Case Study &

Evaluation of
Research:
Using EMDR in
Mental Health
Treatment of Combat
Veterans

By: Daniel R. Gaita, MA,

LMSW
Aug 14th, 2017

With research data supporting reductions in chronic

pain, PTSD, anxiety and depression symptoms, as well as
improved sleep, quality of life and perception of stress in
as little as five sessions, EMDR has seen rapid growth in
clinical popularity amongst the combat veteran
population. - (p.3)
 1

Description

The case study of this EMDR research evaluation is a highly decorated, sixty-eight-year-

old, United States Marine, six combat-tour veteran of the Vietnam War, whose medals

designating combat valor include the Bronze Star and Navy Achievement medal. Additionally,

he earned three (3) Purple Hearts and is also a former prisoner of war (POW). For the purposes

of maintaining his confidentiality he is being referred to herein as Sergeant (Sgt.).

Sgt., originally from Texas, currently resides with his fourth wife in the New England

town of Danbury, located in Connecticut. Since leaving the Marine Corps following his tours of

service in Vietnam, he has held multiple professions. Some less revered than others both

personally and socially. However, he ended up settling successfully into an occupation as a

licensed electrician for thirty years before finally retiring several years ago.

Sgt. has multiple combat and service related injuries, coupled with Post Traumatic Stress

Disorder (PTSD), and comorbid Substance use Disorder (SUD), primarily Irish whiskey;

Jameson, to be precise. Yet, to his credit, he has been enrolled in the Veterans Affairs Health

Care System (VA) and is permanently and totally disabled as determined by the VA. He

currently attends weekly group psychotherapy sessions with fellow combat veterans at a nearby

VA facility, weekly AA meetings, remains involved with camaraderie based combat veterans

organizations, and has been utilizing Eye Movement Desensitization and Reprocessing (EMDR)

treatment, outside of the VA, for the previous year-and-a-half. His utilization of these valuable
 2

resources have enabled him to improve his quality of life, reduce symptoms of Post Traumatic

Stress Disorder (PTSD) and maintain a continued sense of purpose.

While his life journey has been wrought with hardships and trauma, his resilience is both

perplexing and exemplarily of the power of Post Traumatic Growth (PTG) (Jayawickreme &

Blackie, 2014) and neurogenesis (Applegate & Shapiro, 2005; Erickson et al., 1998; Gould et al.,

1999; Gross, 2000). However, herein the focus is on his utilization of EMDR and the efficacy

demonstrated throughout his duration of treatment.

Problem Formulation

The prevalence of PTSD amongst combat veterans is well researched (Kang et al., 2014;

Leardman, et al., 2013; Thompson, 2016; VA, 2016, Kemp & Bosarte, 2012; JAMA, 2014).

Since the wars following the attacks of September 11th, 2001 research funding for PTSD has

been plentiful and the data, as a result, is rich in valuable information across multiple correlates.

However, that was not the case during prior conflicts such as Vietnam where Sgt. had endured

six combat tours and witnessed repeated traumatic exposures that had gone both untreated and

unacknowledged for nearly four decades.

The result was, until about 2013, a post combat existence inclusive of undiagnosed

symptomatic expression of most symptoms of PTSD: Hyper vigilance, disturbing and intrusive

recollections, nightmares and dreams, flashbacks, psychological distress, negative alterations in

cognition and mood, persistent avoidance of stimuli associated with the previous exposure to

multiple traumatic events, negative self beliefs, anger, guilt, shame, detachment, estrangement

from others, sleep disturbances, reckless and self destructive behavior (APA, 2013; Dryden-

Edwards & Stoppler, 2014; PTSD, 2014 ). To cope and or escape from the symptoms, Sgt.

resorted to the overuse of alcohol, and reckless behavior which repeated data demonstrates is
 3

commonly comorbid with PTSD (APA, 2013).

In 2012, Sgt, was aware that something needed to be done to intervene. By this time he

was in his fourth marriage and the combination of both physical injuries and the full-scale

manifestations of PTSD and substance abuse had taken a toll on his quality of life such that

creeping ideations of self destruction to end the pain were now haunting him while both awake

and asleep.

He had been attending group sessions with fellow combat veterans, but distrust of some

of the members created aggravation and frustration. He had attempted to curb his use of alcohol

with limited and short-term success. However, in 2013 he got involved with a local veterans

advocacy agency, Operation Vet Fit, where he began to attend the combat agencys camaraderie

based events. It was here that he warmed up to the idea of utilizing EMDR and began treatment

with an outside of the agency, qualified clinician.

Theoretical Orientation

EMDR

EMDR is an eight-phase psychotherapy with standardized procedures, phases and clinical

applications including comprehensive worksheets for client assessment, case formulation, and

treatment as well as scripts for various procedures (Shapiro, 2006) taking place along a three-

pronged protocol that includes processing of past events (traumas) that have set the foundation

for the pathology (symptoms), current triggers, while providing templates for appropriate future

functioning to address skill and developmental deficits that are all believed to contribute to

therapeutic effect (Shapiro, 2001, 2002).

With research data supporting reductions in chronic pain (Ray & Zbik, 2001), PTSD,

anxiety and depression symptoms, as well as improved sleep, quality of life and perception of
 4

stress in as little as five sessions (Raboni, Tufik & Suchecki, 2006), EMDR has seen rapid

growth in clinical popularity.

Another aspect of EMDR, which seems to highlight its popularity amongst combat

veterans is that it does not require the typical homework and sustained arousal or detailed

descriptions of traumatic events (Shapiro, 2012) typical of other cognitive processing therapies.

Utilizing the Adaptive Information Processing (AIP) model to explain clinical effects,

EMDR is an integrative and distinct approach from other forms of psychotherapy (Shapiro,

2001, 2002, 2007).

Adaptive Information Processing. The AIP model posits that memory is associated,

thus learning occurs through the creation of new associations (Van der Kolk, 2002, 2003).

EMDR allows one to address dysfunctional experiences or traumas by changing their

associations and thus reprocessing the memory to result in more adaptive outcomes (reduction of

symptoms) by targeting and connecting of unprocessed traumatic memories to more adaptive

information in other memory networks producing a reduction in PTSD and other symptoms (Van

der Kolk, 2002, 2003).

Mechanism of Action. It is hypothesized that dual-attention via eye movement results in

a synergistic interaction of multiple mechanisms with many finding a direct effect on emotional

arousal, attentional flexibility, retrieval, distancing and memory association (Gunter, & Bodner,

2008; Lee & Drummond, 2008; Schubert & Drummond, 2011); van den Hout, Muris, Salemink,

& Kindt, 2001). Eye movements change the somatic perceptions accompanying retrieval,

leading to decreased affect, and therefore decreasing image vividness and emotionality (van den

Hout, et al., 2001). EMDR contains both procedures and elements that contribute to treatment

effects. Neurobiological processes have additionally garnered consideration for further

 5

inspection.

Neurobiology. Neurobiological studies have indicated significant effects, including

changes in cortical, and limbic activation patterns, and increase in hippocampal volume (Bossin,

Fagiollin & Castrogiovanni, 2007; Bossini, Tavanti, callossi et al., 2011; Van der Kolk,

Burbridge & Suzuki, 1997) .

Psychophysiology. All psychophysiological studies have indicated significant de-

arousal. Specifically, decreases in heart rate and skin conductance response after a single EMDR

session (Aubert-Khaifi & Blin, 2008; Frustaci, Lanza, Fernandez et al., 2010). Further research

concluded that the eye movements during EMDR activate cholinergic activity and inhibit

sympathetic systems. The reactivity has similarities with the pattern during REM sleep

(Elofsson, von Scheele, Theorell et al., 2008).

EMDR has garnered broad acceptance as an effective evidence based intervention (EBI)

for the combat veteran population (Carlson, Chemtob, Rusnak, et al.1998; Cook, Biyanova, &

Coyne, 2009; Errebo & Sommers-Flanagan, 2007; McLay, Webb-Murphy, Fesperman, et al.

2016; Russell, 2006; Russell & Figley, 2013; Russell, Silver, Rogers & Darnell, 2007 ; Silver,

Rogers & Russell, 2008). One reason noted in the American Psychiatric Association Practice

Guidelines (2004, p.18), in EMDR therapy traumatic material need not be verbalized; instead,

patients are directed to think about their traumatic experiences without having to discuss

them. This approach creates a willingness to initiate treatment, the likelihood for higher

retention and increased therapeutic gains.

Russell et al. (2007) evaluated 72 active-duty military personnel, 48 diagnosed with

combat PTSD and reported that pre-post changes were significant on all measures. A recent

program evaluation of active duty military by McLay et al. (2016), compared various forms of
 6

treatment and reported results indicating that patients receiving EMDR had significantly fewer

therapy sessions over 10 weeks but had significantly greater shifts in their PCLM scores than

did individuals not receiving EMDR.

Meta-analysis

EMDR has been demonstrated equally as or more effective than all other interventions

for PTSD (Bisson, Roberts, Andrew et al., (2013). The additive effect of eye movements in

EMDR treatment studies has been repeatedly demonstrated as either moderate or large and

significant (Lee & Culjpers, 2013). Recently, EMDR has joined cognitive behavioral therapy

(CBT) as the most often studied type of effective psychotherapy (Watts, et al., 2013).

Randomized Clinical Trials

Multiple randomized clinical trials demonstrate not only repeated PTSD treatment

efficacy but moreover, long-term and sustained treatment effects with a relatively small number

of sessions when compared to other treatment interventions (Carlson, Chemtob, Rusnak, et al.,

1998; Hogberg, et al., 2008; Marcus, Marquis & Sakai, 2004; Nijdam, gersons, reitsma et al.,

2012; Van der Kol, Reitsma, jongh et al., 2012 & Wilson, Becker & Tinker, 1997).

Non-Randomized Studies

Multiple studies demonstrate that service members receiving EMDR require significantly

less sessions and benefit from significantly greater gains in reduction symptomatic expression of

PTSD (Mcay, Webb, Fesperman et al., 2016). In another study, active-duty military personnel

were treated with EMDR therapy whereby results indicated that the disturbance associated with

the targeted traumatic memories had been largely eliminated and a new more positive

perspective had developed (Russell, Silver, Rogers et al., 2007).

Problem Definition and Focus of Treatment

 7

Sgt. has been utilizing EMDR for over sixteen months due to the multitude of traumatic

events he has endured, each requiring a period of reprocessing. His current duration of EMDR

utilization is nearly three-times longer than normally required for single trauma clients. It is very

likely that he will require continued treatment for the foreseeable future. He has a strong desire

to reduce symptomatic expression of his PTSD symptoms. More specifically, his recurrent

flashbacks and vivid nightmares. Furthermore, he seeks to control his problematic consumption

of alcohol. Therefore our treatment goal is the reduction of alcohol intake coupled with an

overall improved mood and reduction of PTSD symptoms. To measure his process throughout

treatment, standard PTSD, Depression and Alcohol abuse measures have been utilized as

detailed below:

Measures and Reliability

PTSD. Utilization of the standardized 17-item PTSD Checklist-Military Version (PCL-

M) (Weathers, Litz, Herman, Huska, & Keane, 1993) (Appendix A) was implemented due to its

high reliability = 0.94 (Norris & Hamblen, 2003). A score of 17-33 represents low Post

Traumatic Stress (PTS); 34-43 is representative of moderate PTS and a score between 44-85

demonstrates high PTS. Evidence for the PCL for DSM-IV suggests that a 5-10 point downward

scoring change represents reliable change and a 10-20 point change represents clinically

significant change. For this scale, it is Sgt.s hope to obtain clinically significant downward

scoring change.

Depression. Was assessed utilizing the standardized Beck Depression Inventory (BDI),

(Appendix B), a 21-item, self-report rating inventory that measures characteristic attitudes and

symptoms of depression (Beck, et al., 1961). Internal consistency for the BDI ranges from .73 to

.92 with a mean of .86. (Beck, Steer, & Garbin, 1988). The BDI demonstrates high internal
 8

consistency, with alpha coefficients of .86 and .81 for psychiatric and non-psychiatric

populations respectively (Beck et al., 1988). Scoring of 1-10 is considered normal; 11-16

represents mild mood disturbance 17-20 is indicative of borderline clinical depression; 21-30

moderate depression; 31-40 Severe depression and scoring over 40 demonstrates extreme

depression.

Alcohol abuse severity. Was assessed with the standardized CAGE (Ewing, 1984),

(Appendix C), a 4-item questionnaire that assesses the presence of clinically significant alcohol

use or problem drinking behaviors (Hemphill-Pearson, 2008). A meta-analysis of 22 studies

reported the median internal consistency was = 0.74. (Shields & Caruso, 2004). A score of 2 or

greater is considered clinically significant.

Design and Expectation

As a single-subject study we expect to see an overall reduction in symptomatic

expression of PTSD coupled with a lessening of depression based scores with the hopes of a

reduction in CAGE scoring. The following (Chart 1) cover the period of seventeen months from

February 2016 thru July 2017 and reflect the actual results, as reflected in the standardized PCL-

M, BDI, and CAGE respectfully.

Results

As demonstrated in Graph 1 below, and following an extensive and long durational

period of EMDR treatment of thirty-two sessions, for approximately 60-90 minutes per session

covering a seventeen-month period, Sgt.s PCL-M and BDI score reductions are clinically

significant, while his CAGE score increased. Deeper evaluation of each are provided below:

PTSD
 9

Sgt.s PCL-M score reduced 47 points from 86 to 38 demonstrating exceptional clinical

significance throughout the seventeen-month period of treatment.

Depression

Sgt.s BDI score of 55, which had represented extreme depression, has been reduced to a

borderline region score of 18 demonstrating exceptional clinical significance.

Alcohol Abuse

Sgt.s CAGE score, from 2 to 3 (both clinically significant) interestingly, has increased.

Upon further inspection, it appears that his answer specific to awareness of the need to cut down

drinking and feeling guilty about his drinking became stronger with EMDR treatment ultimately

resulting in his current utilization of weekly AA meetings and repeated attempts to stop

consuming alcohol. In this case example, an increase in CAGE score, when the answers are

evaluated, appear to represent a positive change leading to an actual measured reduction in his

use and abuse awareness.

Chart 1.

PTSD, Depression and Alcohol Abuse scores

100
90
80
70
60
50
40
30
20
10
0
Feb 2016 - Initial Evaluation July 2017 - Re Evaluation
PCL-M Scores 86 38
BDI Scores 55 18
CAGE Scores 2 3
 10

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Appendix A.
 17

Appendix B.
 18

Appendix B. Cont.
 19

Appendix C.
20