The use of EMDR in Military Operational Environments

1. The use of EMDR in Military Operational Environments Defence Mental Health Conference 2008

2. Overview • EMDR with Military Populations • Appropriateness and utility • Use of EMDR with military personnel across the world • Studies on the use of EMDR with military populations • A case study • Policy and procedure for the use of EMDR with the UK military Defence Mental Health Conference 2008

3. Appropriateness & Utility • Quick • Low-tech • Portable • Effective • Proven for use with trauma • Extensive use in military populations and veterans Defence Mental Health Conference 2008

4. Use of EMDR with military populations across the world • Documented use of EMDR in: • Germany • Israel • Turkey • UK • USA Defence Mental Health Conference 2008

5. EMDR in US Military • In 2004 US Department of Defense (DoD) and Veterans’ Administration (VA) endorses EMDR as treatment of choice for combat-related PTSD • EMDRIA has Military Special Interest Group chaired by US Navy Commander Beverly Dexter Defence Mental Health Conference 2008

6. Russell • One of leading proponents of EMDR with US military is Commander Mark Russell (US Navy) • Clinical Psychologist at Naval Hospital Bremerton • EMDR Consultant and Trainer Defence Mental Health Conference 2008

7. Russell (continued) • “Providers are looking for … options … that may provide rapid, lasting, effects” • “2-6 sessions of EMDR would be the range, 2-3 would be the average (compared to the normal 12-15 sessions)” • The ability not to verbalise fits well with the “warrior mentality” Defence Mental Health Conference 2008

8. Russell (Continued) • Russell M (2006) Treating combat-related stress disorders: a multiple case study utilizing EMDR with battlefield casualties from the Iraqi War (Military Psychology, 18 (1) 1-18) • 4 combat veterans treated with 1 session of EMDR in Rota (Spain) prior to onward evacuation to US Defence Mental Health Conference 2008

9. Hacker Hughes (2002) • Case series • 50 cases (25 Army, 23 RAF, 2 Veterans) • Anxiety 9, CSA/Rape 9, Combat 9, Phobia 5, RTA 5, Training 5, Other 10 • Sig improvements after ave 4 sessions on BAI, BDI, GHQ, IES, PDS Defence Mental Health Conference 2008

10. Case StudyIntroduction of the Case • 27 yr old male soldier • 5 days post incident in Afghanistan • Deliver 1st Aid to land mine victim/colleague • Colleague later died on way to hospital • Presented via unit Padre Defence Mental Health Conference 2008

11. Presenting Problems • Re-experiencing • Nightmares • Intrusive thoughts/images/smells • Arousal • Poor sleep • >Anger/irritability/worry • <concentration • Tearful • Avoidance • Anxious about going back but ‘couldn’t let mates down’ Defence Mental Health Conference 2008

12. Client Hx • Single, British, Caucasian • No PPH • Stable home life and childhood • Soldier for 7 years • Deployed to Iraq previously with no problems • In theatre 7/12 – no problems • Bomb disposal and team medic • Good social network and supportive management Defence Mental Health Conference 2008

13. Assessment • Full MH assessment 5 days post • Monitored over next 10 days • ‘watchful waiting’ – Normalise/Educate • Motivated for treatment • Safe place used to good effect Defence Mental Health Conference 2008

14. Case conceptualization • Unable to process trauma due to high levels of horror during event and helplessness about ability to save injured colleague • Poor sleep and re-experiencing maintaining poor coping and general helplessness • Shame about his symptoms means he was reluctant to discuss openly with others Defence Mental Health Conference 2008

15. Course of Rx • Session 1 • Targeted image • NC I’m weak’. PC ‘I’m strong’. VoC 3 • SUDs 6 • Lots of processing (EMs) • No SUDs reduction • Session 2 • next day. No SUD / symptom reduction. • More processing / new insights • Session 3 • marked improvement. SUDs reduced to 0 and VoC to 7. Other PCs • Session 4 • SUDs remain 0 & VoC 7 • 2 R/Vs over next 1/12 • Further improvements in functioning & sleep • Volunteered for front line duties. Positive ++ Defence Mental Health Conference 2008

16. Treatment Implications • Positive outcome • If continued ‘watchful waiting’ • More time in reduced role (reinforce helplessness) • ? Sending back to UK • Negative effects: Client, Unit, FMHT • Delay in Rx • ? Development of PTSD Defence Mental Health Conference 2008

17. Current UK Practice • Introductory (Level I) Training in EMDR provides the clinician with a basic understanding of EMDR together with an introduction to its use with clearly defined single traumatic incidents. Level II is an intermediate stage of training and the completion of Level III Training confers the appropriate degree of skill and competence to use EMDR in the context of an operational theatre. • It is therefore the aspiration that only Level III trained clinicians use EMDR in an operational context. However, whilst Defence Mental Health Services is increasing the number of appropriately trained EMDR practitioners, it is feasible for Level II practitioners to treat selected cases with appropriate supervision. (Guidance for the use of psychotherapy in operational theatres) Defence Mental Health Conference 2008

18. Current UK Practice • It is recommended that EMDR-based therapy in particular, and, if possible, all psychotherapy, should be delivered in a suitably quiet location away from a directly threatening environment. • As with any psychotherapy, the practitioner should confirm, at the end of a session, that there has been no impairment in attention and concentration that would preclude the individual from returning to their duties although if possible one night’s rest away from the base location is desirable. The clinician should use his/her generic skills to make this assessment. In EMDR, however, the prime indicator will probably be the relative decrement in Subjective Units of Distress (SUDs) and the Validity of Cognition (VoC) ratings achieved during the session. (Guidance for the use of psychotherapy in operational theatres) Defence Mental Health Conference 2008

19. Supervision • Any clinician practising CBT or EMDR in theatre must have made arrangements for their supervision before deploying to theatre. Supervision may be carried out with UK-based supervisors and may be conducted, with suitable safeguards regarding client confidentiality, via telephone, email or video. • In the case of CBT, supervision must be conducted by an accredited behavioural or cognitive-behavioural psychotherapist and ideally with someone who is either an accredited supervisor or who has completed training in clinical supervision. In the case of EMDR supervision must be conducted by an EMDR consultant. (Guidance for the use of psychotherapy in operational theatres) Defence Mental Health Conference 2008

20. Summary • EMDR increasingly being adopted by several nations for use with their military both in and out of theatre • Studies being produced demonstrating effectiveness of EMDR with combat veterans as illustrated by case study • Policies and procedures now being adapted to include provision of EMDR in operational theatres Defence Mental Health Conference 2008