EMDR Therapy Quarterly

Learning objectives 

This case study has two learning objectives: 

1. EMDR can help those suffering from CRT in Britain. Military personnel can follow and benefit from the EMDR standard protocol like any other trauma survivor, and they are not alone in suffering moral injuries.  

2. EMDR has forensic potential, as it can help offenders to address a key risk factor for future violence. Colleagues working in forensic settings are therefore advised to consider incorporating EMDR into their practice.  

Introduction

From its inception in the 1980s, EMDR has become a scientifically proven psychotherapy approved by the World Health Organization (2013) for the treatment of PTSD. Although EMDR is similarly approved by the National Institute for Health and Care Excellence (NICE, 2018) for the treatment of PTSD, this approval is restricted to non-combat-related trauma (N-CRT). By implication, therefore, EMDR should not be offered to those suffering from combat-related trauma (CRT) in Britain. This case study explores this area and summarises how EMDR was successfully used to help two former soldiers suffering from CRT. Building on similar research, this study suggests the restriction within the NICE guidelines should be revisited.

Trauma and the adaptive information processing (AIP) model

Trauma can occur when an individual is exposed to single or multiple stressful, frightening or distressing events that leave them experiencing various negative psychological states, such as fear and anxiety, as well as enduring negative symptoms like bad dreams and flashbacks. (MIND, 2020). In some cases, the brain’s self-healing ability, which is a core premise of the AIP model (Leeds, 2023) can deal with traumatic incidents just as our bodies can deal with some physical injuries. NICE (2018, p. 26) defined CRT as “traumatic incidents associated with military combat”. From an AIP perspective, CRT occurs when a disturbing incident (e.g., discovering a mass grave in Bosnia) is stored in the soldier’s brain as it was originally experienced, because the gravity of the incident impedes the brain’s information processing system. Just as the body has difficulty healing serious injuries, a soldier’s brain has difficulty healing CRT. Likewise, as an untreated physical wound can continue to cause physical issues, untreated CRT can continue to cause psychological issues for current and former military personnel.

Prevalence of trauma

Around a third of British adults have experienced trauma in their lifetime, with around 5% having recent experiences of trauma (McManus et al., 2016). Although higher rates of trauma might be expected among the armed forces, the Ministry of Defence (2021) found this was not the case, reporting that only 0.1% of serving military personnel had PTSD. However, there was a 90% increased risk of PTSD among those previously deployed to Iraq and Afghanistan. By contrast, Stevelink et al. (2018) estimated the rate of PTSD among a sample of current and former British military personnel was 6% in a 2014/16 cohort. Later, Rhead et al. (2022) found British veterans who had served in recent military operations were more likely to report a significantly higher prevalence of PTSD than non-veterans. Unfortunately, the link between trauma and offending means some veterans end up in prison. This is confirmed by the Office for Veterans’ Affairs (2020), which reports that around 3% of British prisoners in 2019 were military veterans. While cognitive approaches such as trauma-focused CBT have been offered to those suffering from trauma, with EMDR, these people have a proven and internationally recognised alternative, rooted in helping veterans.

The present study

Along with being an internationally recognised and approved treatment for PTSD, EMDR is considered an effective treatment for CRT in the United States (EMDR International Association, 2020) and is approved by the U.S. Department of Veterans Affairs (2023) for this purpose. Despite this, NICE (2018, p. 54) concluded “the evidence suggested EMDR was not effective in people with military combat-related trauma” and restricted their approval of EMDR in Britain to N-CRT, a finding supported by Kitchiner et al. (2019). The disparity between America and Britain in relation to EMDR and CRT suggests the issue needs revisiting. Accordingly, this study sought to answer the following research question:

• Can EMDR help current and former military personnel in Britain who are suffering from CRT?

Methodological and ethical considerations

This study used a retrospective, multiple-case study design to report on the usage of EMDR to treat two military veterans detained in a British prison who were suffering from CRT. Yin (2018) defines a case study as a means of investigating a contemporary issue in depth and within its real-world context. Although case studies often have single participants, Yin (2018) suggests multiple-case studies are superior as they offer the possibility of direct replication and stronger conclusions. To ensure this study adhered to the ethical standards recommended by the Health & Care Professions Council (2016), the following steps were taken.

1. The first author’s NHS Trust was consulted. They advised that, as long as both men were given information about the study, given the opportunity to ask questions and provided their consent, the Trust’s requirements for a case study would be met. The two men were seen in accordance with these requirements and were advised that all data would be anonymised and pseudonyms would be used. Both men were happy with these arrangements and consented to their data being used.
2. Details about the study were sent to the Ministry of Justice, which approved it.
3. The first author’s NHS Trust and the Ministry of Justice saw a copy of the finished study and agreed it was ethical.

Course of therapy

EMDR was delivered to the men by the first author as per the standard protocol, under the supervision of the second author. Individual hour-long sessions were delivered to each of the men roughly once a week on their prison wing. The first author documented the sessions within the prison health records system, which informs this study.

Phases 1–3: Assessment and preparation

During these phases, case histories were taken, including the participants’ experiences of past trauma and the option of EMDR was considered (Shapiro, 2018). The Adverse Childhood Experiences (ACE) scale (Felitti et al., 1998), was used to explore early life experiences. Scores range from 0 to 10, with higher scores correlating with an increased risk of negative outcomes in adulthood. Additionally, the impact of the Event Scale-Revised (IES-R; Weiss, 2007) was used pre- and post-EMDR to assess the impact of the participants’ CRT. Scores range from 0 to 88, with scores above 33 generally considered indicative of PTSD-related difficulties.

Mr Smith is a middle-aged man who had an uneventful childhood, as indicated by an ACEs score of one. During his 20s, he served in the British Army. He later obtained civilian employment but was unfit for work at the time of his conviction due to military-related injuries. He had not experienced any trauma prior to joining the Army, but in the late 1990s, while on active service, he experienced a traumatic incident (summarised in Table 1). He subsequently experienced depression, PTSD and substance abuse. This was followed by convictions for criminal damage and violence, with the latter leading to his imprisonment.

Mr Jones is a middle-aged man who was born and raised in Africa, where he experienced some childhood difficulties, as indicated by an ACEs score of four. During his 20s, he served in his nation’s Army, followed by civilian employment in Africa and then in Britain. He had not experienced any trauma prior to joining the Army, but in the early 1990s, while on active service, he experienced a traumatic incident (summarised in Table 1). He too subsequently experienced depression, PTSD and substance abuse. This was followed by convictions for driving offences, acquisitive and violent offences, with the latter leading to his imprisonment.

Table 1. Incidents of trauma

Table 1. Incidents of trauma

	Mr Smith	Mr Jones
Traumatic incident	Helicopter shot down killing several on board.	Captured by mercenaries and tortured, comrade murdered.
Symptoms	Poor sleep, thinking about the crash all the time, flashbacks and anger.	Bad dreams, flashbacks, feeling unsafe and angry.
Symptom triggers	Loud noises, helicopters flying overhead and war films (which he avoided).	Crowds and hearing references to his home country in conversation or on TV.
Desired future outcome	Respond to triggers by not worrying that something bad may happen, and sleep better.	Not be bothered by these triggers and to respond to them normally.
IES-R Score	Pre EMDR = 45 Post EMDR = 5	Pre EMDR = 63 Post EMDR = 17
Worst image of the traumatic incident	Expressions of fear on his comrades’ faces after the helicopter was hit.	The murder of his comrade, who was attacked with machetes and shot in front of them.
Negative cognition (NC)	“I am unforgiveable”	“I am going to die”
Subjective units of disturbance (SUD) score and associated feelings	Pre EMDR = 5 (empty inside, sad) Post EMDR = 1 (calm, relaxed, no guilt).	Pre EMDR = 8-9 (scared, vulnerable, angry) Post EMDR = Zero (calm, safe, relieved).
Positive cognition (PC)	“I can forgive myself and move on”	Initial: “It’s over, I’m safe” Revised: “I do matter”
Validity of cognition (VOC) score	Pre EMDR = 3 Post EMDR = 6	Pre EMDR = 1 Post EMDR = 7

Phases 4–6: Desensitisation, installation and body scan

During these phases, their worst image and its relationship to their negative cognition (NC) and positive cognition (PC) were explored. Body scans were also completed, all supported with bilateral stimulation (BLS)  (Shapiro, 2018).

Mr Smith completed these phases over several sessions, beginning with him reporting that establishing a safe/calm place had improved his sleep. When his SUD score reached four, his progress halted. When this was explored, he reflected on the fact that although the helicopter crash was his worst military experience, it co-existed with other incidents he felt guilty about and should have prevented, including the helicopter being shot down. He also reported having an empty feeling in his chest for decades and claimed it would never go. When BLS recommenced, that feeling was eliminated, and with a SUD score of three, he reported feeling calm, relaxed and able to breathe better. When his SUD score reached one, he was feeling that the helicopter crash was not his fault. He believed he could never reach a zero SUD, as that would be like the helicopter crash had never happened. We agreed that a SUD score of one was probably the best he could achieve and reinforced this with BLS until he felt it was solid.
 
In Phase 5, he reported feeling great; he was attending veterans’ meetings and had volunteered to be a Wing representative. The empty feeling in his chest didn’t return, and he felt like a ‘new man.’ Thoughts of the helicopter crash no longer bothered him, and he had not been concerned when a helicopter flew over recently. He confirmed his PC remained valid and his validity of cognition (VoC) score was now six. He believed he could never reach a VoC score of seven, as that too would be like the helicopter crash had never happened. We agreed that a VoC score of six was probably the best he could achieve and reinforced this with BLS until he felt it was solid. In Phase 6, he had no tensions anywhere, and this was reinforced with BLS until he felt it was a solid feeling.

Mr Jones also completed these phases over several sessions. At the end of session one, he reported his worst image was more distant, less intense and less relevant, and he could no longer hear his captor’s voices. He was relaxed, calm and happy, and his SUD score reached four. Subsequent sessions were equally successful, as his worst image became more distant and finally went away. This left him feeling calm, relaxed and at ease, and his SUD score reached zero. This was reinforced with BLS until he felt it was solid. Following an unavoidable two-week break, his SUD score had risen to two. He attributed this rise to concerns about letting go of his CRT and not having a feeling inside he had had for decades. With more BLS, his SUD score returned to zero and he felt calm, safe and relieved, as if a weight had been lifted from his shoulders. This was reinforced with BLS until he felt it was solid. In Phase 5, he identified a more meaningful PC (see Table 1), which he gave a VoC score of seven, feeling calm with a sense of moving on. We reinforced this with BLS until he felt it was solid. In Phase 6, he had no tensions anywhere, and this was reinforced with BLS until he felt it was a solid feeling.

Phases 7–8: Outcome

Here, Phase 7 brought closure to each session and the entire treatment once Phase 6 was completed, and Phase 8 involved a review of progress (Shapiro, 2018). As part of this research, both men provided a reflective account of their experience of EMDR, which are summarised below.

Mr Smith felt fine a week after completing Phase 6. He had watched the film Saving Private Ryan, and it had not bothered him, like it would have done before EMDR. One month later, he reported feeling 100% sorted, back to his old self and better than before. He was able to think more clearly and think before acting. He was not as bad-tempered and was visiting the gym more often. He no longer felt the need to use alcohol and drugs as a coping mechanism. Looking to the future, he thought loud noises may still be an issue, but he did not need help, as he felt fine in prison. However, he recognised that he may need help when released. He felt a test for him would be watching the film Black Hawk Down, but he did not know when it was next on TV and was happy to end EMDR at that point. Six months after completing EMDR, he wrote:

“This procedure helped me a lot, it has changed my life. Before the treatment, I was living with a dark cloud above me which followed me everywhere. I suffered nightmares and flashbacks. I suffered physically and mentally. I learned to live with it, which was hard, but I was ready to change. The things I got out of it were my sleep improved, less nightmares and flashbacks. The biggest thing is I feel alive again, like ‘me’ has returned from the dead. I’m back, and there is no stopping me. I eat better, run 15km, go to the gym. I feel great thanks to EMDR. If I had received this treatment after leaving the Army, my life would have been totally different. I would never have come to prison. I can deal with anything life throws at me, and I can deal with my problems in a mature way, without using violence or hurting anybody. I used to feel worthless and empty before EMDR. Now I feel rejuvenated, I now see the error of my ways, but I do not regret it, as I was needing help and I got it. I would like this treatment given to veterans, this would save lives and victims, and families.” 

Mr Jones felt better and happier a week after completing Phase 6. He was less anxious and felt better about himself. Although he had occasional bad dreams, they were not as frequent, and he could cope with them now. He felt calmer and more understanding about his trauma. He realised it was not his fault, and he could put it behind him. He described EMDR as “life-changing.” Two weeks later, he was sleeping better and felt happier. He was not the same person anymore, as his trauma was no longer taking over his life. He felt more able to deal with things and not in danger. Looking to the future, he felt there were no outstanding issues and was happy to end EMDR at that point. Three months after completing EMDR, he wrote:

“I have suffered with PTSD for over half of my life. It has been very difficult, but I am lucky I am still here. On coming to [prison], I started EMDR. I was amazed at the difference in my life this has made. I don’t believe I am cured or that I will ever live a life without the journey I experienced. EMDR has given me what I have never had. I still sometimes cry at night and have explosive dreams or memories, but EMDR has helped me to realise I am not in danger, I am not going to die, and I am now a very different person. I don’t know if this will last, but I am grateful for the EMDR treatment. I hope that my future is now on track. I feel that it is, and I have the opportunity to lead a normal life. I would recommend this treatment for any sufferers of PTSD. I feel happy, focused and ready for what lies ahead.”

Discussion

The link between combat and trauma has been recognised for centuries, with examples documented in the Napoleonic Wars, the American Civil War, both World Wars and, of course, the Vietnam War. Labels used to describe this condition include traumatic hysteria, shell-shock, combat fatigue, post-Vietnam syndrome and more recently PTSD (Friedman, 2024). While hundreds of British shell-shocked soldiers were shot for cowardice during WW1, others were sent to hospitals such as Craiglockhart in Edinburgh, the Maudsley in London and Moss Side near Liverpool, where advances in this field were made (Jones, 2010). Today, CRT is a recognised condition, and current and former military personnel in Britain can access support services provided by the government, such as the Office for Veterans’ Affairs, the NHS service Op COURAGE, and charitable organisations, such as Combat Stress. This case study suggests EMDR can help current and former military personnel in Britain who are suffering from CRT, and therefore, NICE guidelines regarding EMDR’s restriction to N-CRT should be revisited.

EMDR and CRT: America vs. Britain

While EMDR is not approved for use with CRT in Britain, it is approved in the United States (U.S. Department of Veterans Affairs, 2023). Likewise, the EMDR International Association (2023) has an ‘EMDR and the military’ special interest group, which provides useful information about EMDR for current and former military personnel. This is not surprising given that Shapiro found “some of the most dramatic early successes using EMDR unfolded with Vietnam War veterans who continued to suffer from PTSD fifteen years after returning home” (Shapiro & Forrest, 2016, p. 43). As a result, Shapiro (2018) included combat veterans in one of her selected populations who can benefit from EMDR, and Hurley (2020) developed a clinical guide for treating CRT with EMDR. So why is EMDR not approved by NICE for treating CRT in Britain? This is not just an academic question but a practical one. Although NICE guidelines are not mandatory, if mental health practitioners abide by them, some current and former military personnel may not be offered EMDR to help with their CRT, while their American counterparts who may have served in the same conflict will be. Apart from questioning the efficacy of EMDR for people suffering from CRT, the other reason given by NICE for restricting EMDR to N-CRT is these incidents “might include having to contend with challenging situations to which there is no correct answer, which may lead to shame or guilt (known as moral injuries)” (NICE, 2018, p. 26).

Moral injury

Shapiro was aware of moral injuries among military veterans, their association with shame and guilt, and their potential to promote blocking self-beliefs, such as “I don’t deserve to get over this” (2018, p. 308). Shapiro’s solution was to use cognitive interweaves to challenge such thoughts, such as “Have other Marines experienced similar responses? What would you say to them?” (2018, p. 309).

In this study, EMDR helped Mr Smith to realise he was not to blame for some key events during his Army career, including the helicopter being shot down, and it helped Mr Jones to realise that being captured and tortured was not his fault and he could now put it behind him. Indeed, the idea that EMDR can treat moral injury among current and former military personnel is supported by others in the field, such as Hurley (2020). The fact that moral injuries are experienced by professional groups outside the armed forces (King’s Centre for Military Health Research, 2023), and NICE’s acceptance that “in many cases, the sorts of traumas that military personnel encounter are not particularly distinct from those encountered by civilians” (NICE, 2018, p. 26), suggests that NICE’s decision to restrict EMDR for CRT is intellectually unsound. This may explain why, contrary to what NICE advises, the clinical reality is very different. Not only has EMDR been shown to be effective with British military personnel (Clapson, 2013; Wesson & Gould, 2009), but it is now offered to Britain’s armed forces (Frappell-Cooke & McCauley, 2019). In the northwest of England alone, EMDR is provided by the NHS to military veterans at Greater Manchester Mental Health NHS Foundation Trust, (2024) and  Pennine Care NHS Foundation Trust, (2024). The fact that EMDR has been and is being offered to those suffering from CRT in Britain, regardless of NICE guidelines, suggests the organisation is not keeping up with real-world practice. This underpins the argument of this study: the restriction of EMDR for CRT within the NICE guidelines should be revisited.

Forensic implications

As this study was conducted in a prison, the findings have implications beyond CRT. Research suggests many prisoners have experienced trauma, which is a recognised risk factor for violence (Douglas et al., 2013; Hart et al., 2022) and contributes to the development of personality difficulties (Craissati et al., 2020) and sexual deviancy (Healey, 2006). In cases where an offender’s problematic presentation is related to past trauma, this case study, like others before it (e.g., Fleurkens et al., 2018; Kitchiner, 2000; Wright & Warner, 2020) suggests that EMDR is a therapeutic intervention worthy of consideration. This is supported by Mr Smith, who reported no longer feeling the need to use alcohol and drugs as a coping mechanism and that he can avoid using violence in the future when faced with problems. Therefore, regardless of whether an offender’s past trauma is related to combat or another incident, this case study demonstrates EMDR’s forensic potential.

Conclusion

This case study suggests EMDR can help current and former military personnel who are suffering from CRT. It also suggests EMDR has potential within forensic settings. For these reasons, the present authors call for NICE guidelines to be revisited and encourage colleagues working in forensic settings to consider incorporating EMDR into their practice.