Utilizing EMDR as the Primary Modality To Treat Veteran PTSD in a Community Based Program
This paper describes a community based, free mental health program, founded with the mission to decrease veteran suicide, and overcome barriers to care, especially stigma. PTSD is a significant risk factor for suicidal ideation among both the general and veteran population.
As of February 2021, the program, has provided 68,718 clinical sessions to 2060 veterans with PTSD in 26 cities. EMDR, one of 3 evidence-based treatments (EBT) for PTSD endorsed by the Veterans Affairs Health Administration, has only recently become available at the VA and is still not available at many VA mental health centers. Numerous distinct benefits of EMDR relative to the other 2 PTSD EBT’s, Cognitive Processing Therapy (CPT) and Prolonged Exposure (PE), in this population are described. This program utilizes EMDR as the primary treatment modality for treating veteran PTSD, the only such program for veterans of its kind. Over 90% of the veterans receive EMDR during their treatment. The experience of the program has led to the development of veteran specific adaptations to the first four of eight EMDR phases. The program has been highly successful as measured by suicide rate, treatment retention, symptom improvement, and client satisfaction.
Key Words (4-6): PTSD, veteran, suicide, EMDR, EMDR phases, barriers to care, outcome
Based on 2017 data, the most recent available, 17 veterans die by suicide each day, about 1.5 times higher than non-veteran adults, after adjusting for population differences in age and sex. See Table 1. (USDVA, 2019 September) There were 6,139 veteran suicide deaths in 2017, which is up 129 from the previous year, even as the total veteran population declined. Between 2005 and 2017, 78,875 veterans took their own lives. This number does not include active duty, National Guard, or Reserve military personnel. Deaths by suicide among former members of the National Guard and Reserve, have risen consistently since 2005. The number of military personnel and veterans who died by suicide is more than fifteen times the number of post 9/11 military casualties, and more than the number of Americans killed in each major conflict except for World War II and the Civil War. (USDOD, 2020, June 15)
Numerous barriers to mental health care contribute to the high suicide rate among veterans. A 2008 survey of 1,965 individuals previously deployed for OEF/OIF, (Schell & Marshall, 2008) found that nearly half (47%) of those surveyed with probable PTSD or major depression had not received any mental health care in the previous year, and only 30% of those who had initially sought care reported receiving a minimally adequate amount of care, with many dropping out of treatment prematurely. (Najavits, 2015) (Hoge et al., 2004; Hoge et al., 2014)
At VA health centers, Veterans may experience:
inadequate availability of appointments, especially for individual sessions (vs. group sessions),
difficulty getting through on the phone, or getting calls returned
mental health treatment provided by trainees or providers that rotate to other facilities.
mental health providers with inadequate training in evidence-based psychotherapies and care tailored to Veterans (RAND, 2019)
variability in use of evidence-based treatments. (RAND, 2019)
emphasis on medication treatments that Veterans may find objectionable
Other barriers to care include:
stigma: both public stigma and self stigma (Greene-Shortridge, Britt, & Castro, 2007)
lack of confidence in the system
skepticism about the effectiveness of treatment
concerns about the negative side effects of medication
transportation problems or long distances to the nearest VA center
ineligibility for care due to other than an honorable discharge (That restriction was eased by legislation passed in 2018, but Veterans with dishonorable discharges are still ineligible.)
Higher percentages of perceived barriers and stigma were found in a 2003 survey of 6,153 active military personnel. (Hoge et al., 2004) These findings have been replicated in smaller surveys of military personnel and veterans. (Cheney et al., 2018) (Mittal et al., 2013) (Fox, Meyer, & Vogt, 2015)
PTSD is a significant risk factor for suicidal ideation among the general population (Oquendo et al., 2005) and OEF/OIF veterans; the odds of endorsing suicidal ideation was four times higher among veterans screening positive for PTSD relative to veterans with negative PTSD screens. (Jakupcak et al., 2009) PTSD occurs at a higher rate among veterans and military service members, 23%, than representative samples of U.S. civilian adults, 7-8%. (Fulton et al., 2015) Evidence-based treatment of PTSD can improve suicidal ideation. (Cox et al., 2016) (Gradus, Suvak, Wisco, Marx, & Resick, 2013)
Complex PTSD, (C-PTSD) first described by Herman, (Herman, 1992) incorporates PTSD symptoms as a core component and is caused by exposure to sustained, repeated, or multiple forms of traumatic exposure, typically, prolonged interpersonal trauma with multiple forms of childhood interpersonal trauma. Individuals with C-PTSD have significantly higher levels of dissociative experiences and significantly greater functional impairment compared to those with PTSD. (Cloitre et al., 2009)
This diagnosis was included in the ICD-11 (International Classification of Diseases), published June 18, 2018, and will come into effect January 2022. (WHO, 2018, June 18) ICD-11 defines C-PTSD as the presence of PTSD plus at least one symptom in each of three C-PTSD symptom clusters: affect dysregulation, negative self-concept, and interpersonal disturbances. C-PTSD is not included in DSM-V.
Veterans with complex PTSD
The VA literature documents the presence of C-PTSD, (USDVA, 2020, January 31) although they provide no statistics regarding the prevalence in the veteran or active duty population. Among veterans with PTSD, two surveys found an 81% (Letica-Crepulja et al., 2020) and 91% (Clancy et al., 2006) prevalence of C-PTSD.
The United States military has not had a draft since 1972; all serving members since that time enlist voluntarily. (Selective Service System, n.d.) This may contribute to the high incidence of C-PTSD in this population. Many people choose military service because of national pride, a family history of service, and/or opportunities for personal and professional enhancement; others might seek stability that was previously absent in their life.
A survey of 126,000 OEF/OIF veterans receiving care from the VA before 2006 showed 15% of women, and 0.7% of men reported military sexual trauma. (Kimerling et al., 2010) Military sexual trauma was associated with significantly increased odds of a mental disorder diagnosis, including posttraumatic stress disorder, other anxiety disorders, depression, and substance use disorders and frequently present with substantial mental health treatment needs.
Dissociation is defined in the DSM as a disruption of the usually integrated functions of consciousness, memory, identity, or perception of environment. Symptoms of dissociation are not a necessary criterion for diagnosis in PTSD, but many individuals with PTSD report dissociative experiences. Presence of a dissociative disorder in psychiatric patients is strongly associated with all measures of self-harm and suicidality. One study of 130 male veterans hospitalized with PTSD showed that veterans with more severe PTSD had higher degrees of dissociation. (Nejad & Farahati, 2007)
The high incidence of drug and alcohol use to self-medicate symptoms of PTSD is well documented, (Leeies, Pagura, Sareen, & Bolton, 2010) as is the strong association between substance use and suicidal behavior. (Borges, Walters, & Kessler, 2000) (Cherpitel, Borges, & Wilcox, 2004) (Ilgen, Burnette, et al., 2010) (Goodin et al., 2019) Three large scale surveys describe the higher risk of SUD among veterans, than the general population (Pemberton, 2016, Nov).(Jacobson et al., 2008) (Shen, Arkes, & Williams, 2012)
Numerous studies support the finding that Veterans have a higher prevalence of diagnosable mental illness, including depression, than the non-veteran population (Pemberton, 2016, Nov) and that deployed personnel have higher prevalence than non-deployed personnel. (Shen et al., 2012) In a study of 3,291,891 Veterans who used Veterans Health Administration services, men with depression were 2.6 times more likely to die by suicide than men without that diagnosis; women with depression were 5.2 times more likely to die by suicide. (Ilgen, Bohnert, et al., 2010) Another large scale study delineates the demographics of suicide risk among veterans with depression. (Zivin et al., 2007)
Rates of anxiety disorders are increased in veterans even if they do not have PTSD. (Black, 2004) Depressed veterans with comorbid anxiety have higher risks of suicide deaths than those without anxiety diagnoses. In a study of 887,859 VA patient with depression, the odds of completed suicide were significantly increased for patients with panic disorder, generalized anxiety disorder, and anxiety disorder, not otherwise specified. (Pfeiffer, Ganoczy, Ilgen, Zivin, & Valenstein, 2009)
A history of Traumatic Brain Injury (TBI) is associated with increased risk for suicidal ideation (Gradus et al., 2015) (Shura et al., 2019) and death by suicide (Bahraini, Simpson, Brenner, Hoffberg, & Schneider, 2013; Brenner, Ignacio, & Blow, 2011). “The Department of Defense … estimate that 22% of all combat casualties from (post 9/11) conflicts are brain injuries, compared to 12% of Vietnam related combat casualties. 60% to 80% of soldiers who have other blast injuries may also have traumatic brain injuries.” (Summerall, 2019, Oct. 14)
According to the U.S. Department of Veteran Affairs National center for PTSD, (USDVA, 2020, January 7) the three trauma-focused psychotherapies with the strongest evidence are Prolonged Exposure (PE) (Foa EB, 2007), Cognitive Processing Therapy (CPT), (Resick, 2008), and Eye Movement Desensitization and Reprocessing (EMDR). (Shapiro, 2001) Other PTSD treatments recognized by the VA include specific cognitive behavioral therapies (CBTs) for PTSD, Narrative Exposure Therapy (NET), Written Narrative Exposure, and Brief Eclectic Psychotherapy (BEP). Three non-trauma-focused therapies are recommended by the VA for treatment of PTSD when veterans have difficulty focusing directly on the trauma: Stress Inoculation Training (SIT), (Jackson, Baity, Bobb, Swick, & Giorgio, 2019); Present-Centered Therapy (PCT), and Interpersonal Psychotherapy (IPT).
According to the 2017 VA/DoD Clinical Practice Guideline for Management of Post Traumatic Stress Disorder, (VA/DoD, 2017)(Ostacher & Cifu, 2019) (Jeffreys, 2017), trauma focused psychotherapy (TFP) is recommended over pharmacotherapy for PTSD. When TFP is not readily available or not preferred by a patient, specific pharmacotherapy with SSRI’s or SNRI’s is recommended. The guideline recommends against a long list of other medications for the treatment of PTSD, including antipsychotics and benzodiazepines.
VA recommendations for trauma therapies do not include Internal family system therapy (IFS), (R. C. Schwartz, 1995), (R. C. Schwartz, Schwartz, M. F., & Galperin, L. , 2009), a treatment often used in conjunction with EMDR for trauma treatment, (Twornbly, 2008), and applicable to combat veterans. (Lucero, Jones, & Hunsaker, 2018) Other trauma treatments such as Neurofeedback (also called EEG biofeedback), (Chiba et al., 2019), Somatic Experiencing , (Levine, 1997). (Payne, Levine, & Crane-Godreau, 2015). (Brom et al., 2017) (Andersen, Lahav, Ellegaard, & Manniche, 2017) and Sensorimotor Psychotherapy, (Ogden & Minton, 2000) are also not included in the VA recommendations..
Weill Cornell Headstrong was a community based treatment program providing free treatment for veterans with PTSD, primarily utilizing EMDR. It was founded in 2012, the year the Pentagon reported that “The suicide rate among the nation’s active-duty military personnel has eclipsed the number of troops dying in battle.” (Williams, 2012, June 8) Its mission is “to heal the hidden wounds of war and save lives on the path to ending Veteran suicide by providing cost-free, bureaucracy-free, stigma-free, confidential and effective mental health treatment for post-9/11 veterans and their families.”
As of February 2021, the program provided treatment in 26 cities, has provided 52,534 clinical sessions to 2060 clients (778 active clients), and partnered with 270 clinicians (216 active) across the US. In a 2017 RAND Corporation Research Brief, Headstrong is listed among four private sector programs that are emerging to fill gaps in the mental health care system for veterans. (Tanielian T, 2017)
Numerous aspects of the program structure are specifically designed to overcome barriers to care, including:
1. Veterans are treated in a non-institutional setting, utilizing a private practice office-based model.
2. Treatment is provided by experienced, non-transient, non-trainee, trauma informed providers.
3. Therapists are paid market rate for their services; they are not volunteers.
4. Treatment is free of charge and fully confidential.
5. Treatment is available for any level of military discharge; documentation of service is not required; veterans who register on the website get a callback within 12-48 hours.
6. Assessment and initiation of treatment is provided within 1-2 weeks of the first call.
Of the three treatment modalities endorsed by the VA as having the strongest evidence base, the program elected to focus on EMDR rather than CPT and PE. The basis for this was rooted in the benefits of EMDR relative to CPT and PE for the treatment of veteran PTSD, described below. Also described below are modifications of the first four of eight phases of EMDR, specific to veterans, based on experience with 2060 patients. The program also incorporates the three phased approach to trauma therapy: safety and stabilization, memory processing (remembrance and mourning), and reintegration (reconnection and integration). (Van Der Hart, Brown, & Van Der Kolk, 1989) (Herman, 1992).
Since its beginning, EMDR has effectively been used with veterans and their families. (Shapiro, 1989) EMDR is well suited for the veteran community for numerous reasons.
1. The process of EMDR honors many characteristics important to veteran culture and identity, including giving the client control over the process and trauma disclosures. (Russell, 2013) (S.M. Silver & Rogers, 2002) Shapiro noted that with the multi-layered aspects of veteran trauma, “the key is to allow veterans to find their own resolution rather than try to impose what the therapist believes is the ‘best’ one”. (Shapiro, 2018) p. 304).
2. EMDR allows veterans to choose what trauma information is revealed, or not explicitly revealed at all. (S. M. Silver, Rogers, & Russell, 2008) This is especially important in cases where veterans feel shame, are worried about secondary trauma for the therapist, or are unable to disclose classified information.
3. EMDR’s phased protocol and efficiency aligns with veterans’ structured, results-oriented training. (Shapiro, 2018) (Russell, 2013)
4. Veterans, like other trauma survivors, may fear healing. Enduring grief is seen by many as a means to honor the memory of loved ones, including battle buddies. They may not want to feel “absolved” of misdeeds. They may fear that trauma processing could undermine the aspects of service that were honorable and important, such as life-saving skills, increased character strengths, and pride in self, country and humanity.
1. Drop out: The high veteran dropout rate for the predominant trauma treatments (8 sessions) is well documented, (Najavits, 2015) ranging from 50% (Hoge et al., 2014) to 60% (Niles et al., 2018) to 70%. (Eftekhari, Crowley, Mackintosh, & Rosen, 2020) There are no available studies of veteran dropout for EMDR as it was adopted later and is less prevalent than CPT and PE. A systematic review and meta-analysis of dropout from PTSD in non-veteran adults showed EMDR to have lower dropout (mean 18% of 21 studies) relative to CPT (mean 30% of 8 studies) and PE (mean 22% of 22 studies). (Lewis, Roberts, Gibson, & Bisson, 2020)
2. Aversive aspect of exposure to traumatic stimuli: The aversive aspect of exposure to traumatic stimuli is often cited as one of the variables for poor treatment retention. In a recently published study of 2606 veterans receiving prolonged exposure treatment, distress or avoidance was cited in 45% of the veterans who dropped out. (Eftekhari et al., 2020) EMDR does not involve (a) detailed descriptions of the event, (b) direct challenging of beliefs, or (c) extended exposure. It incorporates techniques to manage the distress and physiologic dysregulation of arousal intrinsic to trauma.
3. Homework: Many veterans report difficulty utilizing or completing the homework assignments required for cognitive processing therapy. (S. M. Silver et al., 2008) There is no homework in EMDR. It is not a manualized treatment and has flexibility
4. Symptom reduction/diagnostic criteria: A review of nine randomized controlled trials in the treatment of military-related PTSD (Steenkamp, Litz, Hoge, & Marmar, 2015), found that, although 49-70% of patients receiving CPT and PE showed improvement, 60-72% retained their PTSD diagnosis after treatment (mean post treatment scores remained at or above clinical criteria for PTSD). Only two randomized control trials testing adequate doses of EMDR for military PTSD are available, and both were conducted before 9/11. (Boudewyns & Hyer, 1996) (Carlson, Chemtob, Rusnak, Hedlund, & Muraoka, 1998) In the 2 trials, there were large symptom reductions, and 78% of completers no longer met criteria for PTSD, with results maintained at 9-month follow-up.
EMDR treatment consists of eight phases (Shapiro, 2018): ONE – Client History and Treatment Planning, TWO – Preparation, THREE – Assessment, FOUR – Desensitization, FIVE – Installation, SIX – Body Scan, SEVEN – Closure, EIGHT – Reevaluation. Adaptations and unique foci during phases one through four emerged during our experience. There were no notable adaptations for phases five through eight.
The key elements of phase one with veterans include 1) appreciation of developmental history due to the high incidence of C-PTSD, and 2) military cultural competence.
Given the increased frequency of C-PTSD in the voluntary military cohort, it is important not to assume military traumas are the most salient ones. In fact, it is not unusual for veterans to report that they felt prepared for combat traumas, and accept their experiences were for a greater good. A comprehensive developmental history may reveal a non-military primary focus for the treatment and help inform the response to more recent events.
Phase one of EMDR includes Therapist Preparation and cultural competence for specialized populations. (Shapiro, 2018) The USDVA and Department of Defense (VA/Dod, 2010), p.92) endorses this competence as essential for establishing a therapeutic alliance with veterans, and the therapeutic alliance is the foundation of successful EMDR treatment. (Shapiro, 2018) Relevant keystones of military culture include: priority of the group and mission above the self, loyalty to peers, trust in chain of command, honoring Rules of Engagement, and the warrior concept. (Russell, 2013) (S.M. Silver & Rogers, 2002) Whereas some soldiers may view asking for help as a sign of weakness, others can apply their grit and steely resolve to achieve the mission of overcoming their symptoms.
Expanded resource development is often indicated in Phase Two with post 9/11 veterans, in part due to the prevalence with which they present with complex PTSD (C-PTSD). Resources specific to the veteran population have emerged and are described below.
Shapiro has described many relaxation and self-regulation techniques necessary for reprocessing. (Shapiro, 2018) It is recommended that all clients develop a safe/calm place to aid in emotional stabilization when reprocessing disturbances. This exercise was originally suggested to Shapiro in 1991 by a clinician who utilized it with veterans. (Shapiro, 2018) A safe/calm place resource is particularly indicated for clients who feel “a need to remain vigilant, a need that may have been conditioned during episodes of sexual abuse or in combat”. (Shapiro, 2018) p. 117). For many veterans, a peaceful place can be an activity, like running on a mountainside. For this active sub-population, exercise in nature can provide a more relaxing or safe feeling than sitting in a cozy chair or on an island beach.
C-PSTD clients often require additional relaxation techniques, including Resource Development and Installation (RDI), to increase self-regulation and improve the efficacy of EMDR. (Shapiro, 2018) (Korn & Leeds, 2002)(Leeds & Shapiro, 2000) (Leeds, 1998) “RDI refers to a set of EMDR-related protocols which focus exclusively on strengthening connections to resources in functional (positive) ‘memory networks’ while deliberately not stimulating dysfunctional (traumatic) memory networks.” (Korn & Leeds, 2002) RDI can enhance access to reservoirs of adaptive coping skills and positive affect experiences.
Given the increased frequency of C-PTSD in the voluntary military cohort, RDI is often valuable in Phase Two. Among the RDI suggestions are relational resources, which are models and supportive figures who embody positive affect qualities. (Shapiro, 2018) (Korn & Leeds, 2002) Some examples of key traits useful in reprocessing are nurturing, protective and wise figures. (Parnell, 2013) RDI can serve as an important guidepost in assessing client readiness for reprocessing. (Shapiro, 2018) (Parnell, 2013)
Even for those without C-PTSD, spending additional time on this step can help build the veteran’s sense of self-efficacy, aligns with the characteristics of control and mastery important to many veterans, allows them to gain confidence that EMDR honors their right to self-determination in the treatment process, and bolsters trust in the therapeutic alliance.
Caution is advised when utilizing military-related positive resources for reprocessing military-related trauma. Although these resources may have therapeutic utility, in other instances, they might complicate reprocessing.
Many veterans connect with an identity of being a warrior and protector. Military service often includes rescue, peacekeeping and community-building, (Russell, 2013) leading some veterans to see themselves as nurturers. For some, these identities provide a solid foundation for easy resource development; conversely, it may prevent them from relinquishing those roles or seeking those traits in others.
Strategies to overcome these barriers include: targeting the aversion as a blocking belief, describing resources as proxies of ego strengths not an abandonment of this aspect of identity, and reinforcing that personal responsibility coexists with loyalty and trust in the team, including the therapeutic team.
Many veterans might use typical nurturing, protector, and wise figures from either their childhood or current life. In the trauma work, they are people, and in asking questions about vulnerability, they might identify an animal or person from their past or present day, not only military folks. Military experiences that might provide options for positive resource development include the following:
The hierarchical structure of the military and the regimented training process offer objective opportunities for mentor figures, such as a medic or Sergeant. In fact, some veterans join the military in specific pursuit of these mentorship relationships, especially when they lacked secure attachments or experienced abuse in their families of origin.
Groups and comrades in arms
Due to the group nature of the military, veterans often relate more readily than civilians to the idea of a group as a singular positive resource that has collective agency. As a result, veterans might choose groups of people as a resource, whether it is their unit, their military branch, or other social, familial, cultural, spiritual or national groups. Veterans use different terms to refer to those with whom they served; it is helpful to honor their nomenclature.
Military service often involves significant national and international travel, exposing veterans to different cultures, people, religions, geographies, and animals. These experiences can be mined for resources. As an army veteran explained, “I thought I knew what a religious person was, until I went to Afghanistan. I thought I had seen stars, until I saw them in an ink black desert sky.”
Because military experience generates existential questions about the meaning of life and death, killing, surviving, good versus bad, and other abstract but fundamental human queries, spiritual figures can be particularly useful resources for veterans. Some veterans might have lost their religious or spiritual identities, while others find religion and spirituality for the first time.
Many veterans are drawn to service in part because they enjoy activity and being in the outdoors. (Russell, 2013) Veteran programs often have activity-based support to harness these characteristics. These activities provide further options for supportive figures in the form of coaches, peers and professional athletes.
Symbols abound in the military, including country and military branch flags, or uniform patches of rank and achievements; some of these symbols can translate into resources. Asking a veteran about what “the uniform” means to them, and the patches they achieved or aspired to, can reveal both personal values and people they admired. Conversations about these symbols can be initiated by noting veterans’ tattoos, military-related symbols on their apparel, or by asking what service memorabilia they have at home.
The American flag in particular is often a sacred symbol for veterans. What the flag means to them can shift during military service and for the rest of their lives depending on individual experiences as well as fluctuations in America’s standing in the world.
Veterans might feel connected to animals as resources due to encountering them in the wild during training and deployment or identifying with animal symbols pervasive in the military, such as the American eagle. Veterans often develop close bonds with highly trained military animals utilized in certain military operations, with whom they have had life and death experiences. Animal assisted therapy and service animals are some of the most common and effective mental health interventions for veterans; these animals can be valuable positive resources.
Use of Military Self
As with other people who identify themselves as the positive resources in their life, when veterans struggle to identify someone other than themselves for resources, it can help to outline the specific characteristics that the veteran feels makes his or herself a positive resource. Once the attributes are delineated, the veteran might be able to choose someone else that embodies all or some of those specific characteristics. When their military identify is positive and strong, veterans sometimes utilize their military self to support their civilian self or their child self.
As previously discussed, the current voluntary military has a high incidence of pre-existing traumas. As a first step, it is helpful to categorize the traumas into pre-military, military and post-military traumas. (Russell, 2013)
Many trauma targets are common among people with any type of military service, such as potential traumas resulting from combat, killing, deaths of peers, training, prolonged separation from loved ones, and loss of identity after discharge. (Russell, 2013) (S.M. Silver & Rogers, 2002) Additional post-9/11 era targets include the implications of military engagements continuing for two decades, complex physical and moral injuries, and military sexual trauma. Military-related traumas can often be further grouped into similar trauma experiences, for example active firefight, traveling in convoys, and bootcamp training.
The bridging step of EMDR helps efficiently clear pre-military traumas that might be influencing military and post-military traumas. While bridging from military trauma to related pre-military trauma is often both effective and necessary, there are sometimes military traumas that stand alone and are unique to military experience that need to be targeted on their own.
Survivor guilt is experienced when a peer is killed, severely injured, or struggles with significant mental health issues. In the post 9/11 era, the high rate of veteran suicide increases the chance that a veteran might lose a peer after service in a way that can trigger survivor guilt long after discharge from service. (S. M. Silver et al., 2008) Survivor guilt is not explicitly mentioned in the criteria for posttraumatic stress disorder. (American Psychiatric Association, 2013)
A key barrier to veterans seeking therapy is that many veterans do not believe that their experiences were traumatic or traumatic enough to warrant support. (Russell, 2013) A 2014 study of veterans with PTSD found: “Many who suffer from mental-health problems do not perceive a need for help, and others grapple with uncertainty about whether their distress is severe enough to warrant it.” (Spoont et al., 2014) Veterans might dismiss the severity of targets or provide a low SUDS (Subjective Unit of Disturbance Scale).
The nature of war leads military personnel to grapple with significant moral and existential questions. (Grossman, 2008) This includes the nature of fighting and killing and doing society’s bidding. (Grossman, 2008) The USDVA recognizes that in “traumatic or unusually stressful circumstances, people may perpetrate, fail to prevent, or witness events that contradict deeply held moral beliefs and expectations”. (Norman & Maguen, 2020, May 19) This can result in what is defined as a moral injury, which can have “distressing psychological, behavioral, social, and sometimes spiritual” implications. (Norman & Maguen, 2020, May 19) Soldiers might witness, participate in, or be directed to participate in, explicit violations of Rules of Engagement, directives that define appropriate use of military force with enemy combatants as well as civilians. Many veterans note that their service let them see both the best and worst sides of humanity. Some have likened it to a bell that cannot be unrung, with others describing that their “moral compass is broken.” (Shapiro, 2018)
Moral injury can be experienced when the standing of the United States shifts in the world, causing some veterans to question their sacrifice, and that of their peers. For some veterans this injury is connected with the image of the American flag.
Like survivor guilt, moral injury is not described in the DSM-V. According to Shapiro, guilt and shame often accompany moral injury and can lead to self-loathing and blocking beliefs around not deserving to heal. (Shapiro, 2018) She suggested that acknowledgement of past responsibilities is a tender point in the therapeutic process, and that cognitive interweaves in EMDR about logistical and maturational limitations can be useful. (Shapiro, 2018) In Phase Four, reprocessing moral injury can aid the veteran in experiencing atonement.
Rank Specific Trauma
There can be a distinction between officer trauma and enlisted trauma; whereas enlisted service members may have experiences more focused on the extraordinary horrors and gore of war, officers might be more traumatized by issues such as setting the right example, or saving the lives of subordinates.
Advances in medicine and technology have resulted in veterans surviving certain catastrophic injuries that were previously fatal. Many veterans refer to the anniversary of their injury as their Alive Day. The increasing population of veterans who return home with significant physical injuries including, loss of limbs and traumatic brain injuries, can have unique trauma targets. Veterans might struggle with the trauma of the catastrophic incident itself, as well as painful resulting medical procedures and months or years of physical rehabilitation. Further traumas can arise when the veteran’s debilitating injury results in changes to the unit structure. One veteran with catastrophic injury was not as traumatized by the memory of the injury, as he was by the guilt and grief that after his evacuation, his unit was fatally attacked.
Catastrophic injuries can require extended hospital and inpatient rehabilitation. Severe mobility limitations, physical and emotional pain, lifelong medical costs, physical therapy, equipment needs, and life adjustments of loved ones, can be stressors. Veterans might feel distress or guilt about the burden this could place emotionally, logistically and financially on them and their loved ones.
Military Sexual Trauma
Military sexual trauma can be compounded by military culture, particularly the hierarchical structure and the importance of unit cohesion, trust, loyalty and mutual responsibility. (Shapiro, 2018) (Russell, 2013) Survivors might fear coming forward because of concerns for what the revelation will do to the unit and mission. Shame can result from both reporting and not reporting an assault. Non-military family and friends might not understand why a survivor would hesitate to report, furthering feelings of shame or alienation. As with any sexual trauma, survivors might have negative cognitions about self-worth, shame, and being damaged physically, emotionally, and spiritually. (Shapiro, 2018) The military culture can compound the negative cognitions, leading to significant shattering of trust in oneself, one’s peers and with the military as a whole. (Shapiro, 2018)
One of the major differences between the Iraq and Afghanistan Wars and prior armed conflicts is the duration of conflict. As a result, many years after service, veterans might not have a clear sense of the meaning or accomplishments of their mission. A decade after leaving service, an Army veteran came to a session shaken by the news that the area she spent her military career defending, had been taken back by insurgents. The news immediately changed the meaning she associated with her service. The disturbance it caused became a target of reprocessing. Moreover, as civilians’ opinions about the ongoing conflicts shift, they can project their opinions onto veterans; the veterans’ pride in sacrifice, can change to uncertainty or shame. After years of fielding unsolicited opinions about his service, a Navy veteran stopped participating in Veterans Day activities and wearing Navy shirts and hats. He explained, “I’m proud of serving and yet still question what it all meant. The last thing I need is for everyone else to tell me how I should feel about it. The longer these conflicts go on, the more people feel they can decide for me.”
There is a plethora of vital jobs in active combat that do not involve being on the front lines. Sometimes not seeing combat can bring up shame. Others in these positions can still experience primary and secondary trauma, for example during transport, when bases are attacked, caring for the injured and attending to the dead. One military technology officer who was in charge of reestablishing communications between the field and base carried the guilt of not re-establishing connections quickly enough, and the grief of listening to fellow soldiers die on the other end of communication lines.
In Phase Four – Desensitization: disturbance is removed from each associative channel of the target memory by processing the dysfunctional, stored information. (Shapiro, 2018) This can be done spontaneously and adaptively in a number of ways as the client focuses on the target memory. However, at times the processing can become stuck with the client looping emotionally or cognitively. (Shapiro, 2018) One strategy for helping clients to become unstuck is to suggest a cognitive interweave, which are questions or instructions that can “jump-start” blocked processing by eliciting useful “thoughts, actions, affects and/or imagery”. (Shapiro, 2018), p. 256) Shapiro noted that cognitive interweaves can help veteran clients “recognize the appropriate level of responsibility, present safety, and future ability to choose” (Shapiro, 2018), p. 311). For example, cognitive interweaves relating to military hierarchy, the fog of war and what others would do in the same situation can help relieve outsized guilt and shame. (Shapiro, 2001)
Imagination interweaves are particularly useful with veterans. These interweaves allow clients to effectively re-do events from the past in their imagination with what they wish could have been different, including changing what was said or done. (Parnell, 2007) Imagination interweaves include Shapiro’s “Let’s Pretend” interweave that allows clients to explore alternative solutions to the past events, bringing in current perspectives, understanding of consequences and posttraumatic growth. (Shapiro, 2018)Examples of such interweaves include: Is there anything you would like to say to the person you shot, killed, bombed, etc? Is there anything you would like to say to your buddies who died? Would you like to invite back the part of you that you left in Fallujah, Afghanistan, Iraq, etc?
This can be a powerful tool for veterans who experience guilt or shame about their or their peers’ action or inaction, including choices that resulted in moral injury. Due to life-and-death scenarios in war and/or the survival necessity of respecting military hierarchies, many military traumatic incidents include situations where veterans could not do or say things they wish they could have. Imagination interweaves can be used to both contextualize the past action and reinforce the lessons the veteran learned from the incident. For targets involving moral injury, this can be especially adaptive and allow veterans to move forward in their lives with acts of atonement. (S.M. Silver & Rogers, 2002)
Weill Cornell Headstrong employed three methods to assure clinical quality and treatment fidelity: review of patient notes, bi-monthly case conference, and treatment Outcome measures. Clinicians who did not have access to their own EMDR clinical supervision and consultation were eligible to participate in free clinical supervision and consultation provided via video conference by EMDR consultants.
Headstrong distributed a Satisfaction Survey in February 2017 to 138 active clients and in May 2019 to 520 active clients; response rates were 30% and 26% respectively. Among other results, 92% of respondents, said they would recommend Headstrong to a friend or family member. This question, also known as the Net Promoter Score, is considered a highly reliable indicator of customer satisfaction, and has also been used in the health care sector to predict patient satisfaction. (Wilberforce, Poll, Langham, Worden, & Challis, 2019) (Alismail et al., 2020)A NPS of 50 is generally deemed excellent, and anything over 70 is exceptional.
For the 2060 veterans treated by the Headstrong Program, the average number of sessions is 32, median 20, and range 1 to 354. This is strikingly longer than the retention reported in prior studies of veteran PTSD care. (Najavits, 2015) (Hoge et al., 2004; Hoge et al., 2014)
Of the 2060 veterans treated by Headstrong since 2012, there has been one non-fatal suicide attempt. Two veterans completed suicide months after discontinuing treatment.
Symptom severity and treatment progress are measured by three scales: PCL-5 (Blevins, Weathers, Davis, Witte, & Domino, 2015; Weathers et al., 2013), ReQol (Recovering Quality of Life), (Keetharuth et al., 2018) and an eleven item PTSD symptom checklist. Unfortunately, although the data quantity is insufficient for comprehensive analysis, there are encouraging signals. Both the symptom checklist and PCL5 show decreased symptoms with treatment.
Based on the checklist completed by the therapists, the percentage of Headstrong clients who report improved PTSD symptoms ranges from 77% who report improvement in at least two symptom categories to 60% who report improvement in all ten PTSD symptom categories. See 2. This data reflects the 310 Headstrong clients treated from December 2015 to December 10, 2019 for whom the checklist was acquired for the first and last sessions (for completed treatments) or first and most recent session (for active clients who have completed at least twenty sessions).
Preliminary PCL5 outcome data was available for 89 Headstrong veterans who completed the instrument at intake (Score #1) and after six months, or at termination, of treatment (Score #2). The cutoff score for PTSD is usually considered to be 31-33, but can vary from 30 to 60. (Blevins et al., 2015). Using a cut off of 31, prior to treatment 73 (82%) of 89 clients met criteria for PTSD, while post intervention, 54 (61%) met this criteria. This decrease was statistically significant with P-value of 0.003. The average decrease in score was 7.3 points, which is statistically significant with a p-value of 0.0001. Although the sample size is small, the trend is encouraging, especially in light of data collected since the Covid pandemic, when many veterans experienced an increase or recurrence of PTSD symptoms.
PTSD is a strong risk factor for veteran suicide. Treatment of PTSD can reduce veteran suicide. There are many barriers to care for veterans receiving mental health care. The VA endorses 3 PTSD evidence-based treatments but CPT and PE are more predominant than EMDR. To date, there are no EMDR outcome studies for post 9/11 veteran PTSD, or studies comparing EMDR with CPT/PE for veteran PTSD. EMDR has distinct advantages for the treatment of veteran PTSD relative to CPT and PE. Headstrong is a community-based program providing free treatment to post 9/11 veterans with PTSD, and veterans of any era with Military Sexual Trauma (MST). It is the only veteran program predominantly utilizing EMDR. They have treated 2060 veterans with PTSD (including MST), 90% of whom have received EMDR as part of their treatment.
Specific adaptations for veterans during EMDR phases one through four are described and recommended. In Phase One, it is important to appreciate the significant role developmental trauma plays in trauma experienced by a voluntary military population. In Phase Two, expanded resource development and installation is particularly valuable. Military specific resources can be useful and are described above. In Phase Three, moral injury and survivor guilt are especially salient in target development. Complicated injuries and on-going wars are unique to the modern warfare era and the post 9/11 conflicts. In Phase Four, imagination interweaves tend to have greater potency than cognitive interweaves when working with veterans. For targets involving moral injury this can be especially adaptive.
This program utilizing EMDR has achieved its mission of decreasing suicide among post 9/11 veterans and has overcome barriers to care as demonstrated by high treatment retention and patient satisfaction. Treatment outcome, as measured by a symptom checklist and PCL5, show symptom improvement. Unfortunately, there was insufficient outcome data for more specific analysis. There is a need for outcome studies of EMDR as a treatment for veteran and military PTSD. Comparisons of EMDR with and without veteran specific adaptations would be desirable but was not feasible in this setting.
Having developed a proof of concept in successfully treating PTSD in veterans primarily utilizing EMDR, in a community based setting, Weill Cornell Headstrong hopes to expand to treat other traumatized populations, including survivors of COVID-19, domestic violence, sexual violence, victims of social injustice including racism, homophobia, transphobia, and victims of torture and human trafficking. This model is also poised to significantly contribute to the field of tele-health, as its therapists have utilized EMDR and other trauma treatments in a virtual environment.
With more outcome data, we hope to determine predictors of outcome, including course and length of treatment, based on parameters such as demographics, diagnosis, substance use, history, trauma types, and adverse childhood experiences.
Veteran specific adaptations to EMDR phases five through eight can be explored. Veterans treated by Headstrong could be surveyed to determine what components of their treatment were the most beneficial, or most helped overcome barriers to care.
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