17 th June 2008 Defence Mental Health Conference The use of EMDR in Military Operational Environments

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

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

17 th June 2008 Defence Mental Health Conference Use of EMDR with military populations across the world Documented use of EMDR in: Documented use of EMDR in: Germany Germany Israel Israel Turkey Turkey UK UK USA USA

17 th June 2008 Defence Mental Health Conference 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 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 EMDRIA has Military Special Interest Group chaired by US Navy Commander Beverly Dexter

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

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

17 th June 2008 Defence Mental Health Conference 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) 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 4 combat veterans treated with 1 session of EMDR in Rota (Spain) prior to onward evacuation to US

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

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

17 th June 2008 Defence Mental Health Conference Presenting Problems Re-experiencing Re-experiencing NightmaresNightmares Intrusive thoughts/images/smellsIntrusive thoughts/images/smells Arousal Arousal Poor sleepPoor sleep >Anger/irritability/worry>Anger/irritability/worry <concentration<concentration TearfulTearful Avoidance Avoidance Anxious about going back but ‘couldn’t let mates down’Anxious about going back but ‘couldn’t let mates down’

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

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

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

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

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

17 th June 2008 Defence Mental Health Conference 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. 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. 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)

17 th June 2008 Defence Mental Health Conference 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. 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. 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) (Guidance for the use of psychotherapy in operational theatres)

17 th June 2008 Defence Mental Health Conference 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, or video. 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, 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. 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)

17 th June 2008 Defence Mental Health Conference Summary EMDR increasingly being adopted by several nations for use with their military both in and out of theatre 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 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 Policies and procedures now being adapted to include provision of EMDR in operational theatres