourth client was a 32-year-old Army Staff Sergeant evacuated for shrapnel wounds reporting a traumatic memory of unearthing a mass gravesite. All four service members received a single session of modified EMDR that will be discussed in Chapter 10. Each military member reported significant pre-post symptom reduction on ASD/PTSD and depressive symptoms that was corroborated by ward staff and, at next-day follow-up before medical evacuation transport to Walter Reed Army Hospital. Due to high OPTEMPO, tracking of military clients was not possible. Therefore, it is unknown whether the intervention possibly prevented chronic war stress injury (Russell, 2006).

Anecdotal reports. Even closer to the battlefield has been the work of Navy Commander Beverly Dexter, who reported using EMDR with front-line troops suffering from combat-related stress reaction, while she was assigned to a Combat Stress Control unit in Iraq. Using three EMDR sessions on consecutive days, Dexter reported that military patients were able to return to their platoons and function normally. She found that EMDR provided immediate positive results (B. Dexter, personal communication, 2007).

United Kingdom Military

Wesson and Gould (2009) successfully treated a 27-year-old U.K. soldier at a frontline, combat stress control unit experiencing a debilitating acute stress reaction after assisting in a land mine casualty 2 weeks prior to being evaluated at the medical facility. After four EMDR sessions on 4 consecutive days, the soldier’s acute stress reaction resolved and he was able to immediately return to full-duty status with his military unit. Significant pre- and post-treatment changes were reported, and sustained improvement at 18 months signifies EMDR’s potential utility in the trenches.

Anecdotal reports. Head of Defence Clinical Psychology, Ministry of Defence, and former Vice Chair of the NATO Task Group on Stress and Psychological Support in Modern Military Operations J. Hacker-Hughes and Wesson (2008) presented a case study of a British Soldier who was suffering significant post-trauma symptoms while serving in Afghanistan. Two weeks after combat trauma, the military therapist used EMDR in the warzone that successfully resolved the incident. The soldier was returned to full duty and avoided the negative consequences often associated with separation from the military unit and medical evaluation back to the U.K.

Summary of Early Intervention Research with EMDR

Unfortunately, institutional military medicine’s ban on EMDR research has prohibited funding of critically needed follow-on research to these case studies. As reviewed earlier, Silver et al.’s (2005) EMDR case study of 62 New York City victims of the terrorist attacks included an early intervention group that reported clinically significant improvement after four sessions on average. The author (Mark Russell) is also aware of further anecdotal reports of EMDR use in forward deployed settings, from various military clinicians trained in EMDR; however, none are documented. Nevertheless, although the total sample size of five military clients is not impressive, other published civilian studies on early intervention with EMDR as reviewed by Elan Shapiro (2009), along with EMDR’s status as an established evidence-based treatment for post-traumatic stress, provides more than sufficient justification for EMDR utilization and research as treatment for acute stress injuries.

Treating Chronic War and Traumatic Stress Injuries in Military Settings

United States Military

The author (Mark Russell) received a referral from the hospital case manager for a 22-year-old Marine Corporal pending medical discharge, who was diagnosed with PTSD, depression, and severe phantom-limb pain and sensations following a traumatic leg amputation from a motor vehicle accident about four months previous. After five EMDR treatment sessions, there was clinically significant reduction of PTSD and depression symptom surveys, along with significant elimination of phantom-limb pain sensations with only mild, non-intrusive “tingling” sensations reported. At a 1-month follow-up, the client reported that PTSD and depression conditions had completely resolved with sustained phantom-limb symptom improvement (Russell, 2008b). Several other case studies on using EMDR with phantom-limb pain in the civilian sector have been published (e.g., de Roos & van Rood, 2009; Schneider, Hofmann, Rost, & Shapiro, 2007).

Using EMDR to treat co-morbid combat-related medically unexplained symptoms with military personnel has been reported. The first case involved a 40-year-old Marine Master Gunnery Sergeant in Explosive Ordnance Disposal (EOD), recently returned from a second combat tour in Iraq. Diagnosed with multiple medically unexplained symptoms (e.g., chronic fatigue, headaches, insomnia, constipation, back pain, etc.) and prominent “non-cardiac chest pain,” the client was referred by the primary care physician for evaluation and treatment. Assessment revealed co-morbid PTSD with severity in the “severe” range and “moderate” depression. Multiple combat-related traumatic memories were identified, including traumatic grief over the death of a close friend. The client received five EMDR treatment sessions resulting in clinically significant pre-post changes on PTSD, depression, pain, and health ratings with symptom improvement maintained at 1-, 3-, and 6-months follow-up. The client’s primary care physician corroborated the significant change in physical condition (Russell, 2008c).

The second case is that of a 73-year-old Vietnam War combat veteran who was seeking EMDR treatment at a military mental health outpatient clinic. He was diagnosed with PTSD, depression, and alcohol dependence after discharge from the Army in 1968, but the principle reason for discharge was due to severe, chronic medically unexplained “myoclonic” jerks that began during close hostilities during the TET Offensive. The client and family members reported excessive neck and upper-torso “shakes” at least 20 times daily at home and 50–60 times if out in social situations. The client has been treated in the DVA since his military discharge with a variety of medication and psychotherapy. Assessment identified PTSD in the “severe” range and depression at “moderate” levels. The client “jerked” constantly during interview of Vietnam experiences and immediate post-deployment adjustment. After two EMDR treatment sessions, the client’s PTSD, depression, and myoclonic jerks revealed clinically significantly pre-post improvement on all symptom measures. The client’s myoclonic jerks were reported to be resolved, even when the family tested the improvement by going into crowded social situations. Sustained symptom improvement was reported and corroborated at 6 months (Silver, Rogers, & Russell, 2008).

War Stress Injury in Wounded-in-Action Personnel and EMDR

A non-randomized retrospective medical record review was conducted resulting in 72 military clients treated with EMDR in military outpatient mental health clinics at different military installations. Eight separate military therapists participated in the review. Of the 72 cases reviewed, 48 service members were diagnosed with combat-related acute stress disorder (ASD) or combat-PTSD. Other clients were treated for non-combat-related PTSD or related diagnoses. Military client rank ranged from Private (E-1) to Marine Captain (0-3). Time since trauma ranged from 14 to 24 months. Number of EMDR treatment sessions ranged from 1 to 14. Eight of the clients had been wounded-in-action. A total of 63 cases had both Impact of Events Scale (PTSD) and Beck Depression Inventory (depression), along with SUDS and VOC ratings. Results indicated statistically significant pre-post symptom improvement on average of four EMDR treatment sessions, if not wounded-in-action, and on average of eight EMDR sessions, if wounded-in-action. Limitations of the study were discussed, including lack of control group, follow-up data, and controls for other interventions (Russell, Silver, & Rogers, 2007). Another published case study was a 22-year-old soldier who served two combat tours in Iraq, recently discharged from the military following repeated hospitalizations after several suicide attempts. The client was transitioned to VA residential care. The precipitant stressor was a break-up with his fiancé. Traumatic combat memories were identified, including severe guilt over killing an Iraqi combatant. The client was diagnosed with moderate-to-severe PTSD and was administered four EMDR treatment sessions. Clinically significant pre-post PTSD symptom improvement was reported that was sustained at 3-month follow-up (Silver et al., 2008).

Iranian Military

Iranian clinicians reported that 51 military personnel were admitted to a hospital with the diagnosis of acute combat-related PTSD. Clients were randomly assigned to three groups, EMDR, and CBT, or a control group, to assess effectiveness as an early intervention to prevent chronic disability. Both EMDR and CBT were reported to be effective in reducing symptoms associated with disturbing memories, anxiety, depression, and anger; however, treatment changes from EMDR were reported to be superior then CBT. The Iranian doctors concluded by recommending EMDR and CBT be used to prevent and reduce symptoms of PTSD in war veterans (Narimani, Ahari, & Rajabi, 2010). In a second study, 45 Iranian war veterans diagnosed with combat-related PTSD were randomly assigned to EMDR, CBT, or a control group. Both EMDR and CBT treatment groups had statistically significant pre-post changes on the PTSD Checklist-Military and the Symptom Checklist 90-Revised, as compared to the control group (Ahmadizadeh, Eskandari, Falsafinejad, & Borjali, 2010).

Sri Lankan Military

A Sri Lankan military mental health clinician, using EMDR for treatment of 18 Sri Lankan military personnel diagnosed with combat-related PTSD, reported clinically significant pre-post changes were reported on symptom measures (Jayatunge, 2006). A second case study indicated that large hostile military operations were conducted in Sri Lanka, resulting in a significant number of Sri Lankan soldiers diagnosed with war stress injuries manifested as PTSD, depression, somatization, and other adjustment reactions. Jayatunge (2011) stated that he and other Sri Lankan mental health clinicians received EMDR training in 2005. EMDR treatment of six Sri Lankan soldiers was described. Four of the soldiers were diagnosed with combat-PTSD, and two soldiers diagnosed with a depressive disorder. After 5 to 8 EMDR sessions, Jayatunge (2011) reported positive treatment effects for PTSD and depression symptoms, with most soldiers becoming symptom free.

Republic of Germany Military

At a military hospital inpatient setting, 40 German soldiers receiving EMDR therapy for non-combat-related PTSD were compared with 49 German soldiers diagnosed with non-combat-related PTSD and received group counseling and relaxation training, with greater improvement in the EMDR group. A total of 20 soldiers who received EMDR and 14 who received group and relaxation training were reevaluated after an average of 29 months. Results indicated that those treated with EMDR were significantly improved over the supportive treatment group even after 29 months (Zimmerman, Biesold, Barre, & Lanczik, 2007).