EMDR in the Treatment of Military Veterans

Workshop Handout

Steven Silver, Ph.D.

Susan Rogers, Ph.D.

EMDR International Association

Pre-Conference Workshop

18 September 2013

Denver, CO

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EMDR Discussion

EMDR has been identified as an effective treatment for PTSD by the following

independent reviewing bodies:

American Psychological Association (1998)

International Society for Traumatic Stress Studies (2000, 2008)

American Psychiatric Association (2004)

Cochrane Database (2007)

VA/DOD Clinical Practice Guidelines (2004, 2010)

RAND Corporation (2008)

SAMHSA (2011)

World Health Organization (2013)

The Institute of Medicine Report appears to be the most conservative of these reviews,

identifying only prolonged exposure as having sufficient empirical support. In that review

EMDR was rated as having insufficient research to permit evaluation. It appears that CPT did not

meet this research standard either, but has been promoted on the grounds that it is also “exposure

based”, even though it has less of an exposure component than EMDR (this is even truer of the

CPT-C variant currently being promoted in the VA rollout).

It should be noted that there have been no randomized clinical trials of prolonged

exposure with male combat veterans. While the Schnurr study of prolonged exposure was a

rigorous, well-conducted study with a large sample of female veterans, only 6% of the subjects

in that study identified a combat stressor as the primary source of their PTSD.

Randomized Clinical Trials with Veterans

CPT

(Monson et al.,

2006)

PE

(Schnurr et al., 2007)

EMDR

(Carlson et al., 1998)

Subjects with Combat

Trauma

75% 6% 100%

Remission

(% losing PTSD dx after

treatment)

30% 41% 78%

Dropout 20% 38% 0%

While PE and CPT both showed a 40% remission rate post-treatment, the remission rate

for CPT fell to 30% at a one month follow-up. Dropout rates for both PE and CPT were

substantial. A recent open trial of group exposure for veterans (Ready et al., 2009) showed a low

dropout rate, but also showed that 40% of the veterans approached about participating in the

treatment declined. These treatments, while effective, may be difficult to apply for a substantial

proportion of the veteran population. This suggests that the VA should broaden the number of

treatments being promoted in rollouts.

VA clinicians who are using PE and CPT with veterans are reporting that the homework

requirement for those treatments can pose difficulties for many veterans. One of the advantages

of EMDR is that it requires no homework, nor does it require the veteran to verbalize the details

of the trauma for the therapist. VA clinicians treating veterans with PTSD plus TBI have

reported that EMDR’s largely non-verbal approach is an advantage with population.

Though questions about the durability of EMDR effects have been raised, all twelve of

the randomized outcome studies of EMDR show treatment effects maintained at follow-up. One

recent study showed maintenance of treatment effects 35 months after the termination of EMDR

treatment (Hogberg et al, 2008). A study of the use of EMDR with German military personnel

showed maintenance of treatment effect at 29 months (Zimmerman et al, 2007). A NIMH-funded

comparison of EMDR and Fluoxetine showed the percentage of subjects meeting good end-state

criterion continued to increase during the 8 months after EMDR treatment (van der Kolk et al.,

2007). In the Carlson et al. (1998) study of Vietnam veterans with chronic combat-related PTSD,

the posttreatment remission rate of 78% for EMDR was maintained at a15 month follow-up.

While some reviewers have suggested that the eye movements do not contribute to

EMDR outcome, a widely-disseminated meta analysis (Davidson and Parker, 2001) showed,

while the eye movements do not have a significant effect on outcome with nonclinical population

(anxious undergraduates), they have shown an effect in studies conducted with clinical

populations and a “spectacular” (Davidson & Parker) effect on within-session anxiety with

clinical populations. More recent studies have shown that the eye movements generate an

immediate decrease in arousal during treatment sessions with PTSD patients (Elofsson et al.,

2007; Sack et al.,2008), which poses a distinct advantage for clients who become hyperaroused

when focused on their trauma memories.

Research is currently being conducted to determine the mechanism of action in EMDR.

Recent studies have shown the following pre-post physiological changes in PTSD subjects:

- Decreased physiological reactivity to trauma script (Sack et al., 2004)

- Increased activity, medial prefrontal cortex and anterior cingulate during trauma script

(Levin et al., 1999)

- Reduced P3a (evoked potentials) (Lamprecht et al., 22004)

- 10% increase in hippocampal volume (Bossini et al., 2007)

References:

American Psychiatric Association (2004). Practice Guideline for the Treatment of

Patients with Acute Stress Disorder and Posttraumatic Stress Disorder. Arlington, VA: American

Psychiatric Association Practice Guidelines

Bisson, J. I., Ehlers, A., Matthews, R., Pilling, S., Richards, D., & Turner, S. (2007).

Psychological treatment for for chronic posttraumatic stress disorder. Systematic review and

metanalyis. British Journal of Psychiatry, 190: 97-104.

Bossini, L., Fagiolini, A, Castrogiovanni, P (2007) Neuroanatomical changes after eye

movement desensitization and reprocessing (EMDR) treatment in posttraumatic stress disorder.

Journal of Neuropsychiatry and Clinical Neurosciences. 19,475-476.

Carlson, J.G., Chemtob, C.M., Rusnak, K., Hedlund, N.L., & Muraoka, M.Y. (1998). Eye

movement desensitization and reprocessing treatment for combat-related posttraumatic stress

disorder. Journal of Traumatic Stress, 11, 3-24.

Chambless,D, Baker, M, Baucom,D, Beutler,L, Calhoun,K, Crits-Christoph, P,

DeRubeis, R, Detwiler, J, Haaga, D (1998) Update of empirically validated therapies, II. The

Clinical Psychologist,51,3-16.

Chemtob, Tolin, van der Kolk & Pitman (2000). Eye movement desensitization and

reprocessing. In E. B. Foa, T. M. Keane & M. J. Friedman [Eds.] Effective treatments for PTSD:

Practice guidelines from the International Society for Traumatic Stress Studies (pp. 139-155,

333-335). New York: Guilford Press

Davidson, P. R., & Parker, K. C. H. (2001). Eye movement desensitization and

reprocessing (EMDR): A meta-analysis. Journal of Consulting and Clinical Psychology, 69, 305-

316.

Department of Veterans Affairs & Department of Defense (2004) VA/DOD Clinical

Practice Guidelines for the Management of Posttraumatic Stress Disorder. Washington, D.C.

http:// www.oqp.med.va.gov/cpg/PTSD/PTSD_cpgframeset.htm.

Elofsson, U, von Scheele, B, Theorell, T, Sondergaard, H (2008) Phsyiological correlated

of eye movement desensitization and reprocessing. Journal of Anxiety Disorders,22(4),622-634.

Hogberg, G., Pagani, M., Sundin, O., Soares, J., Aberg-Wistedt, A., Tarnell, B., et al.

(2007). On treatment with eye movement desensitization and reprocessing of chronic post-

traumatic stress disorder in public transportation workers: A randomized controlled trial. Nordic

Journal of Psychiatry, 61 (1) 54-61.

Lamprecht, F, Kohnke, C, Lempa, W, Sack, M, Matzke, M, Munte, T (2004) Event-

related potentials and EMDR treatment of posttraumatic stress disorder. Neuroscience

Research,49(2),267-272.

Levin, P., Lazrove, S., & van der Kolk, B.A. (1999). What psychological testing and

neuroimaging tell us about the treatment of posttraumatic stress disorder (PTSD) by eye

movement desensitization and reprocessing (EMDR). Journal of Anxiety Disorders, 13, 159-172.

MacCulloch, M. J., & Feldman, P. (1996). Eye movement desensitization treatment

utilizes the positive visceral element of the investigatory reflex to inhibit the memories of post-

traumatic stress disorder: A theoretical analysis. British Journal of Psychiatry, 169, 571-579.

Monson, C., Schnurr, P, Resick, R, Friedman, M, Young-Xu, Y, Steven, S (2006)

Cognitive processing therapy for veterans with military-related posttraumatic stress disorder.

Journal of Consulting and Clinical Psychology, 74(5),989-907.

Sack, M, Lempa, W, Steinmetz, A, Lamprecht, F, Hofmann, A (2008) Alterations in tone

during trauma exposure using eye movement desensitization and reprocessing (EMDR)-results

of a preliminary investigation. Journal of Anxiety Disorders, 22(7), 1264-1271.

Schnurr, P; Friedman, M., Engel, C., Foa, E., Shea, M, Chow, B, Resick, P, Thurston, V,

Orsillo, S, Haug, R, Turner, C, Bernardy, N (2007) Cognitive behavioral therapy for

posttraumatic stress disorder in women: a randomized controlled trial. Journal of the American

Medical Association, Feb 28, 297(8), 820-830.

Spates, C, Koch, E, Cusack, K, Weller, S (2008) Eye movement desensitization and

reprocessing. In Foa, E, Keane, T, Friedman, M, Cohen, J (2008) Effective Treatment for PTSD,

2nd

edition. New York: Guilford.

Ready, D, Thomas, K, Worley, V, Backscheider, A, Harvey, L, Baltzell, D, Rothbaum, B

(2008) A field test of group based exposure therapy with 102 veterans with war-related

posttraumatic stress disorder. Journal of Traumatic Stress, 21(2), 150-157.

United Kingdom Department of Health. (2001). Treatment choice in psychological

therapies and counselling evidence based clinical practice guideline. London: Author. Tetrived

Marcy 15, 2002, from http://www.doh.gov.uk/mentalhealth/treatmentguideline/

Van der Kolk, B, Spinazzola, J, Blaustein, M, Hopper, J, Korn, D, Simpson, W (2007) A

randomized clinical trial of eye movement desensitization and reprocessing (EMDR), fluoxetine,

and pill placebo in the treatment of posttraumatic stress disorder: treatment effects and long-term

maintenance. Journal of Clinical Psychiatry, 68(1),37-46.

Zimmerman, P., Biesold, K., Barre, K., Lanzcik, M. (2007) Long-term course of post-

traumatic stress disorder (PTSD) in German soldiers: effects of inpatient eye movement

desensitization and reprocessing therapy and specific trauma characteristics in patients with non-

combat related PTSD. Military Medicine, 172(5), 456-460.

EMDR References Relevant to Military Treatment Issues

Ahmadizadeh, M.J., Eskandari, H., Falsafinejad, M.R. & Borjali, A. (2010) Comparison the effectiveness of “cognitive-behavioral” and “eye mvement desensitization reprocessing” treatment models on patients with war post-traumatic stress disorder. Iranian Journal of Military Medicine 12(3), 173-178. Randomized group study comparing EMDR, CBT and untreated controls on the M-PCL and Symptom Checklist. Both treatments were effective at reducing general distress compared to no treatment. EMDR was more effective at reducing symptoms of PTSD. EMDR was done in 4 individually-administered sessions, CBT was done in 11 individually- and group-administered sessions.

Boudewyns, P.A. & Hyer, L.A. (1996) Eye movement desensitization and reprocessing (EMDR) as a treatment for posttraumatic stress disorder. Clinical Psychology and Psychotherapy, 3, 185-195. Randomized group study of the

incremental effect of six sessions of EMDR when added to an existing inpatient treatment program for combat-related PTSD. Compared to relaxation training, EMDR had a significantly greater effect on PTSD symptoms as measured by subjective and standardized measures.

Boudewyns, P.A., Stwertka, S.A., Hyer, L.A., Albrecht, J.W. & Sperr, E.V. (1993) Eye movement desensitization for PTSD of combat: a treatment outcome pilot study. the Behavior Therapist, 16(2), 29-33. Randomized group comparison of two sessions of EMD with and without eye movements for Vietnam veterans with chronic PTSD. Neither group showed reliable change in subjective or physiological response to taped trauma scripts. However, the eye movement group showed a significant reduction of distress during the treatment sessions.

Brauser, D. (2013, July, 11). Eye therapy has it over antidepressant for PTSD. Medscape Medical News. Retrieved from http://www.medscape.com/viewarticle/807694 on 7/24/2014. Small RCT comparing

6 weeks of EMDR to Paroxetine in Pakistani war veterans.90% of those receiving weekly EMDR sessions showed positive response to treatment. The EMDR group showed significantly greater improvement in PTSD symptom levels compared to those receiving SSPI only.

Butler, C. M. (2012, August). Comparing the efficacy of eye movement desensitization and reprocessing to treatment as usual for veterans with military-related post-traumatic stress disorder. (Doctoral dissertation, Argosy University). Study of 13 veterans receiving EMDR or talk therapy while in residential substance abuse treatment. EMDR had greater effect on reexperiencing and avoidance symptoms. Neither treatment had an effect on comorbid depression and anxiety.

Carlson, J.G., Chemtob, C.M., Rusnack, K., Hedlund, N.L. & Muraoka, M.Y. (1998) Eye movement desensitization and reprocessing for combat-related

posttraumatic stress disorder. Journal of Traumatic Stress, 11, 3-24. A randomized group study comparing 12 sessions of EMDR to biofeedback-assisted relaxation training and routine care. Compared with the other treatments, greater effects were obtained with EMDR and were maintained at a nine month follow-up. This is the strongest study of EMDR with a military population and meets all of the ‘gold standard’ criteria.

Cerone, M. R. (2000, April). Eye movement desensitization and reprocessing in the psychological treatment of combat-related guilt: A study of the effects of eye movements. Dissertation Abstracts International: Section B: The Sciences and Engineering, 61(10-B), 5555. Single-case multiple component

crossover investigation of EMDR. While there were no differences between EMDR and a non eye movement analog on self-monitored intrusions, dreams and guilt, the full EMDR procedure resulted in greater improvement in objective measures of PTSD and depression and subjective distress (both within-session and pre-post).

Cooks, J.M., Biyanova, T. & Coyne, J.C. (2009) Comparative case study of diffusion of eye movement desensitization and reprocessing in 2 clinical settings: Empirically supported treatment status is not enough. Professional Psychology: Research and Practice 40(5) 518-524. Summary of interviews of staff members in 2

VA PTSD treatment programs, one in which EMDR was used, one in which it was not. Reasons for the difference discussed.

Devilly, G.J., Spence, S.H. & Rapee, R.M. (1998) Statistical and reliable change with eye movement desensitization and reprocessing: treating trauma within a veteran population. Behavior Therapy, 29, 435-455. Randomized group comparing EMDR with and without eye movement and supportive treatment. 67% of the EMDR group showed reliable symptom improvement, compared with 41% of the non eye movement group and 10% of the supportive counseling group. However, the description of treatments in the procedure section raise questions about the fidelity to the EMDR protocol.

Department of Veterans Affairs & Department of Defense (2004) VA/DOD Clinical Practice Guidelines for the Management of Posttraumatic Stress. Washington, D.C. http://www.oqp.med.va.gov/cpg/PTSD/PTSD_cpgframeset.htm A comprehensive review of treatment outcome research on combat-related PTSD. EMDR is one of four psychotherapies receiving the highest recommendation.

Errebo, N. (2005) EMDR-HAP trains clinicians. Vet Center Voice, 26(2), 30-33. This article describes Dr. Errebo’s experiences as a volunteer with the EMDR Humanitarian Assistance Programs, including the training conducted for VA and DOD clinicians.

Errebo, N. (2007) Like a ghost: using EMDR to revive a traumatized veteran’s marriage. Psychotherapy Networker, Jan-Feb. This critiqued case report gives a detailed description of the course of treatment of a veteran with combat-related PTSD and the improvement in marital relations.

Errebo. N. & Sommers-Flanagan, R. (2007) EMDR and emotionally focused couples therapy for war veteran couples. in F. Shapiro, F Kaslow & L Maxfield Eds EMDR and Family Therapy Practice. Wiley: Indianapolis. This book chapter focuses on the use of EMDR on the marital problems that often accompany combat-related PTSD. Illustrative case examples.

Foa, E., Keane, T. & Friedman, M., Eds (2000) Effective Treatments for PTSD: Practice Guidelines from the International Society for Traumatic Stress Studies, Guilford Press, New York. Comprehensive review of PTSD treatment

outcome research up to 1999. EMDR received highest rating, along with prolonged exposure and cognitive therapy.

Grbesa, G., Simonovic, M., & Jankovic, D. (2010, April). Electrophysiological changes during EMDR treatment in patients with combat-related PTSD. Annals of General Psychiatry, 9(Supplement 1), S209. doi:10.1186/1744-859X-9-S1-S209. Continuous EEG recording showed decrease in

subjective anxiety correlated with increased amplitude in cortical activity immediately post-treatment.

Howard, M.D. & Cox, R.P. (2006) Use of EMDR in the treatment of water phobia at Navy boot camp: a case study. Traumatology e-journal, http://tmt.sagepub.com/cgi/content/abstract/12/4/302 A detailed case report describing the treatment of a Navy recruit with water phobia based in childhood trauma (brother’s drowning death). The trauma was resolved in four treatment sessions and the recruit was able to pass his swim test.

Ilic Z., & Jovic, V. (1997). Eye movement desensitization in therapy of war veterans. European Psychiatry, 12, Supplement 2, 1997, 193s-193s. doi:10.1016/S0924-9338(97)80583-4. Case study of a veteran receiving two sessions of EMDR with posttest improvement on the SCL-90R and IES (all symptom clusters).

Jensen, J. (1994) An investigation of eye movement desensitization and reprocessing (EMDR) as a treatment for posttraumatic stress disorder (PTSD) symptoms of Vietnam combat veterans. Behavior Therapy, 25, 311-35. Randomized group study comparing 2 sessions of EMD with VA standard care. The fact that fidelity checks were failed renders this study uninterpretable.

Lee, C.W. & Schubert, S. (2009) Omissions and Errors in the Institute of Medicine’s Report on Scientific Evidence of Treatments for Posttraumatic Stress Disorder, Journal of EMDR Practice and Research, 3(1), 32-38. Discussion of

inaccuracies in IOM’s review of EMDR research.

Lipke. H. & Botkin, A.L. (1992) Case studies of eye movement desensitization and reprocessing (EMDR) with chronic post-traumatic stress disorder. Psychotherapy, 29(4), 591-595. A case report describing the treatment of

five hospitalized Vietnam veterans in a VA inpatient treatment program using subjective and standardized measures.

Macklin, M.L., Metzger, L.J., Lasko, N., Berry, N.J., Orr, S. & Pitman, R.K. (2000) Five year follow-up study of eye movement desensitization and reprocessing therapy for combat-related posttraumatic stress disorder. Comprehensive Psychiatry, 41(1), 24-27. Nonrandomized follow-up of 13 veterans

from a previous evaluation of the eye movement component-see Pitman et al, 1996 below. In this study, subjects in the EMDR and control condition were combined and compared with a new sample of untreated or standard care patients. No differences in symptom severity were observed.

Musruck, D. (2003) Korean war flashbacks: treating PTSD. Mental Health Nursing, 23(4), 4-8. Case report describing the successful treatment of a Korean War

veteran with a combination of EMDR and journaling. Outcome was measured with subjective and standardized measures.

Narimani, M., Ahari, S. S., & Rajabi, S. (2008). Comparison of efficacy of eye movement, desensitization and reprocessing and cognitive behavioral therapy therapeutic methods for reducing anxiety and depression of Iranian combatant afflicted by post traumatic stress disorder. Journal of Applied Sciences, 8(10), 1932-1937. doi:10.3923/jas.2008.1932.1937. Hospitalized Iranian veterans treated with EMDR or CBT. Both groups showed improvements in anxiety and depression.

Nettz, S. L. (1996, July). Effects of a single session of EMDR, flooding, and a credible placebo treatment on traumatic memories in male veterans. Dissertation Abstracts International: Section B: The Sciences and Engineering, 57(1-B), 0687. Comparison of the effects of a single session of EMDR, exposure or

active control on 45 veterans. There were no change in heart rate or blood pressure for any group, both active treatments resulted in significant change in self-reported anxiety. Exposure resulted in a significantly greater increase in skin temp than the control.

Nikmorad, A. R., Nejad, A. S., Safdari, S., Goddini, A. A., Azadi, E., Babaei, M. A., Shariffi, Z., Kafrashi, S., & Bahrampour, O. (2014, August). Comparison of the influence of eye movement desensitization therapy and reprocessing (EMDR) and cognitive-behavioral therapy(CBT) method on reducing post-traumatic stress disorder in the war injured. Journal of Social Issues & Humanities, 2(8), 166-171.

Comparison of 45 Iranian combat veterans receiving 8 sessions of CBT or EMDR. Both treatment showed significant improvement on PCL scored compared to controls.

Occhietti, K. E. (2012). The effectiveness of PTSD treatment on symptoms of PTSD and depression in military veterans. (Master's thesis, St. Catherine University). Retrieved from http://sophia.stkate.edu/cgi/viewcontent.cgi?article=1068&context=msw_papers.

Comparison of veterans treated with EMDR, prolonged exposure or Cognitive Processing Therapy in a VA program. All three treatments were comparably effective initially but significant symptom rebound was observed at 6, and 1 month follow-ups.

Pitman, R.K., Orr, S., Altman, B., Longpre, R., Macklin, M (1996) Emotional processing during eye-movement desensitization and reprocessing therapy for

Vietnam veterans with chronic stress disorder. Comprehensive Psychiatry, 37, 419-429. This randomized group study was designed to evaluate the contribution of eye

movements to treatment outcome. EMDR was compared to an identical analog condition in which eye movements were replaced with a complex control procedure (staring at a point and tapping thumbs while the therapist moved their hand in front of the clients face). Relative to untreated controls, both conditions were effective. There were no significant differences in outcome. The study was limited by small sample size and the fact that the long treatment trials were focused on a single memory.

Rogers. S., Silver, S., Goss, J., Obenchain, J., Willis, A. & Whitney, R. (1999) A single session group study of exposure and eye movement desensitization and reprocessing in treating posttraumatic stress disorder among vietnam veterans: preliminary data. Journal of Anxiety Disorders,13(1-2), 119-130. A randomized

group comparison of one session of EMDR and prolonged exposure with hospitalized Vietnam veterans. Both groups showed improvement. The EMDR group showed significantly greater reductions in within-session distress and self-monitored intrusive re-experiencing with a trend toward greater reductions in heart rate during trauma script. The study was limited by the use of different therapists for the EMDR and exposure conditions.

Russell, M. (2006) Treating combat-related stress disorders: a multiple case study utilizing eye movement desensitization and reprocessing (EMDR) with battlefield casualties from the Iraqi War. Military Psychology, 18(1), 1-18. A case report with standardized measures showing the successful resolution of trauma memories in four combat-wounded evacuees in 1-2 sessions. Though limited by a lack of follow up, the study demonstrates the utility of EMDR as an early intervention close to the front.

Russell, M.C. (2008) War-related medically unexplained symptoms, prevalence and treatment: utilizing EMDR within the armed services. Journal of EMDR Research and Practice, 2(3), 212-225. Historical review of treatment for

medically unexplained symptoms (MUS) and single case study of OIF veteran with EMDR.

Russell, M. C. (2008, April). Treating traumatic amputation-related phantom limb pain: A case study utilizing eye movement desensitization and reprocessing within the Armed Services. Clinical Case Studies, 7(2), 136-153. doi:10.1177/1534650107306292. Case report of an active duty serviceman. 4 sessions

of EMDR eliminated phantom limb pain and significantly reduced PTSD symptoms.

Russell, M., Cooke, T.M. & Rogers, S. (2014) EMDR and effective

management of acute stress injuries: early mental health intervention from a military perspective. in Luber (Ed.) Implementing EMDR Early Mental Health Interventions for Man-Made and Natural Disasters. Springer: New York. Reviews military definitions of stress reactions, guiding principles of front-line treatment, screening, early treatment and adaptation of EMDR to military settings.

Russell, M.C & Figley, C.R. (2012) Treating Traumatic Stress Injuries in Military Personnel: An EMDR Practitioner’s Guide (Psychosocial Stress Series). Routledge: New York and London Guidance to the EMDR-trained clinician for establishing therapeutic alliance and working through all stages of treatment. Includes scripts and case examples.

Russell, M.C., Figley, C.R. & Lipke, H. (2011) Eye movement desensitization and reprocessing. in Eds Moore, B.A. and Penk, W.E. Treating PTSD in Military Personnel: A Clinical Handbook. Guilford: New York Book chapter reviewing the

use of EMDR with military personnel.

Russell, M.C. & Friedberg, F. (2009) Training, treatment access, and research on trauma in the armed services. Journal of EMDR Practice and Research, 3(1), 24-31. Examines the ability of the Department of Defense to meet

mental health needs and argues for increasing the availability of evidence-based treatments, including EMDR.

Russell, M & Silver, S.M. (2007) Training needs for the treatment of combat-related posttraumatic stress disorder: a survey of Department of Defense Clinicians. Traumatology 13:4-10. doi:10.1177/15347656305440. 137 clinicians from all military branches were surveyed about their training in evidence-based PTSD treatments. 90% reported not using any of these treatments and those who did were trained prior to their affiliation with the military.

Russell, M., Silver S., Rogers, S. and Darnell, J. (2007) Responding to an identified need: a joint DOD-VA training program in EMDR for clinicians treating trauma survivors. International Journal of Stress Management, 14(1), 61-71. This article is focused on the development and evaluation of an EMDR training program for VA and DOD clinicians. Clinician ratings of the training program were very positive. Treatment outcome data on 73 patients shows that trainees were able to successfully implement EMDR in their practices.

Silver, S.M. & Rogers, S. (2002) Light in the Heart of Darkness: EMDR and the Treatment of War and Terrorism Survivors. Norton: New York. This book has chapters covering each of the 8 phases of the EMDR protocol with veterans, chapters reviewing the the use of EMDR for combat-related grief, anger and guilt, chapters on therapist issues and a review of EMDR research. Numerous illustrative case examples, including a Korean War veterans who showed positive effect of EMDR lasting as long as 11 years.

Silver, S.M., Brooks, A. & Obenchain, J. (1995) Treatment of vietnam war veterans with PTSD: a comparison of eye movement desensitization and reprocessing, biofeedback and relaxation training. Journal of Traumatic Stress, 8, 337-342. A nonrandomized study of the incremental effects of EMDR, biofeedback and

relaxation training when added to a VA inpatient PTSD treatment program. The EMDR group showed a significantly greater improvement than the groups receiving the other treatments.

Tobias, M. (1999) EMDR therapy requires training and assessment. Vet Center Voice, 20(1), 26-29. The use of EMDR with combat-related PTSD is described

from the perspective of a therapist working an an outpatient Vet Center.

Thomas, R. & Gafner, G. (1993) PTSD in an elderly male: treatment with eye movement desensitization and reprocessing (EMDR). Clinical Gerontologist, 14, 57-59. This case report describes the use of EMDR with a veteran of WWII and Korea.

Trauma symptoms were resolved in two sessions. Two month follow-up showed good maintenance of improvement. The report shows that EMDR can be used for the resurgence of PTSD symptoms often seen in elderly veterans.

U.S. Department of Veterans Affairs & U.S. Department of Defense. (2010, October). VA/DoD clinical practice guidelines for the management of post-traumatic stress. Washington, DC: The Management of Post-Traumatic Stress Working Group.

Wesson, M. & Gould, M. (2009) Intervening early with Eye Movement Desensitization and Reprocessing on military operations: a case study. Journal of EMDR Practice and Research 3(2), 91-97 Describes the treatment of an active duty

soldier’s acute stress reaction with 4 sessions of EMDR on consecutive days with successful resolution of symptoms and ability to return to frontline duty. Treatment effects were maintained at 18 month follow up.

Wright,S. & Russell, M.C. (2012) Treating violent impulses: a case study utilizing eye movement desensitization and reprocessing with a military client. Clinical Case Studies 12(2) 128-144. Four sessions of EMDR resulted in significant

decrease in obsessive violent impulses, traumatic grief and depression in an active-duty client.

Young, W. (1995) EMDR: its use in resolving the trauma caused by the loss of a war buddy. American Journal of Psychotherapy, 49, 282-291. This case report

focuses on the successful resolution of trauma-related grief and survivor guilt with EMDR.

Zimmerman, P., Biesold, K.H., Barre, K. & Lanczik, M. (2007) Long-term course of post-traumatic stress disorder (PTSD) in German soldiers: effects of inpatient eye movement desensitization and reprocessing therapy and specific trauma characteristics in patients with non-combat-related PTSD. Military Medicine, 172(5), 456-460. Retrospective study of 89 German soldiers receiving inpatient treatment for posttraumatic stress disorder. A follow-up 29 months after treatment showed that soldiers receiving EMDR were significantly less symptomatic than those receiving supportive treatment and relaxation training. Limitations of the study include nonrandom assignment and nonstandardization of treatment times. However, the study does demonstrate the durability of EMDR’s effects.

Related issue - Use of EMDR with chronic pain

de Roos C, Veenstra AC, de Jongh A, den Hollander-Gijsman M, van der Wee NJ,Zitman FG, van Rood YR (2010) Treatment of chronic phantom limb pain using a trauma-focused psychological approach. Pain Res Manag. 2010 Mar-Apr;15(2):65-71. Eight of 10 patients with phantom limb pain showed significant

reduction or elimination of pain maintained at 2.8 year follow-up.

Grant M, Threlfo C. (2002) EMDR in the treatment of chronic pain. J Clin Psychol.2002 Dec;58(12):1505-20. Describes the successful treatment of 3 chronic pain patients with EMDR.

Mazzola, A, Calcagno, M, Goicochea, M, Pueyrredòn, H, Leston, J, Salvat, F. ( 2009) EMDR in the treatment of chronic pain. Journal of EMDR Practice and Research, 3(2), 66-79 38 chronic pain patients treated with 12 sessions of EMDR showed significant decreases in pain sensations, negative affect, anxiety and depression.

Schneider, J., Hofmann, A., Rost, C. & Shapiro, F. (2007) EMDR and phantom limb pain: theoretical implications, case study and treatment guidelines. Journal of EMDR Practice and Research, 1(1), 31-45. This case study describes the

successful resolution of treatment-resistant phantom pain with 9 sessions of EMDR. Treatment gains were measured with subjective and standardized measures and were maintained at 18-month follow up. This study illustrates the potential of a non-medication approach that can be applied to combat veterans. Article also reviews the literature on EMDR treatment of somatic problems.

Tesarz J, Leisner S, Gerhardt A, Janke S, Seidler GH, Eich W, Hartmann M. (2014) Effects of eye movement desensitization and reprocessing (EMDR) treatment in chronic pain patients: a systematic review. Pain Med.Feb;15(2):247-63. Review of studies of EMDR for chronic pain.