June 12, 2009

Review: Eye Movement Desensitization and Reprocessing (EMDR) in the Treatment of War Veterans

Silver, Rogers and Russell (2008) outline EMDR as an “eight-phase therapeutic approach” based on the Adaptive Information-Processing (AIP) model to treat combat veterans. The foundation of EMDR resides in the clients “neurologically based information processing” (Silver, et al., 2008, p. 948) center and employs an “adaptive resolution” mechanism from the neuroprocessor to resolve traumatic memories by utilizing the two underlying cognitions of adaptation; accommodation and assimilation. Accommodation involves the modification of our internal representations to adapt our normal operating schema. Assimilation involves utilizing an old schemata in a novel way.

When the individual traumatic experience such as combat, the mind begins to lose concordance with the internal operating system and equilibrium begins to unravel into trauma induced sequelae. EMDR seeks to reconcile the traumatic memories into a more collective consciousness within the individual by unblocking the portion of memory that has become entrenched. The combination of EMDR coupled with the AIP model corrects maladaptive behavior and cognitions through an adaptive resolution of the triggering stressor and the unprocessed memory that cause abreactions within everyday living.

The authors provide a brief overview of each phase in relation to the clinician’s main goals and expectations of the combat veteran. The treatment begins with a client history centering on the presenting problem(s), expressively the history of stressors and triggers. During the second phase the clinician prepares the client by educating her in what to expect, the clients role in treatment, information of EMDR and stress reduction techniques. An assessment follows in the third phase, concentrating on a goal-directed triggering of the patient’s affect through the client talking about the major stressors. The client has been given directions to deliberate on imagery, negative emotions and thoughts, and corporal sensations thus leading to the desensitization process.

During this step the practitioners expound on a key tenet of the procedure; the patient controls the therapy sessions and can at anytime halt the treatment. The fourth phase represents a fluid exchange between the client and the clinician where initially the patient is directed to speak of experiences shared in the history and assessment phases. The client has been informed that they do not need to disclose detailed dissections of the memories; a superficial discussion of the memories holds enough salience to stimulate eye movement. The practitioner employs a technique known as bilateral stimulation; a combination of eye movements, sounds and physical tapping to induce information processing to combine associated memories. This process proceeds until a complete resolution has been achieved. In phase five the helper helps the consumer to consolidate a new self affirmation in relation to the original stressors and formulate a novel experiential connexion to replace the trauma driven script.

The next step seeks to check bodily sensations to explore the need to reverse direction in phases or to go forward. Phase six involves a “body scan” whereby the client is directed to concentrate on the presenting problems and the newly associated positive perceptions. Bilateral stimulation can be implemented during this phase when bodily sensations do not match congruently with the recently identified cognitions. As with all therapies a closure needs to be ensured. The seventh phase addresses unfinished processing, covers the use of stress reduction and the probability of possible processing between sessions. The eighth phase includes a reevaluation and assessment to see if additional sessions would be needed to continue unprocessed memories, sensations, emotions and imagery.

In the article the authors chose to leave out two of the techniques in bilateral stimulation, the use of sounds and physical taps. I found this to be concerning, but not surprising as to the historical handling of the bastard child of psychological etiology of somatic disorders and related sequelae. Other considerations I encountered were their conclusions that EMDR therapy was “especially useful during combat situations” (Silver, et al., 2008). The article spent much of its time explaining the therapy and only one paragraph to state the argument in one of the main points in the abstract; that homework would not be necessary for using EMDR and would prove useful in a combat zone.

Considered an evidence-based practice, EMDR has weathered the storm of critics and naysayers and has attained the approval and endorsement of governmental and private entities including but not limited to the Veterans Administration, the Department of Defense and the American Psychological Association. Since the treatments inception in 1989, the efficacy has been proven to a high standard. Silver et al. (2008), reports of research on combat veterans has resulted in remission rates as high as 77% of PTSD patients. After 3-month and 9-months follow-up testing were reported to maintain the positive effects of the treatments.

One of the most interesting aspects of EMDR was the capacity to treat concurrent diagnosis such as depression and anxiety disorders in the same sessions with no distinctions made. Another feature I found that entice my interest to learn and master this therapy was empowering the client to control the procedure, mirroring a fundamental principle in social work, the strengths perspective. The final characteristic that has attracted me was the ability to maintain a safe distance from vicarious traumatization and avoid compassion fatigue that permeates the treatment of trauma based disorders.

Silver, S. M., Rogers, S., and Russell, M. (2008). Eye Movement Desensitization and Reprocessing (EMDR) in the Treatment of War Veterans. Journal of Clinical Psychology: In Session, 64(8), 947-957.

8 comments:

  1. I don't mean to insult you, but my father served in heavy combat in Vietnam for 8 months, and he suffered from severe PTSD all of his life until he died of a stroke. If I posted his expriences, everyone would puke. I read a post about something you said that you missed feeling alive in combat. This is not and never was a part of his illness or what caused it in the least. I just don't think that eye treatment would have helped him. It's not something the VA offers, as he was actively being treated by the VA just 3 years ago before his death.

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  2. Anonymous, I am not insulted at all. Not every combat veteran experiences the same phenomenon while serving in a battle zone. Additionally, the veterans reactions to unimaginable situations could be polar opposites.

    I do not expect everyone who reads my material to have a complete understanding of my combat experiences and reactions. Further, some people do find my writings difficult to read and troublesome. I have included a warning disclaimer at the top of my blog for this reason.

    When I wrote the article about missing the feeling of aliveness. I was describing a psychological and phyisological change within myself. This altered conscouisness shifts the brains entire focus on the immediate arena of experience. All the rambling thoughts that we incur in normal life cease to exist and all of the minds faculties automatically focus on interpreting sensory input. All of the senses sharpen exponentially and time suspends its rush toward the future, where seconds become days and hours become eternity.

    I do not expect you to understand this unless you have encountered a life threating episode. Please, go back and reread the post and try to get past the line you described. The entire article should be absorbed to appreciate my reaction to an unimaginable situation. I did not think that the killing was beautiful; I was in awe of the massive tank battles, the Apache Helicopters rain of hellfire missiles, the Bradley Fighting Vehicles missiles and cannon, and the A10 Warthog airplanes strafing of the enemy.

    One has to distance themselves from that kind of carnage to do what needs to be done to survive and win the battle. Some use anger to create an "othering effect" where they assign a monstrous value to the enemy in order to justify killing them. In my case my experience converged on omnipresence.

    The VA does have EMDR therapy at many hospitals. I believe that this therapy is new to the VA, so your father may not have had access to it. I have read some on EMDR and the research has proved many successes using this treatment. I am in the PTSD program at the VA in Louisville, Kentucky and have been considering going through EMDR treatment. I want to stress that not all therapies will help everyone. Thoughtful consideration on choosing a therapist will maximize the benefits on deciding what treatment(s) will the individual profit from. It has taken me three years of extensive treatment to obtain the level of independence that I command today.

    God bless you and your father, may you find peace.

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  3. To Anonymous: If you go to the VA's National Center for PTSD, you will find information about EMDR. For your convenience, I have copied and pasted it below:

    "What is EMDR?
    Eye movement desensitization and reprocessing (EMDR) is a fairly new therapy for PTSD. Like other kinds of counseling, it can help change how you react to memories of your trauma.

    While talking about your memories, you'll focus on distractions like eye movements, hand taps, and sounds. For example, your therapist will move his or her hand near your face, and you'll follow this movement with your eyes.

    Experts are still learning how EMDR works. Studies have shown that it may help you have fewer PTSD symptoms. But research also suggests that the eye movements are not a necessary part of the treatment."

    I am sorry for the loss of your father. My father was a WWII Veteran, and I miss him terribly everyday.

    Sue Lamoureux
    Wife of Iraq war Veteran rated at 70% for PTSD

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  4. When Anonymous commented, I could feel their anger and and confusion coupled with grief. It is hard to watch someone who suffers and not be able to sooth their pain.

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  5. I am not a combat vet but am a life long sufferer of PTSD from horrendous sexual abuse. So I will humbly submit my opinion.

    7 years of cognitive therapy helped, but the last year of continuous EMDR therapy worked to minimize the symptoms and triggers. I would recommend it to anyone. Some people cannot tolerate EMDR with light but my therapist gave me a choice and I normally watched her move the wand in her hand. You feel like crap after but later it all becomes 'foggy' like it is behind a veil. You remember but there is not pain with it.

    Although I do use the VA, I used a private therapist for psychotherapy.

    I have a friend who is a WWII vet and I am so sorry for the loss of your father, anonymous.

    Susan

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  6. I am doing the, "Hey not in my backyard" thing with the VA again. I go to one therapist in an attempt to be admitted to the PTSD program and they tell me, no, that I am depressed to go see another therapist. It took me 2 months to see this one, then I get another appointment, and then, they tell me to move on down the road. Now at the VA getting in to see a new therapist. So, now I have to wait to see another therapist and guess what? Yep, you guessed it, another two months, add this up, 5 freaking months.

    I know that I am depressed AND I know that my PTSD is kickin. Treat PTSD in one clinic, depression in another.....this is madness! No wonder veterans do not come back to another appointment.

    Wait, did I just go into a tangent? I was trying to say that I want to go through EMDR therapy, it might take me another 5 months to receive it, but THEY will not get me to turn away!! Thats all folks a little help here please!!

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  7. I stumbled upon this site by accident...you are doing great work here.

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