12 EMDR Treatment of Traumatic
Grief and Interpersonal Violence
In Chapter 5 we reviewed some potential indicators or signs of traumatic grief reactions including the presence of guilt. What is most critical is that the client’s grief and loss be treated in addition to their PTSD and depression for a more complete recovery (e.g., Pivar, 2004). One of the truly unique advantages of EMDR treatment is that it allows the therapist to assist the client in reprocessing multiple components of their war/traumatic stress injury, nearly simultaneously—as opposed to a piecemeal approach whereby one package of interventions is for addressing guilt, another for grief, depression, PTSD, MUS, and so forth (see Chapter 4, this volume). Unfortunately, there is not sufficient research to understand why EMDR works one way for some and another for others—and is there a more efficient and effective application that has yet to be uncovered? In regards to EMDR treatment of traumatic grief reactions, there are no specialty protocols or techniques that one must learn outside of the standard EMDR evidence-based approach. Here are some general treatment considerations from experts that make their living helping war veterans, as well as several EMDR-specific tips to inform the therapist’s treatment planning.
Timing of Presentation—Why Now?
Whether the client has been referred by a medical provider, self-referral, etc., it is always helpful to know “why now?” The client either disclosed his or her distress or others saw it, but why are the problems evident now and not many months or years since returning from the warzone or other traumatic event? For most combat veterans, particularly those who suffered traumatic losses, the full brunt of their experience doesn’t begin to sink in until after the homecoming and honeymoon period ends—and the numbing and distractions stop working. For many deployed personnel, the impact of the war will not be felt nearly as much until they separate from their supportive networks via PCS transfer, military separation at EAOS, ADSEP, or MED-Board, or demobilization of National Guard and must return to their past civilian lives. Individual Augmentees (IA) are also in this at-risk group. When the protective or resiliency effect of one’s social support system ends, this is when most returning war veterans or other trauma survivors can be at their most vulnerable. The inherent stressors of saying goodbye, packing up households, and resettling into new living quarters, schools, and work environments, without the familiar friendly faces, can often be the tipping point—prompting the mental health referral.
“Killing in Combat: What to Say to a Returning Veteran”
That is the title of one of the chapters in LTCOL David Grossman’s (2007) book On Combat, as he introduces the reader to the “Three Gifts You Can Give Returning Veterans That Will Last Them a Lifetime” (p. 340): understanding, affirmation, and support.
Understanding. A sense of understanding is communicated by our attempts to comprehend and show respect for what the warrior has experienced from doing society’s bidding. Namely, that warring means killing, and killing, as Grossman (2007) explains, is as traumatic a personal experience there is because it is fundamentally counter to our moral and evolutionary instinct to avoid killing one’s own species, or what Grossman (1996) calls the “Universal Human Phobia.” Rarely do combatants brag or boast about killing, those who do are probably fabricating or sociopaths. Psychological distance is instilled in military training to allow humans to overcome their natural resistance toward killing. So, on the firing range, or in a combat zone, we shoot “targets” not people. The greatest fears that men and women carrying a loaded weapon have is to kill an innocent, cause the death of their own, or of themselves (Grossman, 2007). Grossman (2007) recommends that people don’t ask a combat veteran if they have “killed” anyone, but keep it open-ended “how did things go over there?” At least until sufficient rapport has built up, we would completely concur with that recommendation. Clients who are ready and wanting to talk about their combat experiences, and killing in particular, may do so the first session. Otherwise, establishing the alliance is what is most crucial at this time, and disrespecting someone isn’t a good start.
Affirmation. Whatever the therapist’s political view about the war, or the morality of killing in war, members of the warrior class don’t really have a say, theirs is to do. A grateful nation, citizens, and therapist can express affirmation of the veteran by shaking the veteran’s hand and sincerely telling them that they did they right thing, they did what we asked them to do, and that you are proud of them (Grossman, 2007).
Support. After the parades and reunions are over, Grossman (2007) talks about the long-term ways that society can demonstrate their support of its warrior class, including thanking them and congratulating them on doing a great job.
In working with military clients that present with war stress injuries, of the number of potential issues, it has been recommended that the first priority be dealing with the client’s guilt (see Silver & Rogers, 2002). Therapists should keep in mind, however, that military members surviving a traumatic loss in the warzone will more likely mask intense emotional feelings (e.g., sadness, pain, anger, guilt) in order to carry out the mission—especially those in leadership roles. They keep their “game face on,” and stay “in the zone”—living in the moment to survive, kill first or be killed. Sympathetic arousal, fear, and other emotions are compartmentalized so the combatant can carry out the business (mission) of the day. Not until people get back to their barracks does the weight of what happen start to creep in. Therefore, by the time the client sees the therapist, he or she may or may not be ready to drop the protective guard (usually anger or numbness). Therapists should carefully and patiently assess and show respect to the service member’s ability to cope and manage these feelings at any time. The client may feel a sense of relief knowing that somebody understands the grief that he or she is experiencing after losing a buddy or is not passing judgment on the guilt they felt from engaging in certain acts like killing. It is important that sufficient trust and rapport have been established prior to probing too hard for the client to express the depth of their feelings—a threatening experience for some, not unlike combat. Regardless of the interventions used, central to treating war veterans for prolonged and complicated grief is recognition of the significance of their losses (e.g., Pivar, 2004).
Guilt and Shame
Guilt is among the most frequently reported emotion during assessment of targets for processing in military personnel in general, and combat veterans in particular (e.g., Silver & Rogers, 2002). It has a strong association with co-morbid depression and substance abuse that raise the risk for suicide. In regards to clinical practice, it may be helpful to keep in mind that there are essentially two major types of guilt: (a) guilt about surviving when others died and (b) guilt about actions taken (or not taken). The level of guilt deployed personnel may experience is often heightened in high-threat environments, where people may believe that they have more control over things than they do. Not to mention the fact that from day-one in the military, the constant message in the culture is developing leaders through assigning personal responsibility and accountability for whatever happens—and no excuses are tolerated. Maybe that might have something to do with the propensity for military personnel to return from war with a heap of guilt and grief when the worst case scenario becomes someone’s reality. Clients often are quite secretive about their most personal thoughts around guilt and shame and may test the therapist about their willingness to “go there” with them with throw away lines like: “I’m not ready to talk about that right now,” “I don’t really want to go there,” “I’d rather not talk about that now,” “I’m not comfortable talking about these things,” “I don’t like talking about things I’ve done,” etc. (Silver & Rogers, 2002). For those who may be open to it, religion and spirituality may provide a framework by which many survivors of trauma construct a meaningful account of their experience and seek solace, and may provide a useful focus for intervention with trauma survivors.
The Psychological Impact of Killing
Grossman’s (1996) On Killing: The Psychological Cost of Learning to Kill in War and Society is the best text available on the biopsychosocial and spiritual effects of killing. He related that when someone kills another human being and watched the “mystery of life and death flicker in front of your eyes, and a living breathing person have become a piece of meat, and you are the one that caused that, you cannot help to think ‘I’m going to have to answer to my maker for what I did?’ Such guilt-ridden beliefs, no matter how legitimate it was by military or moral standards in terms of lives saved, etc., can set into perpetual motion the thought every negative happenstance to the client, their friends, or family, is a sign of God’s punishment for his or her mortal sin.”
Thou Shalt Not Kill and Thou Shalt Not Murder
Some military clients express traumatic grief and guilt around having killed and believe their souls are condemned to the depths of hell with other murderers. Grossman (2007) cites biblical passages that draws upon the moral distinction between killing and murder that can be brought into the discussion with the client as a “cognitive interweave” if reprocessing gets derailed due to the client’s negative belief of themselves as “evil,” “murderer,” etc. Grossman (2007) reports that the King James Version of the Bible’s Sixth Commandment within the Old Testament says, “Thou Shalt Not Kill”; however, in Matthew 19:18 of the New Testament, Jesus is cited as saying, “Thou Shalt not Murder.” According to Grossman (2007), “in the Bible, King David is a man after God’s own heart (Act, 13:22); it says, ‘Saul hath slain his thousands and David his ten thousand’ (I Samuel, 18:7). David killed tens of thousands of men in combat and was honored for it, and it was not until he murdered Uriah to get Bathsheba that he got himself in trouble (II Samuel Chapter 11)” (p. 352), and concludes with the question, “can you tell the difference in killing 10,000 men in lawful combat and murdering one man to get at his wife? If you can, then maybe God can too!” (Grossman, 2007, p. 352).
Cautionary notes. Expert agreement on a few non-starters for therapists include avoiding good natured joking around killing by referring to the client as “Terminator” or other off-handed jests. Therapists should refrain from overriding the client’s sense or right and wrong too quickly by rushing to absolve him or her of guilt with statements like “How could you have known?” “You didn’t do anything wrong,” or “You have nothing to feel guilty about!”
Possible Cognitive Interweaves on Guilt Over Killing
If the client’s reprocessing appears stymied and/or a blocking belief emerges—“I’m a killer, I don’t deserve to live”—the therapist can introduce the cognitive interweave that is simply new information or a perspective that the client thinks about while the therapist adds BLS. For instance, the therapist can ask, “Do you know the difference between killing and murder?” or “If you (or someone) have to kill in the lawful act of your duty, in defense of yourself or another, is that murder?” “If a policeman shoots a hostage taker about to kill innocent women and children, is that murder?” The attempt is to help draw the distinction between a warrior fulfilling his or her sworn oath to protect versus acting with malevolentintentions such as greed or personal gain. For the religious-oriented client, it can also be pointed out that the first non-Jew Christian was a Roman Centurion, a soldier named Cornelius (Grossman, 1996).
Useful Metaphors and Approaches:
Guilt as a smoke alarm. Usually both are there to protect.
Responsibility pie chart. Therapist and client can fill in the pieces to show proportionality of control and responsibility that the client may realistically own and the overwhelming proportion they do not.
Concept of atonement. Steven Silver talks eloquently about using a metaphor of how the extremely conscientious, honor-bound knights of old would be wracked by guilt and self-condemnation for relatively minor offenses, and the religious leader was searching for a more adaptive punishment to fit the crime. The answer was atonement. So, the guilt-ridden knight made up for his transgression by giving back to others. In this case, watching an unlit road every night for 6 months to protect the unarmed villagers as they returned to their homes for the evening or a similar task (see Silver & Rogers, 2002). To be effective, the atonement must come from the client themselves, but the therapist can offer guidance because proper atonements must meet three standards:
1. Sacrifice. It should place a demand on the client that would not ordinarily be there;
2. Look outward. It should be something that clearly benefits others;
3. Make use of the client’s abilities. It should be something practical that the client can realistically do, or rapidly acquire the skills to do. Examples given are volunteer types of activities, working at a homeless shelter, giving hospice to AIDS patients, and reading books to young children. (For additional details, see Silver & Rogers, 2002.)
Sources of Guilt—Kubany’s Guilt Typology:
Impossible decisions. Forced choice situations with no good options—the therapist can ask, “What other choices could you have made?” or “How could you have known their consequences?”
I should have known better. “What didn’t you have that would have allowed you to make the correct decision? What kept you from getting it?” (Silver & Rogers, 2002, p. 199).
The pleasure of violence. Clients make feel guilty for the natural adrenaline surge that human beings experience in high stress events like combat and mistaken their reaction as “pleasure” or “liking” to have killed. They may harbor a self-appraisal of being a “psychopath” that enjoys the sensation of killing. Clients should be given Grossman’s (2007) On Combat to read, which clarifies many misconceptions veterans have about what they’ve experienced.
I should have felt worse. As Silver and Rogers (2002) write, military clients harboring guilt because they did not feel bad or “anything” when they killed, or a close friend was killed, are describing the body’s natural, involuntary numbing or dissociative response that occurs when endogenous opioids are released in the blood system to block anticipated pain from injury.
Survivor guilt. Grossman (2007) offers some pointed remarks regarding how he approaches survivor guilt with warriors such as, “When someone gave their lie to save your life, you must not waste it.” “If someone buys your life at the price of their life, you do not dare waste it.” “Your moral, sacred responsibility is to lead the fullest, richest, best life you can.” “If you were the one to die and your partner lived, would you want him/her to have the best life possible?” (p. 362).
Suicidal ideation. “Make a conscious effort to set aside self-destructive thoughts and dedicate yourself to leading a full life.” Repeat with me: “Nobody takes my life without one hell of a fight, including me!” “I will fight for my life. I will seek counseling, meds, leave no rock unturned,” “Because I’m a warrior and nobody takes my life without one hell of fight—including me!”(Grossman, 2007, pp. 362–363)—If phrased properly for the client, it can send a powerful message by tapping into the warrior ethos.
Saving Private Ryan. Grossman (2007) makes poignant use of cinema that may penetrate the client suffering from survivor guilt. Most warriors have seen Steven Spielberg’s movie Saving Private Ryan, about a true story of a unit of Army Rangers during the Normandy invasion (D-Day) that was tasked by the leading Army General to find and return Private Ryan safely home immediately after his family had already lost three brothers. Before leaving the warzone, Captain Miller, who was responsible for returning Ryan home and had lost several of his men, looks up at Ryan and says in his dying words, “Earn this, Earn it!” in reference to the lives shed—be worthy. Don’t waste it. At the very end of the movie, a gray-haired Ryan and his grandchildren are visiting the graves of those who fought and gave their lives so that he could live. Ryan looks at his wife and tearfully says, “Tell me I’ve led a good life. Tell me I’ve been a good man.” Grossman (2007) challenges all of us who have benefitted from the sacrifices of the warrior class—to ask our loved ones the same question.
I’m a coward! Military clients may feel shame and/or guilt about freezing, urinating, or defecating during combat—especially if a friend or unit member was injured or killed during the fire fight—providing information on normal combat reactions (e.g., Menninger, 1948) is a good start—or have them read an Army Ranger’s perspective (Grossman, 2007).
Participating-witnessing atrocity. This can be the toughest of all. The saying “pain shared is pain divided” often does not apply if military personnel have committed crimes or acts of vengeance that they dare not share with another, including possibly the therapist. Traumatic grief can be exponentially compounded when acutely distraught individuals with automatic weapons are blinded by revenge. Decent people can do horrendous things. Not all war atrocities are committed as a result of traumatic grief reactions, others are decisions made under the tremendous duress of high threat environments violating ancient code of the honorable warrior. Again, Grossman (2007) gives a powerful example of this as an elderly WWII veteran approaches him: “Colonel, I’m an old man now, and I’m going to have to answer to my maker soon, I’m going to have to answer for that day it was inconvenient to take those German soldiers back. The day we shot them while they were quote ‘trying to escape.’ I murdered those men that day; we murdered them. We didn’t have to kill them. We murdered them, and soon I will have to answer to my maker for what I did!” (pp. 359–360). This is where Silver’s “atonement metaphor” (Silver & Rogers, 2002) can come into good use—some sort of constructive or meaningful penance that is not intended to absolve—but to heal a society and maybe save a soul.
TREATMENT PLAN CONSIDERATIONS FOR TRAUMATIC GRIEF
Pivar (2004), who works at the National Center for PTSD, makes the distinction between acute traumatic grief reactions (less than 3 months), and chronic traumatic grief reactions (greater than 3 months). Pivar recommends the following interventions:
Acute Traumatic Grief Reaction: (a) Communicate that “I give a damn about you, that you’re okay!”(b) acknowledgement of the loss; (c) communication of understanding of the depth of feelings; (d) encouragement to recover positive memories of the deceased; (e) recognition of the good intentions of the survivor to come to the aid of the deceased; (f) education about what to expect during the course of acute grief; (g) encouragement of distraction and relaxation techniques as a temporary palliative; (h) efforts to reduce symptoms of PTSD and depression as co-morbid disorders would take precedence over grief symptoms in the initial phases of treatment, unless the loss itself is the main cause of distress.
Chronic Traumatic Grief Reaction: Assist the client by (a) creating an opportunity to talk about the deceased; (b) validating the pain and intensity of their feelings; (c) offering education about the cognitive processes of guilt; (d) restructuring of cognitive distortions of events that might lead to excessive guilt (clinical experience supports the importance of education about normal and complicated grief processes); (e) looking at the function of anger in bereavement; (f) restoring positive memories of the deceased; (g) acknowledging caring feelings towards the deceased; (h) affirming resilience and positive coping; (i) encouraging the retelling of the story of the death; (j) teaching that tolerating painful feelings or part of the grieving process; (k) encouraging participation in a support group for veterans (contact the Chaplain’s office or Family Support Program for information); (l) helping to reassure clients that you will not try to whitewash their experiences.
Case Study: EMDR Treatment of Combat-Related Traumatic Grief
The following case study is presented in its entirety to provide a sense of pacing and continuity within and between sessions, especially when time and environment constraints result in irregular scheduling of therapy sessions, and how the therapist can still use EMDR effectively. The reader should understand the co-morbidity of this and other cases, and how frequently medically unexplained conditions are present. Unfortunately, in the vast majority of cases of medically unexplained conditions, without an identifiable neuropsychiatric diagnosis, it will be a war stress injury that will typically go unrecognized and untreated for years until eventually a neuropsychiatric condition emerges such as depression.
Staff Sergeant (SSGT) “W” is a 37-year-old, married, African American, male, combat-decorated Marine Corps SSGT (E-6) with over 11 years of active-duty service, referred by his military primary care physician for a mental health evaluation due to a positive post-deployment health rescreening for post-traumatic stress disorder (PTSD) and major depression disorder (MDD) symptoms.
History of Presenting Illness
SSGT W related that within 1 week after returning home from his second and most recent combat tour in Iraq 2 years ago, he began to experience progressively worsening changes in his sleep, mood, concentration, behavior, and motivation, characterized by daily intrusive recollections of combat-related events triggered by a wide-range of environmental stimuli (e.g., sight of older women, children, crowded places), initial insomnia, mid-night awakenings, anxiety-related nightmares, intermittent crying jags, irritable and dysphoric mood, irritable bowel syndrome, anhedonia, chronic fatigue, problems with concentration and memory, feeling socially disconnected, frequent headaches, periods of emotional numbing alternating with intense anger outbursts or seemingly unprovoked crying spells, hypervigilance, exaggerated startle, loss of appetite, lethargy, and profound guilt feelings in the context of multiple war-related memories.
Initial coping strategies to deal with his war-stress symptoms included social withdrawal, avoid thinking or other reminders of his war experiences, contemplating leaving the military, 1–2 beers at bedtime, use of over-the-counter sleep medications, and seeking help from the military health clinic that led to his being diagnosed with PTSD and MDD. He was prescribed Ambien for sleep and Zoloft for depression and PTSD symptoms, and taken them over the past year, but with little to no benefit. He also attended 6 individual counseling sessions at the Family Support Center but claimed that none of the above was effective. SSGT W reported that he and his wife of 8 years argued frequently since his return home and his work supervisors threatened to give him low performance marks if his motivation and behavior did not improve, prompting the present referral.
Relevant History
SSGT W is the oldest of five children from an intact family. There was no reported history of childhood abuse or other early traumatic experiences. He had a history of reading difficulties but never repeated a grade or received special education services. Medical history was unremarkable. SSGT W reported that prior to his first military deployment he was a physically healthy and fit person. However, after returning from his first combat tour in Iraq, he began to receive treatment for persistent headaches, gastroesophageal reflux disease (GERD), and constipation, along with sleep difficulties that completely resolved about 6 months later. He denied any persistent PTSD or depression symptoms after his initial deployment and expressed surprise over his current inability to “snap back” to shape. SSGT W denied any previous psychiatric history until returning from his second deployment. He also denied any active suicidal ideation, but admitted to passive suicidal thoughts related to his current lack of appetite, lethargy, feelings of hopelessness, and deficient self-care (e.g., stopped exercising, social isolation).
Psychological Testing
SSGT W was administered the Impact of Events Scale (IES) to assess the severity of his PTSD symptoms and the Beck Depression Inventory-Second Edition (BDI-II) and Beck Hopelessness Scale (BHS) to measure his depressive symptoms. Testing results indicated significant PTSD symptoms (IES = 30) along with a high level of depression (BDI–II = 33) and hopelessness (BHS = 38) symptoms.
EMDR Phases One–Three: Clinical Interview and Assessment
When queried about his war-related experiences, SSGT W evidenced no particular difficulty discussing his first deployment. He described being engaged in multiple fire-fights, including his shooting and killing several Iraqi insurgents, and having several members of his unit killed and/or wounded in action. He expressed minimal distress in recalling his experiences, except when mentioning the death of one young Marine under his command who was killed when executing a battlefield maneuver ordered by SSGT W. SSGT W admitted to feeling considerable remorse and guilt over the death of one of his Marines, often second-guessing his decision. However, other than the intense emotional hardship of writing a letter to the deceased Marine’s mother, he reported no persistent guilt or other post-traumatic stress symptoms.
During the second deployment, SSGT W revealed that he actually saw less combat overall, but one incident in particular stood out. While guarding a critical bridge in Iraq, a civilian vehicle crowded with many apparent Iraqi occupants came speedily toward his checkpoint. Following protocol, SSGT W and his subordinates made numerous attempts to inform the apparently elder male, Iraqi driver that he needed to immediately stop the vehicle, but the driver did not stop. Several warning shots were made, but the vehicle maintained its speed and approached a point at which it could endanger the entire platoon. SSGT W gave the command to open fire on the oncoming vehicle. He described the effects of multiple automatic weapons striking the vehicle, the driver, and other occupants, most of whom were women and one to two adolescents, in vivid detail. The disabled, smoke-filled, bullet-riddled car rolled to a stop. A few occupants slowly attempted to open the passenger doors. Exiting the rear passage door was an elderly Iraqi woman, who was mortally wounded and bleeding profusely. She cried out in obvious anguish and pain, as SSGT W and his men watched her collapse in spasms. SSGT W related that the other vehicle occupants were all badly shot-up and lay either dead or quietly dying. However, the elderly Iraqi woman writhed on the ground and moaned loudly for what he reported seemed like hours, but lasted possibly minutes until she eventually bled-out. SSGT W’s facial and emotional expression changed dramatically while retelling the horrific incident. He lowered and shook his head in his hands that were trembling, as he tearfully recollected the ordeal which he reported reliving several times a day and night. Pervasive shame and guilt led him to question why he should continue to live, although he denied active suicidal thoughts.
A brief assessment of the traumatic memory revealed the worst image was the initial sight of the elderly woman exiting the car with gaping wounds leading to her collapse. His negative cognition (NC) was “I killed her,” with “tightened” sensations around his jaw and eyes, and stomach queasiness coinciding with the primary emotional response of “extreme guilt,” all of which was given a SUDS rating of 10+ on the 0–10 Likert scale. In contrast, SSGT W’s desired positive cognition (PC) was “It was all a tragic accident” with an initial VoC rating of –1 on the 1–7 Likert scale with 1 equating to full disbelief and 7 full belief in the self-statement. The obtained NC or PC would be considered ideal EMDR targets due to their lack of a present self-referencing belief. However, the above mentioned was the best solicited from this guilt-wracked Marine who obviously associated considerable affect with the cognitions provided.
As the only clinical psychologist a remote Marine base of 6,000, there was an extremely limited amount of time available to conduct psychotherapy. Treatment options were discussed with the client including referral to stateside therapist due to grossly insufficient mental health resources. SSGT W was informed that a brief therapy like EMDR might be beneficial given the serious restrictions and he consented to a trial of EMDR therapy. A brief description of EMDR was provided, along with a demonstration of bilateral stimulation (BLS) in the form of alternating eye movements.
Diagnostic Impression
| Axis I: | Post-Traumatic Stress Disorder—Combat-Related Major Depressive Disorder—Single Episode With Traumatic Grief Features |
| Axis II: | No Diagnosis |
| Axis III: | Headaches, IBS, GERD |
Phase Four: EMDR Reprocessing Session 1
SSGT W announced no changes in his psychophysical symptoms at the outset of the next session which was 2 weeks after our initial meeting. He was asked to bring up the original target memory involving the tragic bridge incident and related no change to the image, feelings, sensations, or cognitions, given the SUDS rating of “10+.” He was asked to notice these memory components while simultaneously focusing on an alternating light from a light bar device. He reported no change after the initial BLS set, mentioning that he could not hold the image while tracking the light. SSGT W was asked to notice the physical sensations of tightness in his face instead and reported a shift to a different aspect of the memory going back to the beginning of the day. Further BLS sets revealed frequent associations to different experiences within the target memory, different emotions (e.g., anger, sadness, guilt, despair), alternative cognitions vacillating from maladaptive (e.g., “I killed her”) to more adaptive (e.g., “the driver was more responsible because he didn’t stop”), and changes in bodily sensations and location (e.g., tense jaw, tightness around his eyes, tears, queasy stomach). After approximately 30 minutes of BLS following his numerous free associations, SSGT W’s responses appeared to be moving toward a progressively more adaptive manner. A recheck of his SUDS to the target indicated that it had diminished all the way down to about a “4,” which followed a couple of cathartic emotional releases. Unfortunately, time was running out, so an appointment was made for a second treatment session in 3 weeks. SSGT W complained of feeling “wiped out” physically and mentally and expressed great surprise over the nature of his responses to EMDR and the puzzling string of associations that often included previous war and childhood memories.
EMDR Reprocessing Session 2
SSGT W entered the second treatment session expressing considerable optimism over the progress made since our last meeting. He reported sleeping better, more even-tempered emotional states, and overall feeling more uplifted. When the target memory was rechecked, he reported a SUDS rating of “4,” which was the same level we had left off. The image of the scene had faded some, and the tightness was mostly around his eyes along with mild queasiness in his stomach when he thought of the episode. He expressed eagerness to resume EMDR therapy, and, given the restricted session time available (50 minutes), a BLS set was initiated. Similar to the previous session, SSGT W reported many changes in his associations to the original trauma, but, after 20 minutes, a recheck of his SUDS indicated we were “looping” with a SUDS stuck at “4.” He frequently made references to the elderly nature of the female victim, so I asked him whether she reminded him of anyone else he knew before. SSGT W appeared to carefully deliberate on my question. He initially answered “no,” but then quickly changed his mind stating, “come to think of it, she reminded me of my grandmother” (on his mother’s side). When asked how so, he replied “my grandmother was from Nigeria but lived with us for a few years when I was around 8, but she and my mom constantly argued, I mean really argue and I remember one day my grandma told me she couldn’t live here anymore and was going to return to Africa.” I asked him whether she did indeed return to her home and he replied, “Yeah, she left almost the next day. I remember her crying when she said goodbye to me the day she flew back … and I never saw her again.” You never saw her again? I asked. “Nope, she didn’t have a phone and couldn’t write and did not have email … the last I heard about my grandma was about 2 years after she went home, my mom told me she had been diagnosed with cancer and died.” SSGT W lowered and shook his head, “I should have stopped her from leaving … if I had, she might still be alive.” When asked to clarify his statement he replied, “If her cancer was diagnosed in the States, she could have gotten treatment here instead of Nigeria, which could have saved her life.”
SSGT W went onto express his guilt for not intervening between his mother and grandmother and preventing the rupture in the family ties. When asked how he thought that his grandmother and the elderly Iraqi woman might be connected, he gazed ahead and said, “I never realized that before, but she was about the same age of my grandma, and in both cases I felt responsible for their deaths?” At which time a BLS set was initiated, and he made several associations to his experiences with his grandmother alternating to memories of the shooting. At the end of the session, a recheck of the target memory revealed a SUDS of “2” with considerable lightening of his facial expression and body posture including a broad smile as he recalled a positive childhood memory involving his grandmother. As time expired, a follow-up meeting was scheduled in 5 days.
EMDR Reprocessing Session 3
SSGT W came into the session looking much brighter than in previous sessions. He was smiling, and appeared more animated and upbeat in his mood and demeanor. He reported his sleep had significantly improved as had his overall physical and mental health. SSGT W expressed astonishment over how rapidly the changes in his health status have emerged and disclosed that the night after our last meeting he had dreamt for the “first time in decades” about his beloved grandmother and his dream merged his recollection of his grandmother with the elderly Iraqi woman. The recheck of the target memory revealed a very faded recollection to his surprise with a SUDS of “2,” which he considered to be appropriate guilt for his involvement in the death of the Iraqi woman with “just a little tightness” around his eyes and some queasiness in his stomach. Although his self-report might be considered ecologically valid, another BLS set was initiated. SSGT W reported alternations between memories of the elderly Iraqi victim, the first deployment incident involving death of his subordinate, and his grandmother, with an apparent adaptive resolution. The SUDS remained a “2,” therefore we went onto the installation phrase. His initial PC was still valid for him and had increased to a “6,” which did not change after several small BLS sets. We went onto the body scan phase. He closed his eyes and, while focusing on the PC and his bodily sensations from head to foot, he quickly stopped and reported “maybe just a little queasiness.” This was followed by a BLS set, which appeared to do nothing. Given SSGT W’s previous associations to childhood events and my residual gut feeling that something else may be keeping his SUDS at a “2,” I elected to use a variation of the “float-back” technique. SSGT W was asked to concentrate on the stomach sensations and the earliest time in his life where he felt those sensations along with feeling responsible or guilty about someone getting harmed. Almost immediately he recalled an outing with his younger brother when he was around 6 years old and his brother was 4. They were walking on rocks near a pond when his brother slipped and hit his head. SSGT W’s hands began to tremble as he told about being “scared” and guilty as his brother cried-out loudly, with his face covered in blood. He ran home to get his father who chastised him verbally and later physically for not watching out for his brother with the familiar queasy sensations in his stomach.
Additional BLS sets resulted in shifts in the childhood memory, along with new associations to the previous memories we had worked on. This time, when the SUDS was checked, he registered a “1” rating. When asked what kept it from being a “0,” he replied, “an innocent old woman died, and it will never be a ‘0’ … even though I know I had something to do with her death…. I also know that we had no choice … all we saw was a car speeding right toward us that did not respond to our warnings…. If we did not fire, a lot more people would have been killed … it’s one of those tragedies that isn’t right, but is a fact of war.” The SUDS rating held with two additional BLS sets, as did the VOC of “6.” This time around, the body scan revealed some “warm” sensations that led to a smile as he remembered his grandmother during a happier time with no apparent negative physical sensations. Time ran out, so another session was scheduled in 2 weeks.
Phase Eight: EMDR Reevaluation
SSGT W enthusiastically reported that he was no longer symptomatic and his overall health had significantly improved. Both his wife and co-workers had all commented on the positive changes. He stated no troubles sleeping, although the night after our last session was “a little weird” in regards to the dreams he had, there was no residual depression or PTSD symptoms. A recheck of the SUDS held at “1” with a “6” VOC. SSGT W agreed to complete the IES, BDI-II, and BHS measures for us to check if there was anything we may have missed. Results from the IES indicated PTSD symptoms in the non-clinical range (IES = 8) with similar non-clinical findings regarding his depression symptoms (BDI-II = 4) and feelings of hopelessness (BHS = 7). SSGT W announced that he has already submitted his paperwork to re-enlist in the Marine Corps. He reported stopping all psychotropic medications after the second EMDR session. When asked to imagine returning to the warzone he endorsed no particular distress and added that he believed that his experiences including what he went through with his PTSD and traumatic grief had made him a better military leader. An open-ended offer to meet and check-up on him was agreed to.
Phase Eight: EMDR Reevaluation: Four-Month Follow-Up
Due to scheduling conflicts and an intolerable pressure to meet the expanding mental health demand, it took 4 months to arrange a 15-minute follow-up session with SSGT W. He patiently completed the assessment measures in the waiting area which we reviewed. Essentially, there had been no major changes in his mental and physical health since our last session (e.g., IES = 6; BDI-II = 4; BHS = 3). Other than occasional constipation, he no longer is being treated for IBS. He reported no problems with headaches and only intermittent GERD symptoms for which he continues to take medication. SSGT W informed me that he and his family will be transferring in a couple of months to another Marine base, which will very likely mean another deployment in the near future. He expressed general enthusiasm for continuing his military career and confidence that his past experiences were more a benefit than detriment to his ability to cope with another deployment and more importantly to help those under him. SSGT W explained further by disclosing that his prior attitude toward mental health care had been predominantly, stereotypically negative. However, after experiencing his own war stress injuries and the treatment he received, he was now “a major believer.” He mentioned that he has already disclosed his personal struggles with PTSD and mental health treatment with several other military peers and subordinates, leading them to seek help. However, he also reiterated frustration that I had shared with him earlier, that the critical shortage of mental health treatment in the military renders it near impossible even “for those who need and want the help, to get the help,” a leadership concern that he has conveyed to his chain of command.
Reversing the Flow
Clinical note. Reversing the flow refers to when clients with traumatic grief are “looping” from one negative association to another, sometimes we have had success by asking them to recall a “good memory” when their friend, spouse, unit leader, etc., was still alive, and process that. In the MUS case study above, the therapist reversed the flow, which led to the client accessing positive memories and then follow the free associations. Use this sparingly.
EMDR TREATMENT OF SURVIVORS OF INTERPERSONAL VIOLENCE
There is evidence that some military personnel with PTSD, especially if co-morbid with substance use disorder or other neuropsychiatric condition, may be at risk of perpetrating violence toward others, including their spouse, partner, and/or children. Violent incidents are usually a response to perceived threat or cumulative frustrations. Therapists should be aware of risk for domestic violence. EMDR can be effective in treatment of the experiential contributors that may have led or maintain aggressive responding (Silver & Rogers, 2002; see Chapter 13, this volume: EMDR Treatment of Anger/Aggression). Both perpetrators and victims of interpersonal violence can benefit from using the standard EMDR protocol. At-risk warning indicators for interpersonal violence include: (a) ideation and/or intent to harm others; (b) past history of violent behaviors; (c) severe agitation, aggressiveness, threatening, or hostile behaviors; (d) actively psychotic; and (e) substance abuse.
Case Study: EMDR Treatment of Domestic Violence Survivor
The following case study involves a military spouse victim of domestic violence treated at a military community family counseling program.
Phase One. The client is a 40-year-old, East Indian female, spouse of an active-duty Air Force member, referred for treatment at a military mental health outpatient clinic after a domestic violence incident involving altercation with her estranged husband. The client appears fatigued, with restricted affect; her mood is calm and sad. The client has been separated from her husband for the past 3 years. She has no children. There were no immediate safety concerns. Presenting symptoms included poor sleep, bruxism (teeth grinding), social isolation, strong mistrust and avoidance of Caucasian American people given the abuse from her Caucasian husband, and notable problems with intimacy: “I don’t like to be touched.”
Phases Two and Three. After being informed and giving consent to her therapist for EMDR therapy, a treatment plan was developed after a total of 15 past memories were identified as past experiences currently contributing to her interpersonal and sleep difficulties including chronic physical, verbal, and emotional domestic violence by her husband, motor vehicle accident, rape during adolescence and forced abortion, incidents of overt racial discrimination, familial death, and childhood physical abuse. For brevity’s sake, we will not list the assessment of all 15 target memories, but we will describe the primary target memories involving domestic violence incidents.
First Target. Approximately 4 years ago, the client experienced a miscarriage after her husband punched her in the stomach several times, causing bleeding. The worst part of this incident was “the blood.” Negative cognition: “I’m stupid for staying with him.” Positive cognition: “I can take care of myself.” VOC: “5.” Emotions: “hate” and “anger.” Location of “nervous” body sensations was in the “chest.” SUDS: “8.” [Posttreatment SUDS: “1”]
Second Target. Being pinched, shoved, and punched by her husband consistently “in places where he knew wouldn’t show anyone” the injuries. This occurred 3–4 times a week over a six-year marriage. The worst representative issue of the cluster of domestic abuse events: SUDS of “9” [Post-treatment SUDS = “2”].
Resources Identified: The therapist solicited: (a) three best events/accomplishments of her adult life, (b) three best events/accomplishments of her childhood, and (c) the client’s favorite activities.
Standardized Measures: Dissociative Events Scale—revealed no dissociative disorder.
Second Meeting (First EMDR Reprocessing)
Phase Four. Rechecked first target memory—no change in SUDS: “8.” The therapist reported that the client reprocessed primary domestic violence incident, husband’s adultery, difficult interactions with the police, and client concerns over emerging racism. Phase Seven: Incomplete Session First Target SUDS: “3.”
Third Meeting (Second EMDR Reprocessing)
Phase Eight: Reevaluation: Client reported no distress from previous week’s session: “I didn’t even think about it,” which had not been the case for years. Phase Four: Initial recheck of target memory “The way he treated me after the miscarriage.” [Add BLS]. Therapist reported that client reprocessed multiple incidents of verbal and emotional abuse to include property damage, isolation, seeing her dog mistreated and “almost killed,” being blamed for their marital discord, and being strangled. The client ended the session tearfully with adaptive statements that she was able to develop friendships with people who were willing to protect her and offered that the “hate” she feels is only hurting “me.” Phase Seven: Incomplete Session/closure.
Fourth Meeting (Third EMDR Reprocessing)
Phase Eight: Reevaluation: The client is preparing for upcoming PCS transfer and reports general improvements. Rechecked the first target memory, which revealed SUDS: “9.” Phase Four: Therapist reported that the client reprocessed multiple events of emotional/verbal abuse, disrespect to her parents by husband, her husband leaving her isolated, feeling abandoned by the military after filing domestic violence complaint. Phase Seven: Incomplete Session/closure: Rechecked SUDS: remained at “9.”
Fifth Meeting (Fourth EMDR Reprocessing)
Phase Eight: Reevaluation: The client reported “feeling a lot better” and cited examples of finding evidence of her husband’s past adultery but reacting with “I’m glad this will soon be over” versus the characteristic anger and hurt. Phase Four: The therapist indicated that the client reprocessed several incidents of being strangled by her husband, adultery, and property destruction. The client was able to note that these behaviors reflected poorly on her husband and, while she still took responsibility for her role in getting married in spite of not loving him, she endorsed the fact that she took the responsibility of paying off debts (incurred by him on her credit card) instead of filing for bankruptcy, being “stronger” now, and “more confident” now—in sum, “resilient” now. Phase Seven: Incomplete Session/closure: Rechecked SUDS: “4.”
Sixth Meeting (Fifth EMDR Reprocessing)
Phase Eight: Reevaluation: The client stated that she began taking an online college course and is pending to PCS soon. Phase Four: The therapist reported the client reprocessed a second miscarriage, head pain, and many incidents of controlling and abusive behavior by her husband, ending with her resolve to move on. Phase Seven Incomplete Session/closure: Rechecked SUDS: “3.”
Seventh Meeting (Reevaluation only)
Phase Eight: Reevaluation: Due to the client’s imminent PCS transfer, the meeting was around termination. No further EMDR reprocessing. Primary target memory (#1)—Rechecked SUDS: “1.5”
Eighth Meeting (Two-month Follow-up)
Phase Eight: Reevaluation: After the client had geographically relocated, the therapist called to check on her mental status. The client reported that her mood remained calm and appropriate even after the hectic relocation. Rechecked primary (#1) target memory—SUDS: “1.” A reassessment of all the remaining 14 target memories indicated significant generalization effects. For example, the second target memory—SUDS: “1”; the MVA went from SUDS: “8” to “1”; the memory of adolescent sexual assault went from SUDS: “7” to “1.” However, other target memories showed a decline, but not as significant. For instance, the memory of forced abortion went from SUDS: “8” to “2.5”; and grief over death of a close family member went from SUDS: “10” to “7”. Overall length of treatment was 5 weeks, and a 2-month follow-up reevaluation.
Clinical note: We chose this case for several reasons. First, not every EMDR session goes like clockwork, and we did not want to leave the reader with impression that, if they did not complete all eight phases within half a dozen sessions, something is wrong. Second, the above case illustrates the time and environmental constraints that are inherent within most military treatment settings that we have been mentioning throughout the book. Third, despite not getting to phases five (installation) and six (body scan) on any of the target memories, the client’s access and strengthening connections to her adaptive neural networks were clearly evident in the progress notes. This case also serves to support our recommendation that therapists need to consider those realities in their treatment plans and limit the number of past target memories to the “worst of the worst.” However, this too presents a dilemma of possibly not identifying all potential target memories for comprehensive reprocessing of the maladaptive neural networks. This is true. In this case, and others we presented, the generalization effects of EMDR reprocessing are striking, but not absolute. Left open is the possibility that some of the unprocessed target memories may come back and create havoc for the client. We do the best we can—just as the therapist in this case—who is not one the authors—did, and we salute Smith and his clinical staff for the great work they do to support military families and personnel every day!