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Abstract
Since the onset the US led wars in Iraq and Afghanistan in response to the terrorist
attacks of September 11th, 2001, rates of combat related Post Traumatic Stress Disorder
(PTSD) have escalated. This observation has led to an ongoing national multi-billion dollar
investment into research and treatment covering a wide range of evidenced based interventions
(EBIs). One such EBI gaining popularity is Eye Movement Desensitization and Repossessing
(EMDR). Despite its initially slow acceptance by mental health professionals and veterans
agencies, EMDR is providing results that are either equal to or far greater than previously
popular modalities. This work presents an analysis of EMDR for PTSD, allowing for greater
understanding of the treatment, why it works, and the challenges and successes of its
Background
America has engaged in her longest consistent period of war, while doing so on multiple
battlefronts and with diminishing funding and resources following the economic collapse of
2008. Since then our service men and women have endured repeated and long duration exposure
to combat trauma coupled with depleted resources (Eckardt, 2017; Venable, 2016; Gertz, 2015)
that would normally enable active duty service members to effectively process those traumas.
As a result weve witnessed a spike in the number of combat veterans experiencing PTSD (VA,
& Foa, 2011; Nacasch, Hupport, Tzur et al., 2011; Tuerk, Yoder, Grubaugh et al., 2011; Yarvis,
2011). The environment contained in combat operations provides the armed forces member with
many opportunities to experience and witness traumatic events that when left unresolved or not
processed effectively can manifest into the many outcomes symptomatic of PTSD. Specifically,
desperation, hopelessness, depression, deeply rooted anxiety, guilt, or shame (Kaplan & Tolin,
concentration, dissociation and avoidance which commonly lead to substance use and or abuse
(APA, 2013).
PTSD
As the area of PTSD has gained attention and funding for research, modifications from
the DSM-IV now appear in the DSM V. Rather than discuss the variations in diagnosis from IV
EMDR for PTSD
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Whereas PTSD is identified as a trauma and stressor related disorder with a diagnostic
related)
with the traumatic event(s), beginning after the traumatic event(s) occurred:
traumatic event(s)
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ii. Recurrent distressing dreams in which the content and/or affect of the
event(s)
of the following:
traumatic event(s)
himself/herself or others
iii. Hypervigilance
oneself (e.g., feeling as if "this is not happening to me" or one were in a dream).
Full diagnosis is not met until at least six months after the trauma(s), although onset
Biological/Neurobiological
amygdala and hippocampal volume due to reduction in size, impacting memory and well being,
as well as problems with affect regulation and cognitive processing (Cozolino, 2010). Such
structural malformations also lead to ineffective processing of psychological responses via the
EMDR for PTSD
7
interruption of normal modulation, while amplifying stress related anxiety (Badenoch, 2008).
Research typically credits this structural phenomenon to the impact caused by excess and
long duration release and processing of the neurochemical, cortisol, which gets released during
stressful events and in higher amounts during traumatic periods of high stress (Applegate &
Shipiro, 2005). The result can be the weakening of the immune system via the prevention of T-
cell proliferation and disruption of protein synthesis, which halts neural growth, and actually
kills neural circuits. (Cozolino, 2010). Ironically, this is also correlated with why those with
PTSD also exhibit dissociation from social engagement, emotional blunting, depersonalization
Prevalence of PTSD
Recent study data has provided a greater understanding of PTSD prevalence across broad
population variations.
February 2001 and April 2003, estimated an approximate 7% prevalence of PTSD amongst
Americans aged 18 years and older (Kessler, Berglund, Delmer et al., 2005; Kessler, Chiu,
Demier et al., 2005; NCS, 2005). These findings nearly replicate earlier studies (Kessler,
Sonnerga, Bromet et al., 1995) Adolescent rates were about half (Kilpatrick, Ruggiero, Acierno
et al. 2003).
Veterans. Prevalence of PTSD varies slightly across conflicts. However rates overall
tend to be about double the civilian population. Vietnam veterans have a rate of about 15%
(Kulka, Schlenger, Fairbanks et al., 1990); Gulf War veterans 12% (Kang, Natelson, Mahan et
al., 2003); Iraq and Afghanistan (OIF/OEF) veterans about 14% (Tanielian & Jaycox, 2008; VA,
2017,1).
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for prevalence and severity of PTSD symptoms through self-reporting on the military version
of the standard PTSD checklist (PCL-M) or by way of the Clinician Administered PTSD
Scale (CAPS)
CAPS. The Clinician Administered PTSD Scale (CAPS) serves as the standard in the
evaluation of treatment efficacy and determination of a diagnosis of PTSD. The CAPS is a 30-
item scale, measures the existence and intensity of 17 symptoms, and is completed by a mental
health professional interviewing the subject (Blake, Weathers, Nagy et al., 1995). Severity scores
symptomatology," (Weathers, Keane, & Davidson, 2011). When utilized to determine treatment
efficacy, a decrease or increase in CAPS scores ranging from 10 to 15 have been recommended
or used as interpretations of clinical significance (Weathers et al, 2011; Ready, Thomas, Worley,
PCL-M. The PTSD Checklist is a much shorter and less intrusive with only 17
CAPS diagnoses (Weathers, Litz, Herman, Huska, & Keane, 1993; Weathers et al., 2011).
EMDR
and body-based therapies in structured procedures and protocols which take place over eight
phases and incorporate past, present and future aspects of the clients presenting problem
EMDR for PTSD
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(Solomon & Siegel, 2003). Another often preferred aspect of EMDR that differs from previous
cognitive processing therapy models is that the client is not required to fully engage in the
Since its inception, the name has created confusion. To simplify this title, conceptualize
EMDR as a more dynamic form of reprocessing therapy, or EMDR as Emotional and Mental
Development and Reorganization (Solomon & Siegel, 2003). EMDR utilizes the Adaptive
Information Processing model (AIP), which posits that memory is associated with experiences,
thus learning occurs through the creation of new associations by way of cognitive reprocessing.
application. While both CBT and EMDR allows one to target and connect unprocessed traumatic
memories to the more adaptive information located in other memory networks and thus reprocess
the memory to result in a reduction of symptoms, EMDR accomplishes this objective with
different treatment mechanics which work on a more subconscious level (Solomon & Siegel,
EMDR typically occurs along a two-three month treatment period with the client meeting
Evaluation of Efficacy
A broad range of research on EMDR (Solomon & Siegel, 2003; Van der Kolk, 2002; Van
der Kolk, 2003) has resulted in promising findings specific to treatment efficacy across a broad
range of trauma related diagnosis. Several studies have reported 77-90% remission of PTSD in
single-trauma victims in as few as five hours of treatment of EMDR (Solomon & Siegel, 2003,
pg. 197).
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Seventeen previous studies covered in a recent critical review showed strong efficacy for
Cognitive Processing Therapy (CPT) when compared with Exposure Therapy, Present Centered
Therapy, Skill Building, Focused Cognitive Behavioral Therapy (CBT), and Multimodal
Therapy (Dworkin, 2011). Surprisingly, EMDR was not included in those comparisons, but has
scores, pre and post treatment, (EMDR), demonstrated a 53% rate of success in resolving PTSD
symptoms, which was equally as effective as both Cognitive Behavioral Therapy (CBT)
modalities of Cognitive Processing Therapy (CPT), and Prolonged Exposure Therapy (PE).
(SIT), which has a success rate of 20%. Furthermore, EMDR appears to outperform the
Norepinephrine Reuptake Inhibitors (SNRI) which demonstrate a 42% success rate (VA, 2017
,2).
For a full breakdown and delineation of principals, protocols, and procedures see Shapiro
(2001).
Phase 1.
history taking, evaluation, and treatment planning. This phase, while similar to
traditional psychotherapy, also works to identify key life events for further targeting and
processing. While additionally considering present situations interfering with adaptive functions
causing distress(Shapiro, 2001; Solomon & Siegel, 2003; Van der Kolk, 2002; Van der Kolk,
2003). Whereas other treatment modalities fixate on the here-and-now environment to work
EMDR for PTSD
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through reforming cognitive maladaptations, EMDR takes a more holistic approach inclusive of
Phase II.
preparation. Herein, the client is educated and prepared for possible symptoms of
treatment and provided some levels of progress expectation while establishing a therapeutic
alliance with the mental health practitioner (Solomon & Siegel, 2003).
Phase III-VI
present triggers in an effort to mobilize the information and facilitate connections with other
adaptive information. The goal of each phase is to mobilize the materiel and facilitate its linkage
Phase VII.
closure. This phase provides feedback via an evaluation of processing along with self-
calming interventions from phase two. Additionally, the client monitors intersession responses
Phase VIII.
session. Throughout this phase, various EMDR protocols are utilized to address specific clinical
Barriers to Treatment
veterans that are ambivalent, reluctant, or resistant to utilize them is not simply due to the
perceived stigma associated with seeking mental health services. It is also a component of access
or lack thereof due to availability of resources and status of service members discharge from
military service.
Access to Resources
Veterans that have earned an Honorable discharge and served during a combat period can
access the wide array of available VA services and programs such as education, disability
compensation, medical and mental health services. Conversely, those that have not served their
full term of duty due to disciplinary action and premature discharge under less than honorable
Discharge Status. Up until recently, the status of discharge of an armed forces veteran
had not been a matter of either comprehension or concern. However, recent data demonstrates
that 70% of suicides are committed by veterans that never used the VA (Kemp and Bossarte,
2012; VA, 2016; Thompson 2016). Furthermore, the highest risk factor for veteran suicide is
amongst the veteran population that has been discharge under less than honorable circumstances
Many in this population have been discharged due to the behavioral outcomes resulting
from mental health problems (PTSD) that were neither properly diagnosed nor treated while the
service member was still actively serving. Worse, upon discharge, they are no longer eligible for
Availability. Lack of proper funding has had negative impacts on access to treatment and
EMDR for PTSD
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resources. Impacts from the 2008 economic collapse had long lasting deteriorating effects across
the VA and Department of Defense. (Eckardt, 2017; Venable, 2016; Gertz, 2015) As evidenced
by the spike in veteran suicides following 2008 despite previously lowering rates of suicide
between 1999-2007 (Kemp and Bossarte, 2012; VA, 2016). In addition, drastic budget cuts
resulted in outdated processes, understaffed and underfunded DOD and VA systems, which were
unable to handle the demand, and were not equipped to adequately address the surge in need for
mental health services. (Garske, 2011; Jaeger, Echiverri, Zoellner, Post, & Feeny, 2009; Hoge,
Thankfully, leading up to and since the release of the 2012 VA suicide report (Kemp and
Bossarte, 2012) billions of dollars have poured into VA and DOD programs for services,
research, and outreach (Thompson, 2016; Garske, 2011; Gros et al., 2011). Mental health
professionals specializing in combat related trauma are now available in combat areas
thus working to prevent these issues from becoming chronic (Gros et al., 2011; Garske, 2011).
Cost. Unfortunately, EMDR is not widely available through VA facilities (VA, 2017, 2)
thus veterans are required to pay out of pocket cost for the treatment which, in most cases, is a
primary deterrent.
The term Combat Masculine Warrior Paradigm (Dunvin, 1997) articulates our social and
cultural model of the combat fighter as one whose core activity is the preparation for and conduct
of war. The social and cultural ideal of a combat veteran swirls around the expectation of traits of
courage and strength. Such constructs are historically in conflict with the thought of seeking
help. Moreover, mental health treatment requires self-reporting. However, mission readiness and
EMDR for PTSD
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peer pressure often result in underreporting symptoms (Hoge et al., 2007). Consciously, the
combat veteran may be aware that he needs treatment, but other factors tend to permeate.
Internal Bias. Our unconscious and conscious tendencies are often times unreasoned
opinions and prejudices about other social groups or individuals based formed via life
experiences (Robbins, Chatterjee & Canda, 2011). Based on their training alone its obvious that
combat veterans have a drastically counterintuitive internal bias toward mental health treatment.
The concept is subconsciously contradictory to the established norms of the warrior mentality.
onto others both feelings and attitudes that were formed early on in life or even later on in life
internal attitudes and beliefs, which are continually shaped and formed throughout the life cycle
creating cognitive dissonance. The thought of therapy creates conflict because it is not consistent
with the combat veterans indoctrinated beliefs. The result is commonly irrational and sometimes
maladaptive behavior due to an internal clash, which creates unpleasant tension (Festinger,
1957).
Conclusion
With a prevalence rate double the civilian population, combat veterans will benefit from
the growing popularity and acceptance of EMDR as an evidence based best practice in the
treatment of PTSD. Primary barriers that are of greatest concern will rely upon legislative and
institutional actions at the macro and mezzo levels in order to open access to both availability
solutions to both affordability and accessibility. It would seem that EMDR, while in its
receptive infancy stage, may very well be an area where military and family mental health
social work practitioners find exciting opportunities for growth and professional development.
Simultaneously, EMDR appears set to offer our combat veterans an improved quality of life
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