EMDR and Counselling for Individuals and Couples in East London

Lights signal end of Iraq trauma A ‘bonkers’ treatment ended five years of horrifying flashbacks (EMDR) – Clare Goldwin (The telegraph 20 Feb 2012)

Lights signal end of Iraq trauma

A ‘bonkers’ treatment ended five years of horrifying flashbacks for Hilary Horton.

No-nonsense nurse: Hilary Horton at Al Amarah base in Iraq, where she dealt with the bodies of six military poilcemen - Lights signal end of Iraq trauma

No-nonsense nurse: Hilary Horton at Al Amarah base in Iraq, where she dealt with the bodies of six military poilcemen Photo: GABRIEL SZABO/GUZELIAN

Hilary Horton has the no-nonsense attitude you’d expect from someone who was an intensive care nurse for 20 years, has worked in women’s prisons and is a former Air Force reservist. So it is a surprise to learn that five years of her life were virtually destroyed by constantly reliving one of the Iraq war’s grimmest episodes.

The former Air Force nurse was responsible for the bodies of six Royal Military Policemen who were murdered as they manned a police station in southern Iraq in June 2003, a killing spree that became notorious. Hilary was badly affected by her experience, and in 2009 she was diagnosed with severe post-traumatic stress disorder (PTSD), suffering regular flashbacks, fits of weeping and loss of confidence.

She is a lifelong sceptic about alternative therapies, yet she has found recovery from the trauma through a little-known treatment that required her to sit in a darkened room and watch lights flashing alternately left and right.

“At my first session I just thought it was bonkers,” she says. “I couldn’t believe it would ever help me.”

The therapy, called EMDR (Eye Movement Desensitisation and Reprocessing), is designed primarily to treat PTSD, a disorder triggered by the experience of a shocking or violent event. Although EMDR remains controversial, its reputation is gaining ground.

With recent figures showing that almost one in 50 servicemen and women were diagnosed with mental health problems last year, the Ministry of Defence signed a three-year contract in June to provide EMDR for personnel with psychological trauma.

Had it come earlier, this initiative might have made all the difference to Hilary.

The 55-year-old from Stafford, who became a reservist 16 years ago, was deployed to Iraq in May 2003 in the aftermath of Saddam Hussein’s fall. She was a flight lieutenant nursing officer managing a team of 15 nurses at the hospital at Al Amarah base.

Everything was routine until June 24, when the bodies of the six murdered Red Caps were brought to the base. Hilary was responsible for tending to the bodies before they were repatriated, and performing the last offices. The injuries the soldiers had suffered were horrific; as well as being shot multiple times, they had been attacked with machetes.

Later that same year, with the arrival of her first grandchild, Hilary returned home to civilian life, believing that she had coped with what she had witnessed. But in 2004, working as an occupational health nurse, she was called to attend to a seriously injured railway worker.

“I rolled up his sleeve to take his blood pressure, and saw a Celtic tattoo,” she recalls. “It was the same as one I had seen on the arm of a dead soldier. I was instantly transported back to Iraq. I could see the bodies and smell the cordite, the blood, the stench.”

Soon Hilary found herself reliving the horror “film” of that day in Iraq on a daily basis.

“It got to the point that I knew when the ‘film’ was starting to come – I would see one of the men’s faces – and do a bargain in my head that I would ‘watch’ it later. It was the only way I could do a day’s work. But as soon as I left work and got into my car, it would come. Sometimes it would last five minutes, sometimes hours. The ‘film’ would always end with my feelings of utter failure.

“One evening a policeman came to my car to ask if I was OK. It was about 1am – and I had been sitting there, outside the office, having a flashback since 6pm.

“I also developed rituals – I would go through the names of the dead soldiers every day and talk to them.”

Outwardly she was determined to carry on as usual. “I was ashamed and embarrassed,” she says. “I had been such a senior nurse and here I was weeping like a child. I was tormented by thoughts of why had I been given the dead to look after, not the living. Was I not a good enough nurse?”

Hilary, who is divorced with three grown-up sons and two granddaughters, adds: “Before Iraq I had been in a serious relationship, but that ended after I came back. I now understand that it broke down because of everything I had been through.”

Things came to a head in 2009 when Hilary, by now lead consultant nurse for a large insurance company, was on her way to work. “The next thing I knew I was sitting in the park opposite the station having a flashback and an acquaintance was asking me if I was all right.”

This time Hilary went to her GP. She was also assessed by a military liaison officer and diagnosed with severe PTSD. “The military were supportive in a way that they hadn’t been in 2003,” Hilary says. “Back then I had mentioned that I thought I wasn’t right, but was told to get a grip, that I would be fine once I got back to civvy street.”

But now she was quickly referred for EMDR with Dr Shirley Timpson, a clinical psychologist specialising in PTSD at Stafford Hospital.

“I had serious doubts, but my GP had told me that if I didn’t take it seriously, then he would say I couldn’t work with patients any more.

“I had to look at a bank of blue lights. Dr Timpson then darkened the room and a light would flash from left to right which I had to follow with my eyes as I recalled what had happened.”

Therapists can create a similar effect by waving their fingers from left to right, or by clicking their fingers alternating from ear to ear. Hilary adds: “We realised the trigger for the flashbacks was the face of one of the men, and so she took me back to that repeatedly, asking me what I had felt.

“Those early sessions were traumatic. Each lasted for an hour or two, and I would be exhausted afterwards. For a while the flashbacks got worse.

“But during the fourth session I was able to recall that day without feeling dread, panic, fear or anger. From that point, we concentrated on how I wanted to remember those events – as an experience I could learn from professionally. I started to feel I had done a good job, rather than an overwhelming sense of failure.”

It’s not known exactly how EMDR works, but the act of repeatedly moving the eyes from left to right is thought to help unblock the brain’s information-processing system, which experts believe becomes frozen as a result of mental trauma.

While EMDR – which was developed in the 1980s by Dr Francine Shapiro, an American psychologist – doesn’t make distressing memories go away, it often causes them to lose their power.

While clinical trials have demonstrated high success rates, critics say eye movement plays no part in its effectiveness and that the therapy is simply a means of desensitisation. But the therapy has influential supporters. William Yule, Emeritus Professor of Applied Child Psychology at King’s College London, uses it for patients with PTSD and was on the National Institute for Health and Clinical Excellence committee that first approved EMDR for use in PTSD in 2005.

“When I first heard about it, it seemed crazy, but there was interesting outcome data,” Professor Yule says. “I had quite amazing success with children suffering from psychological trauma. In one series of cases, nine out of 10 lost their symptoms after three sessions.

“Yes, it’s an effective treatment without an explanation – but it shouldn’t be dismissed because of that.”

By the end of Hilary’s nine sessions, the flashbacks had gone. She was a changed person. Now running her own occupational health company, she says her feelings towards Iraq have been transformed.

“I was able to recover happy memories of Iraq – the time one of the lads sourced me some of my favourite marmalade, the day we had a pretend wedding with mosquito nets. And how positive it was that I, an experienced nurse, was there on that day. It would have been unfair to ask a less experienced colleague to look after the bodies of those soldiers.

“Most importantly, it was a privilege to care for those men at the end of their lives.”

What is PTSD and how is it treated?

Post traumatic stress disorder (PTSD) is a psychological condition that can develop after witnessing or experiencing a distressing event. Triggers include military combat, losing a loved one, violent mental or physical assault, natural disasters and serious road accidents.

The symptoms, which sometimes occur years after the event, are varied, but usually include flashbacks or nightmares in which patients relive the trauma. Sufferers may be distracted, unable to sleep and feel isolated from friends and family. It can have an impact on personal relationships, employment and driving ability.

PTSD affects up to 30 per cent of people who have had a traumatic experience. It can occur at any stage of life, including childhood, and is present in one in every 20 men and one in every 10 women. Treatment options range from patient monitoring to medication, cognitive behavioural therapy and eye-movement desensitisation and reprocessing (EMDR). .

The Role of Eye Movement Desensitization and Reprocessing (EMDR) Therapy in Medicine – Francine Shapiro PHD

The Role of Eye Movement Desensitization and Reprocessing (EMDR) Therapy in Medicine: Addressing the Psychological and Physical Symptoms Stemming from Adverse Life Experiences

Background:

A substantial body of research shows that adverse life experiences contribute to both psychological and biomedical pathology. Eye movement desensitization and reprocessing (EMDR) therapy is an empirically validated treatment for trauma, including such negative life experiences as commonly present in medical practice. The positive therapeutic outcomes rapidly achieved without homework or detailed description of the disturbing event offer the medical community an efficient treatment approach with a wide range of applications.

Methods:

All randomized studies and significant clinical reports related to EMDR therapy for treating the experiential basis of both psychological and somatic disorders are reviewed. Also reviewed are the recent studies evaluating the eye movement component of the therapy, which has been posited to contribute to the rapid improvement attributable to EMDR treatment.

Results:

Twenty-four randomized controlled trials support the positive effects of EMDR therapy in the treatment of emotional trauma and other adverse life experiences relevant to clinical practice. Seven of 10 studies reported EMDR therapy to be more rapid and/or more effective than trauma-focused cognitive behavioral therapy. Twelve randomized studies of the eye movement component noted rapid decreases in negative emotions and/or vividness of disturbing images, with an additional 8 reporting a variety of other memory effects. Numerous other evaluations document that EMDR therapy provides relief from a variety of somatic complaints.

Conclusion:

EMDR therapy provides physicians and other clinicians with an efficient approach to address psychological and physiologic symptoms stemming from adverse life experiences. Clinicians should therefore evaluate patients for experiential contributors to clinical manifestations.

Introduction

Eye movement desensitization and reprocessing (EMDR)1 is an empirically validated psychotherapy approach that medical personnel can employ to treat the sequelae of psychological trauma and other negative life experiences. Its ability to rapidly treat unprocessed memories of these adverse experiences has important implications for the medical community, as they appear to be the foundation for an array of clinical symptoms. Clinical applications of EMDR include a wide variety of psychological problems affecting patients and family members, as well as stress-induced physical disorders and medically unexplained symptoms. The frequent ability of EMDR to bring about substantial improvement in short periods of time has relevance to major current problems in medical practice such as increasing patient load and the cost of medical care. The therapy procedures can be used by qualified medical personnel to improve comfort levels and functionality in managing some of their most difficult cases in everyday practice.

EMDR therapy was introduced in 1989 with the publication of a randomized controlled trial (RCT)2 evaluating its effects with trauma victims. The same year, the first RCTs on trauma-focused cognitive behavioral therapy (CBT) and psychodynamic therapy were published.3,4 In 2008, an Institute of Medicine report5 stated that more research was needed to determine the efficacy of EMDR, cognitive therapy, and pharmacotherapy in the treatment of posttraumatic stress disorder (PTSD); psychodynamic therapy and hypnotherapy were not considered because of the paucity of relevant evidence (one study each). However, since that time additional EMDR therapy RCTs with PTSD participants have been published, and this therapy is recommended as an effective treatment for trauma victims by numerous organizations, including the American Psychiatric Association,6 Department of Defense,7 and World Health Organization.8 Although meta-analyses report comparable effect sizes for CBT and EMDR therapy9,10 and both are considered “highly efficacious in reducing PTSD symptoms,”10p225 there are significant differences between the two treatments. As noted in the World Health Organization’s 2013 Guidelines for the Management of Conditions That Are Specifically Related to Stress,8 whereas both therapies are recommended for PTSD treatment in children, adolescents, and adults, “Like CBT with a trauma focus, EMDR therapy aims to reduce subjective distress and strengthen adaptive cognitions related to the traumatic event. Unlike CBT with a trauma focus, EMDR does not involve a) detailed descriptions of the event, b) direct challenging of beliefs, c) extended exposure, or d) homework.”8p1

Twenty-nine RCTs have evaluated EMDR therapy as a trauma treatment. Excluding 4 RCTs determined by the International Society for Traumatic Stress Practice Guidelines Taskforce11 to have provided insufficient treatment doses, fidelity, or both, the remaining 25 studies have created a strong knowledge base. Twenty-four RCTs support the use of EMDR therapy with a wide range of trauma populations (see meta-analyses cited above for a comprehensive listing of most studies and critiques). Seven of 10 RCTs have indicated that EMDR therapy is more rapid or otherwise superior to CBT,1219 and only 1 has reported superior effects for CBT on some measures.20 The latter is likewise the only RCT (of 25) to report a control condition superior to EMDR. Whereas the EMDR therapy involved only 8 standard sessions and no homework, the CBT treatment was vastly more complex and entailed 4 sessions of imaginal exposure (describing the trauma) and 4 sessions of therapist-assisted in vivo exposure (physically going to a disturbing location) plus approximately 50 hours of combined imaginal exposure and in vivo exposure homework. The EMDR therapy condition involved only 8 standard sessions and no homework. Of particular note with respect to general clinical practice is a study conducted at Kaiser Permanente21,22 that reported that 100% of single-trauma victims and 77% of multiple-trauma victims no longer had PTSD after a mean of six 50-minute EMDR therapy sessions, demonstrating a large and significant pretreatment versus posttreatment effect size (Cohen’s δ = 1.74). This is consistent with 2 other RCTs that found that 84% to 90% of single-trauma victims no longer had PTSD after three 90-minute EMDR sessions.2325 Most recently, a study funded by the National Institute of Mental Health evaluated the effects of 8 sessions of EMDR therapy compared to 8 weeks of treatment with fluoxetine.26 EMDR was superior for the amelioration of both PTSD symptoms and depression. Upon termination of therapy, the EMDR group continued to improve, whereas the fluoxetine participants who had reported as asymptomatic at posttest again became symptomatic. At follow-up, 91% of the EMDR group no longer had PTSD, compared with 72% in the fluoxetine group.

EMDR therapy is an eight-phase treatment approach composed of standardized protocols and procedures. The eight phases and three-pronged protocol facilitate a comprehensive evaluation of the clinical picture, client preparation, and processing of a) past events that set the foundation for pathology, b) current disturbing situations, and c) future challenges (Table 1).27

Table 1.

Overview of eight-phase eye movement desensitization and reprocessing (EMDR) therapy treatment27

Phase Purpose Procedures
History taking Obtain background information
Identify suitability for EMDR treatment
Identify processing targets from events in client’s life according to standardized three-pronged protocol
Standard history-taking questionnaires and diagnostic psychometrics
Review of selection criteria
Questions and techniques to identify 1) past events that have laid the groundwork for the pathology, 2) current triggers, and 3) future needs
Preparation Prepare appropriate clients for EMDR processing of targets Education regarding the symptom picture
Metaphors and techniques that foster stabilization and a sense of personal control
Assessment Access the target for EMDR processing by stimulating primary aspects of the memory Elicit the image, negative belief currently held, desired positive belief, current emotion, and physical sensation and baseline measures
Desensitization Process experiences toward an adaptive resolution (no distress) Standardized protocols incorporating eye movements (taps or tones) that allow the spontaneous emergence of insights, emotions, physical sensations, and other memories
Installation Increase connections to positive cognitive networks Enhance the validity of the desired positive belief and fully integrate the positive effects within the memory network
Body Scan Complete processing of any residual disturbance associated with the target Concentration on and processing of any residual physical sensations
Closure Ensure client stability at the completion of an EMDR session and between sessions Use of guided imagery or self-control techniques if needed
Briefing regarding expectations and behavioral reports between sessions
Reassessment Ensure maintenance of therapeutic outcomes and stability of client Evaluation of treatment effects
Evaluation of integration within larger social system

One of the components used during the reprocessing phases is composed of dual attention stimuli in the form of bilateral eye movements, taps, or tones. The eye movements have been the subject of great scrutiny and were called into question a decade ago by a meta-analysis28 of studies evaluating treatment effects with and without this component. However, guidelines published by the International Society for Traumatic Stress Studies11 indicated that no conclusions were possible because the studies evaluated in the meta-analyses were fatally flawed owing to the use of inappropriate populations, insufficient treatment doses, and lack of power. In contrast, since that time, 20 RCTs have indicated positive effects of the eye movement component. Twelve RCTs demonstrate an immediate decrease in arousal, negative emotions, and/or imagery vividness,29,30 and the remainder report additional memory effects, including increased attentional flexibility,31 memory retrieval,32 and recognition of true information.33 A recent meta-analysis34 has reported that significant outcomes are evident in both clinical studies, with a moderate effect size (Cohen’s δ = 0.41), and laboratory experiments, with a large effect size (Cohen’s δ = 0.74). Three dominant hypotheses regarding proposed mechanisms of action of EMDR therapy that have been supported by research3537 include that the eye movements a) tax working memory, b) elicit an orienting response, and c) link into the same processes that occur during rapid eye movement sleep.

Experiential Contributors to Pathology

EMDR therapy is guided by the adaptive information processing (AIP) model. Developed in the early 1990s,1 this concept posits that, except for symptoms caused by organic deficits, toxicity, or injury, the primary foundations of mental health disorders are unprocessed memories of earlier life experiences. It appears that the high level of arousal engendered by distressing life events causes them to be stored in memory with the original emotions, physical sensations, and beliefs. The flashbacks, nightmares, and intrusive thoughts of PTSD are prime examples of symptoms resulting from the triggering of these memories. However, as indicated in the AIP model, a wide range of adverse life experiences can also be stored in a dysfunctional manner, providing the basis for diverse symptomology that include negative affective, cognitive, and somatic responses. Sufficient processing of those accessed memories within the standard three-pronged EMDR therapy protocol brings about adaptive resolution and functioning. It is conjectured that processing the targeted experiences transfers them from implicit and episodic memory to explicit and semantic memory systems.1,38 The originally experienced negative emotions, physical sensations, and beliefs are altered as the targeted memory is integrated with more adaptive information. What is useful is learned and stored with appropriate affective, somatic, and cognitive concomitants. Consequently, the disturbing life experience becomes a source of strength and resilience.39

Support for the AIP tenets positing the primacy of life experiences to pathology comes from research showing that general life experiences (eg, relational problems, problems with study or work) can be the source of even more posttraumatic stress symptoms than major trauma.40 Hence, patients presenting with anxiety, depression, hypervigilance, frequent anger, etc, should be evaluated for adverse experiences contributing to current dysfunction. Two RCTs have demonstrated the effectiveness of EMDR therapy in treating distressing life experiences that do not meet the criteria for traumatic events in the diagnosis of PTSD.24,25,41 Both trials reported positive treatment effects within 3 sessions. One of the studies using a mixed sample24,25 reported comparable decreases in symptoms whether or not the participant met all criteria for PTSD. The 3 sessions of EMDR therapy resulted in an 84% remission of PTSD diagnosis with a large and significant pretreatment versus posttreatment effect size (Cohen’s δ = 1.69).

The ability of EMDR therapy to rapidly treat unprocessed memories of distressing life experiences has multiple applications in medical practice, as such memories have been identified as the basis for a wide variety of clinical symptoms. Research has revealed widespread mental health treatment implications. For instance, “Harsh physical punishment [ie, pushing, grabbing, shoving, slapping, hitting] in the absence of [more severe] child maltreatment is associated with mood disorders, anxiety disorders, substance abuse/dependence, and personality disorders in a general population sample.”42p1 Additional research demonstrates that “Exposure to adverse, stressful events … has been linked to socioemotional behavior problems and cognitive deficits.”43p270 These studies highlight the significance of carefully evaluating patients for a history of adverse life experiences. It is particularly important in the treatment of children to identify interpersonal experiences, including household dysfunction, bullying, and humiliation, that may be contributing to problems such as anxiety, lack of focus, angry outbursts, inattention, and impulsivity issues that might otherwise be incorrectly diagnosed as attention deficit hyperactivity disorder. A course of EMDR therapy treatment can be used to alleviate the effects of experiential contributors and to evaluate whether or not medication is actually needed. Reports of insomnia, nightmares, and night terrors should be similarly evaluated, as memory processing alone can improve the quality of sleep.

Although these studies have contributed greatly to our knowledge base, the most important research underscoring the importance of experiential contributors to both physical and mental health problems is the Adverse Childhood Experiences (ACE) Study. This study examined more than 17,000 adult members in the Kaiser Permanente Medical Care Program and “… found a strong dose-response relationship between the breadth of exposure to abuse or household dysfunction during childhood and multiple risk factors for several of the leading causes of death in adults.”47p251 The implications for combined medical and psychological treatment are relevant to both prevention and remediation. In this regard, the use of EMDR therapy to treat the patient and to identify the adverse life experiences that contribute to current symptoms, and processing the memories to an adaptive resolution, can significantly contribute to efficient clinical practice.

EMDR Therapy Approach

According to the AIP model, current experiences link into already established memory networks and can trigger the unprocessed emotions, physical sensations, and beliefs inherent in earlier-stored adverse life experiences. In this way, when the past becomes present and patients react in a dysfunctional manner, it is because their perceptions of current situations are colored by their unprocessed memories. The AIP conceptualization provides the basis for a comprehensive evaluation of the clinical picture, the targets selected for treatment, and the procedures used during reprocessing. Unlike CBT, which involves extended focused attention on the disturbing event, EMDR reprocessing sessions promote an associative process that clearly reveals the intricate connections of memories that are triggered by current life experiences. The transcript of a patient who requested treatment for PTSD following an earthquake  reveals the experiences of household dysfunction that set the foundation for her current symptoms (see Sidebar: Partial Transcript of EMDR Therapy Session, available online at: www.thepermanentejournal.org/files/Winter2014/EyeMovement.pdf). Note the spontaneous emergence of insight that ties together both past and present trauma, as well as the rapid change in affect and cognitive response. Also of note is the recognition of childhood feelings of powerlessness that provide the foundation for psychosomatic problems. Such rapid decline in subjective distress during a single EMDR therapy session has been reported in a number of RCTs. A short course of EMDR therapy has also been found to successfully treat cases of perceived neuropathy48 as well as stress-related dermatologic disorders such as atopic dermatitis, psoriasis, acne excoriee, and generalized urticaria.

Importantly, while CBT trauma treatments involve one to two hours of daily homework to achieve positive effects, EMDR therapy uses none. As reported in a controlled study funded by the National Institute of Mental Health, “An interesting potential clinical implication is that EMDR seemed to do equally well in the main despite less exposure [to the trauma memory] and no homework.”54p614 Rapidly attained treatment effects and the absence of homework make EMDR therapy highly amenable to physical rehabilitation services. An RCT with patients suffering from PTSD following a life-threatening cardiovascular event compared eight sessions of EMDR therapy to imaginal exposure therapy (which involves concentrating on the trauma memory and repeatedly describing it in detail).12 EMDR therapy resulted in greater reductions on all measures posttest, indicating a rapid decline in trauma symptoms, depression, and anxiety. Of note, significant improvement in trait anxiety was also reported and maintained. No such improvement was reported for imaginal exposure therapy. The authors reported that EMDR therapy was initially posited to be more “gentle” and therefore amenable for this debilitated population because “distancing” rather than reliving has been found to be correlated with treatment effects,55 and the eye movements used in EMDR appear to immediately cause parasympathetic activation, resulting in physiologic calming.34,56,57 Further, RCTs of initial treatment sessions indicate that the subjective distress of patients decreases with EMDR therapy, whereas it increases with exposure therapy.14,52

EMDR therapy was initially posited to be more “gentle” and therefore amenable for this debilitated population because “distancing” rather than reliving has been found to be correlated with treatment effects,55 and the eye movements used in EMDR appear to immediately cause parasympathetic activation, resulting in physiologic calming.

Rehabilitation services can benefit from EMDR therapy to support both patient and family members. The traumatic impact of dealing with life-threatening, incapacitating disease can be mitigated by incorporating relatively few memory-processing sessions to address distressing medical experiences, current situations, and fears of the future. As reported by Gattinara,58p170–1

“Using this approach in the field of neuromuscular disease is useful on three levels:

  1. It can facilitate the processing of the traumatic event in the patient and the whole family.
  2. It can rapidly reestablish a secure interpersonal context between the patient and his or her caregiver by reducing the high arousal level.
  3. It can transform the health service into a network of support for patient and family, offering help in managing the emotional vulnerability connected with physical vulnerability, thus buffering the adverse impact of worsening clinical conditions.”

In addition, because EMDR therapy requires no homework, it can be used on consecutive days, allowing rapid completion of treatment. The cost implications are obvious.

EMDR therapy can also be used to help support family members dealing with the death of a loved one. The results of both prolonged debilitation and sudden death can involve trauma symptoms that include distressing intrusive images of the suffering patient. The family member is often unable to retrieve positive memories of the deceased, which further exacerbates and complicates the grieving process.59 As indicated in a nonrandomized multisite study,60 EMDR therapy reduced symptoms significantly more rapidly than the CBT on behavioral measures and on 4 of 5 psychosocial measures. EMDR was more efficient, inducing change at an earlier stage and requiring fewer sessions (6.2 vs 10.7 sessions). Positive recall of the deceased was significantly greater (twice the frequency) posttreatment with EMDR.

A wide range of patients suffering from debilitating medical conditions can also benefit from EMDR therapy. For instance, the utility of psychological services for burn victims has been reported, with EMDR therapy specifically recommended on the basis of both effectiveness and brevity of treatment.61 As indicated previously, three to six sessions are generally sufficient to alleviate symptoms from a single trauma. Of particular note is the elimination of both PTSD and somatic symptoms in a burn victim who had been severely debilitated for almost a decade.62 The rapid alleviation of the patient’s symptoms and return to independent functioning are consistent with the AIP model, which posits that the feelings of helplessness and hopelessness are the result of unprocessed memories of the trauma that contain the perceptions experienced at the time of the event.1,48,49

These findings have important implications for the medical community in that many chronic pain patients may actually be debilitated by unprocessed memories encoded with the original somatic perceptions. As noted by Ray and Zbik,63 whereas CBT treatments address chronic pain through cognitive interventions that can reduce distress, EMDR therapy can result in the elimination of the pain sensations. For instance, a number of researchers have reported positive outcomes of EMDR therapy for the treatment of phantom limb pain. The 4 evaluations of patients published to date6467 indicate an aggregate 80% success rate as defined by complete elimination or substantial reduction of pain sensations. According to the AIP model, the phantom pain is caused by the unprocessed memory of the experience during which the limb was damaged. This unprocessed memory contains the physical sensations experienced at the time of the event. EMDR processing of the memory results in a simultaneous shift in emotions, physical sensations, and beliefs.1,49 Completed processing is posited to involve an alteration of the originally stored memory through a process of integration and reconsolidation.1,68 The change in the targeted memory results in an elimination of those pain sensations that are not caused by physical nerve damage. Successful elimination and/or reduction of pain to tolerable levels has been reported after 2 to 9 EMDR therapy sessions. Therefore, when no neuropathy is observed in chronic pain patients it is often beneficial to explore the potential results of a short course of memory processing.69,70 In addition, EMDR therapy has been reported to be beneficial in the treatment of migraine headaches in an open trial71 and an RCT.72

Potential Neurobiologic Concomitants

The different treatment outcomes and the procedural differences between EMDR therapy and CBT indicate potentially diverse underlying neurobiologic mechanisms. For instance, trauma-focused CBT exposure therapies entail extended, detailed repetitions of the disturbing event that are repeated during both sessions and homework. Research has indicated that prolonged exposures, as used in CBT, result in extinction, whereas brief exposures as used in EMDR therapy trigger memory reconsolidation.73 These differences have significant neurobiologic and clinical implications. As noted by Craske et al,74p6 “… recent work on extinction and reinstatement … suggests that extinction does not eliminate or replace previous associations, but rather results in new learning that competes with the old information.” This mechanism is posited to account for relapse. Further, “Extinction is conceptualized as the development of a second context-specific inhibitory association that, in contrast to fear acquisition, does not easily generalize to new contexts.”74p12 These factors may account for differences in treatment time, with EMDR therapy reported to be more rapid than CBT in five RCTs,1315,1719 as well as reported positive effects obtained with EMDR treatment that have not been reported with CBT (eg, elimination of phantom limb pain, increased positive recall of the deceased). The fact that CBT exposure therapies are posited to leave the original memory intact may be the reason these beneficial results have not been reported with CBT. Likewise, a recent pilot study indicated that six sessions of EMDR therapy with patients with psychosis and PTSD also resulted in “a positive effect on auditory verbal hallucinations, delusions, anxiety symptoms, depression symptoms, and self-esteem.”75p664 By contrast, successful CBT has resulted in a continuation of auditory hallucinations that the patient experiences, but with less distress. In the EMDR study, the majority of participants who had initially experienced auditory hallucinations reported that these had disappeared. The findings that “ … childhood adversity is strongly associated with increased risk for psychosis”76p2 suggest the need for additional rigorous research evaluating the effects of memory processing with this population.

Future Research

The ACE Study47 conducted at Kaiser Permanente provides an ideal platform for future research to evaluate the effects of EMDR therapy for a wide range of psychological and physical problems pertinent to medical practice. Some of the conditions found in the ACE Study to be correlated with exposure to adverse life experiences in childhood are alcoholism, drug abuse, severe obesity, depression, and suicide attempts. These conditions would lend themselves well to rigorous RCTs in which integrated EMDR therapy protocols that include processing the disturbing memories are compared to current standard care. Both immediate and long-term follow-up of at least a year’s duration to evaluate maintenance of treatment gains would greatly inform current medical practices.

Of equal importance is the finding in the ACE Study that ACEs result in the increased incidence of physically debilitating conditions such as ischemic heart disease, cancer, chronic lung disease, skeletal fractures, and liver disease. Rigorous longitudinal studies to evaluate the utility of EMDR therapy for preventive care would provide the medical community an important opportunity to determine whether processing the memories of adverse experiences can ameliorate these detrimental effects. The social policy and financial implications of such studies underscore their importance in providing optimal care.

For any of the suggested studies, it is vital that clinical personnel with appropriate treatment fidelity carefully assess the nature of the disturbing events in the patient’s history and allocate adequate treatment time to process a sufficient number of memories to potentially achieve asymptomatic status. As reported in the ACE Study,47 there is a “strong graded relationship between the breadth of exposure to abuse or household dysfunction during childhood and multiple risk factors for several of the leading causes of death in adults.”47p245 As indicated previously, a short course of EMDR therapy may be sufficient to eliminate a variety of psychological and somatic conditions. However, patients who have been serially abused throughout childhood will generally need more treatment time to achieve comprehensive adaptive resolution.1,50 Given that EMDR treatment effects generalize to similar memories, it is unnecessary to process each disturbing event. However, sufficient time should be provided to process the relevant memories within the various categories of adverse experiences.

For all the suggested studies, the inclusion of procedures to identify epigenetic and neurophysiologic changes subsequent to treatment also opens the door to potentially important assessment possibilities. Since EMDR therapy can be provided on consecutive days, successful treatment can be accomplished over a matter of weeks, rather than months, which can reduce time confounds and provides both efficient and cost-effective research opportunities.

Conclusions

A substantial amount of research indicates that adverse life experiences may be the basis for a wide range of psychological and physiologic symptoms. EMDR therapy research has shown that processing memories of such experiences results in the rapid amelioration of negative emotions, beliefs, and physical sensations. Reports have indicated potential applications for patients with stress-related disorders, as well as those suffering from a wide range of physical conditions. The medical community can also benefit from the use of EMDR therapy for prevention and rehabilitative services to support both patients and family members. A thorough assessment of potential experiential contributors can be beneficial. If relevant, EMDR therapy can allow medical personnel to quickly determine the degree to which distressing experiences are a contributing factor and to efficiently address the problem through memory processing that can help facilitate both psychological and physical resolution. Rigorous research of the use of EMDR therapy with patients suffering from the conditions identified in the ACE Study can further contribute to our understanding of the potential for both remediation and preventive care.

The hardest battle: my fight to defeat Post Traumatic Stress Disorder (EMDR) – Mark Evans The Daily Telegraph 3 March 2015

he hardest battle: my fight to defeat Post Traumatic Stress Disorder

In 2008, Mark Evans witness the horrors of war in Afghanistan, which left him suffering from PTSD. Here he describes his long road to recovery

Mark Evans: ‘PTSD and war walk hand in hand’ Photo: Mark Evans

As the wiry IRA man leant over to hold a spatula of lavender oil to my nose, he joked how only a few years ago he’d have been offering me a far more “permanent” solution to my insomnia.

It was 2010, I was 32 and a serving officer in the Coldstream Guards. Two weeks before, I had been working at my desk in Aldershot, but now I was in The Priory, taking aromatherapy classes with Michael, another ‘soldier’ who was finding life hard.

My life had taken a strange turn, but on reflection it was obvious what had happened.

Mark Evans in Afghanistan

In 2008 I had been in Helmand Province, Afghanistan, fighting the Taliban. I had seen my share of horror and violence and on my return I had developed PTSD (Post Traumatic Stress Disorder). I was broken and needed mending. I needed therapy.

PTSD and war walk hand in hand. Stress is a natural product of danger. We survive by becoming hyper-vigilant, hyper-aware, ready for action. But once danger passes stress subsides – it might take time but it does. Unless you have PTSD, that is, when it builds up and up until it bursts.

PTSD can be treated, however, as I can testify. For me, that process started with talking, or “opening up”. I vividly remember confessing all to an army doctor. The appointment wasn’t voluntary and as I broke down, overwhelmed by relief and fear, I also felt ashamed that I needed help. I was a soldier, strong and brave, with no idea that my reluctance to seek help was one of the common problems facing military personnel returning from war.

Psychotherapy (talking therapy) came first. If a problem shared is a problem halved, then sharing with a trained professional should be even more effective. But it relies on establishing a one-to-one relationship and that doesn’t always happen. The first therapist I saw was an army psychiatric nurse who I couldn’t open up to at all. I saw him as part of the problem, not the solution.

Next was Christina who had no idea about the military and we found some success because I felt she wouldn’t judge me. Finally, I needed Andy, who had seen war himself, to find resolution, four years after I’d started talking.

CBT (Cognitive Behavioural Therapy) was also applied. The use of more than one technique is commonplace, which says as much about there not being an elixir as it does about the complexity of the condition. CBT teaches plans and techniques to alter harmful ingrained behaviour – you see the cookie jar but you choose to put your hand back in your pocket.

It has some very good results but requires a base level of willingness to change. As much as I wanted to get better, I had become attached to my PTSD and Afghan memories. They defined me and had perversely become my norm. I was experiencing a phenomenon often associated with battered person syndrome. I was finding comfort and stability in my damaging mental state.

“Alternative”, non- scientific approaches, when used, tend to be in conjunction with “traditional” western methods. Aromatherapy isn’t a cure on its own, but does help support change – lavender oil, for instance, did help me sleep. It also helps explain the important phenomena known as triggers – the sights, sounds and smells that are part of normal life but which remind us of our past and can send us back in time in an instant.

Mark Evans today

Loud bangs reminded me of mortars or gunfire and the smell of bitumen reminded me of being blown up by a landmine. Walking past building sites or roadworks, I relived that traumatic experience so vividly it would become a traumatic experience in itself.

EMDR (Eye Movement Desensitisation and Reprocessing) finally solved that problem for me. A form of hypnosis, it helps reroute your memories. Instead of thinking bad thoughts you think good ones in their place. It sounds incredible, and is, but it took me almost two years to agree to try it because I was afraid of being “brainwashed”. I tried it once and immediately wanted more. I still had PTSD, but one of the layers had been removed.

Drama therapy was another. It works by “doing not thinking” and encourages you to experience emotions in a safe environment, then let them go. With PTSD you hold onto your emotions (anger, guilt, fear) and get caught up in them 24/7. Living like that day after day is terrifying and unbearably painful and why so many sufferers reach for alcohol, drugs, even suicide – anything to escape. Therapy of any kind is often too hard to come to.

Yoga and mediation now form part of my daily routine. I enjoy yoga as a physical exercise, but it is meditation that has really been life-changing. It’s not all sitting crossed legged. Staring at a wall and concentrating on a simple task can keep the mind calm by stopping it going off on tangents, such as thinking about people dying in Afghanistan.

These days I work for Operation Nightingale, an MoD backed project that take soldiers with PTSD on archaeological excavations. Digging in the dirt with a trowel can be mediative and an incredibly successful aid to recovery.

And lets not forget medication. I do yoga, but I also take pills daily. Not as a crutch or a cop-out, but as an important part of the mix that has got me to where I am today.

So PTSD can be fixed, but each case is different and requires individual treatment. What works for one might not for another and what works one day might not a week later. Not every therapy is readily available – there might not be a local practitioner or it might be too expensive.

Of course, you have to spot PTSD in the first place. It took 18 months and acts of self-harm before people finally noticed I was ill. I remember feeling ‘different’, but I couldn’t do anything about it by myself. PTSD, like many other mental health illnesses, is insular and introspective and for the sufferers it quickly becomes their “normal”. You need help to get out. But all too often no one knows what to do, until it is too late.

Mel B is watching flashing lights to help with trauma. But does EMDR therapy really work? (Emine Saner The Guardian 10 Sept 2018)

Mel B is watching flashing lights to help with trauma. But does EMDR therapy really work?

The singer is trying it, and while it was once controversial, it now has NHS approval. What is Eye Movement Desensitisation and Reprocessing, and how does it compare to CBT?

Illustration of eyes
Illustration: Guardian Design Team

In late 2016, Ben had a breakdown, triggered by someone getting too close to him on a crowded train. It brought on vivid flashbacks of a severe childhood trauma 30 years ago. Until then he had lived a successful life – he had done well at school, had a good career and was married with a family. Referred to a trauma clinic at his local hospital, Ben started a psychotherapy treatment, Eye Movement Desensitisation and Reprocessing (EMDR) earlier this year. It sounded, he says: “like witchcraft. How can this possibly work? They sit you in front of flashing lights and it makes you better? It sounds like alchemy.”

EMDR was recently highlighted by the pop singer Mel B, who is said to be undergoing the therapy for post-traumatic stress disorder (PTSD). Talking about her diagnosis, a condition she had been using sex and alcohol to self-treat, she said: “I am still struggling but if I can shine a light on the issue of pain, PTSD and the things men and women do to mask it, I will do”. Of the EMDR, she said: “So far, it’s really helping me.”

EMDR works, says Robin Logie, clinical psychologist and former president of the EMDR Association, by helping the brain to process traumatic memories – it is mainly used as a treatment for PTSD, but can be used for depression, anxiety, addiction and phobias. “The way we do that is to get the person to think about a particular moment. For example, with a road traffic accident – it could be the moment just before you’re hit. We ask them to describe what negative belief they have about themselves.” It could be something like: ‘I’m not safe.’” We ask what emotion seems to go with that and where they feel it in their body.”

While the person is doing all this, they are asked to move their eyes from side to side – this could be by following the therapist’s finger, or following flashing lights. It can also be done by holding a device in each hand, which pulses alternately. Each set could be repeated 20 or 30 times in each session. “The memory starts to become less distressing,” he says. “It transforms it from a memory that previously made you feel anxious or scared, into a memory that is like any other that wouldn’t normally produce an emotional response. People start to be more rational about it: ‘I wasn’t in a safe situation then, but I’m safe now.’”

In the early stages of treatment, says Ben: “It was like being in the event. It’s like a kind of time travel. The whole EMDR process is like a controlled flashback – you’re aware that you’re here and now, but you also feel like you’re in the body from then and re-experiencing as then. I was not prepared for the physical, visceral nature of reliving the experience. I would be seeing things, smelling things. I felt this pressure across my front and it was unnerving.”

He says he felt like a ventriloquist’s dummy “because the words I was using to describe [my experiences] were children’s words. It was like the child, the person who experienced the trauma, was using me as a mouthpiece.”

As the treatment went on, the memories became more and more vivid and detailed. It has, unsurprisingly, been a difficult process to go through, and Ben’s mental health seemed to get worse before it started to get better. He is still going through treatment. “It’s a process I have found genuinely transformative,” he says.

EMDR was discovered by accident in the late 80s by an American psychologist, Francine Shapiro, who noticed that her eye movements, while looking at things on a walk through a park, appeared to reduce negative emotions. It used to be considered controversial but that is now an outdated view, says Melanie Temple, consultant psychiatrist and EMDR consultant (it is approved for use by the National Institute for Health and Care Excellence).

One of the problems for EMDR is that nobody can explain exactly how it works – one theory is that the eye movements mimic the rapid-eye-movement phase of sleep, which is when the day’s events are processed. “We understand it works on the information-processing models within the brain, but we don’t know exactly how,” says Temple. “But then we don’t know exactly how cognitive behavioural therapy (CBT) works. It’s really the same for all therapies.”

Not everyone is ready for EMDR. “If someone has had a simple one-off trauma, such as an accident, in their adult life, you don’t need to do a lot of preparation, but we also work with people who have multiple traumas going back to early childhood,” says Logie. “With people like that you have to do more preparation and the therapy will last longer.” Preparing someone to undergo EMDR can include teaching them relaxation techniques, and strengthening the support structures in their lives.

If not properly used, says Claudia Herbert, clinical psychologist and managing director of the Oxford Development Centre and author of Overcoming Traumatic Stress: “Any type of therapy can be re-traumatising. It has to be used by someone who is properly trained and experienced to know when to use it and not to use it.” It wouldn’t be used with someone who was dissociated – one symptom of PTSD – where they are not “grounded” in their body, or feel disoriented. “We would have to work with the dissociation first before we work with EMDR.”

For Katherine Gilmartin, an artist and family mental health activist, diagnosed with complex PTSD as a result of childhood abuse, EMDR couldn’t begin immediately. “I was asked to think of somewhere I’d felt safe in the past. There was nothing,” she says. “So I had to make one.” She says EMDR, which she had once a week for more than six months, was “physically exhausting. The heightened experience of being in those traumatic memories whirls everything up and nightmares occur.”

Was it difficult to go through? “Yes, but I felt in control [when] ordinarily I didn’t feel in control. It is hard work and [you have to be] open to it. It’s not a fix-all and you have to trust the person you are doing it with.” For her, it has made an improvement. “Different places, or really silly things, which could be quite triggering are no longer a problem. I’m able to recognise and understand my feelings around whatever the thing is.” These tend to be things she recognises from childhood – once, she was in a department store and saw a houseplant she hadn’t seen for decades. “I was taken right back to being 10. I couldn’t be anywhere near it and I walked out of the shop.” That sort of thing, she says, wouldn’t happen now.

Temple used to work for the military where EMDR is a standard therapy for people suffering PTSD; she now practises it for the NHS. Where EMDR may have the edge, she says, is that it: “Suits a lot of people because unlike CBT [which is also offered as treatment for trauma], it doesn’t have homework. EMDR is very well-established now [and is] equally offered alongside trauma-focused CBT because one size doesn’t fit all. If one doesn’t suit them, then they can use something different, so they don’t feel that they’re not treatable.”

Although it can be powerful and effective, people shouldn’t expect a magical quick fix, she says. Ben has had more than 30 sessions and does not know when he will stop. “It’s had a hugely beneficial effect,” he says. Although the two or three days after each session are, he says, a “write-off”, he has been able to go back to work part-time. “I have moved from being this ventriloquist’s dummy for the child inside, to being an adult looking at what was happening; being really sad and upset and angry about it, but having a natural emotional reaction, rather than feeling the distress of it happening to me.”