A note from the editor

By Dean Whybrow

Welcome to the Autumn edition of EMDR Therapy Quarterly! I am delighted to share a range of thought-provoking articles, research updates, and practice insights. This issue also introduces a new comments feature, giving you the chance to join the conversation—share reflections, ask questions, and engage directly with peers. Please remember to abide by professional standards when commenting and remain respectful to ensure constructive dialogue. Here is a link to the ETQ Commenting Guidelines.

This issue begins with a compelling case study on EMDR for combat-related trauma in prison settings. Two ex-soldiers benefited from the standard protocol, demonstrating EMDR’s potential in forensic environments. We also explore EMDR’s reach beyond traditional applications, including a service evaluation in an NHS high secure hospital reporting clinically meaningful reductions in PTSD symptoms and associated risk. Other highlights include EMDR combined with Pilates for chronic lower back pain and a pilot study on EMDR for adolescents with misophonia, both showing promising outcomes and calling for larger-scale research.

The Research News section brings the latest additions to the EMDR Publications Database, including new RCTs and systematic reviews that broaden EMDR’s evidence base. The EDI Committee shares important reflections and initiatives promoting equity, diversity, and inclusion in EMDR practice and research—an essential conversation for our community.

Finally, don’t miss details of the EMDR UK Annual Conference at Delta Hotels Bristol City Centre. With 12 CPD points, a hybrid format, and an outstanding programme of national and international speakers, this is an event not to be missed. Book early to secure your place.

Together, these articles highlight EMDR’s adaptability and growing impact across diverse and challenging contexts. Dive into the full issue—and I warmly invite both seasoned and new contributors to submit articles, whether sharing practice experiences, offering opinion pieces, or presenting research. Your voice matters in shaping the future of EMDR.

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EMDR therapy for adolescents with misophonia: A pilot study of a case series

By Hannah Howes

Introduction

Misophonia is a sound intolerance disorder characterised by severe aversive reactions, often manifesting as anger, panic or disgust, when confronted by certain repetitive auditory stimuli such as chewing or breathing (Jager et al., 2021; Jastreboff & Jastreboff, 2002). Other trigger sounds include common daily human-produced sounds, such as tapping, rustling, sniffing or throat clearing (Guetta et al., 2024).

Misophonia has been defined as an emotional response disorder that is poorly understood (Swedo et al., 2022). Köroğlu and Durat (2024, p254) state that, “Misophonia symptoms overlap with the emotional and autonomic response that can be seen in mental disorders such as PTSD, panic disorder and phobias.” Evidence suggests that the condition often presents alongside depressive and anxiety disorders, with additional, though less frequent, associations observed with obsessive-compulsive disorder, Tourette’s syndrome, attention-deficit/hyperactivity disorder, autism spectrum disorder, panic disorder, various personality disorders and suicidality (Mattson et al., 2023). The powerful aversive reactions lead to avoidance of certain situations, such as family meals or eating in restaurants. The associated sequelae of misophonia impact social and family relations (Jager et al., 2021).

The estimated prevalence of misophonia in the population is approximately 8 to 20% (Brennan et al., 2024). Some authors suggest symptoms typically start at age 13 (Jager et al., 2020; Schröder et al., 2013); however, in the service the study was based, children report symptoms of misophonia starting from as young as age six. “The onset of misophonia is often associated with early childhood experiences. Unpleasant childhood experiences can be remembered with misophonic triggers that reveal negative emotions in the person” (Edelstein et al., 2013; Claiborn et al., 2020, as cited in Köroğlu & Durat, 2024, p.252).

There is a limited evidence base for the treatment of misophonia, especially among adolescents. Some authors have noted that “exposure therapy is not widely accepted as a credible intervention among individuals with misophonia” (Mattson et al., 2023, p.7). Gregory (2024) suggested that exposure therapy may be ineffective, as emotions such as anger, disgust and shame may not habituate and could potentially increase symptoms rather than reduce them.

Cognitive behavioural therapy (CBT), incorporating various components, has been the most often utilised and effective treatment for reducing misophonia symptoms in one randomised trial and several case studies/series (Mattson et al., 2023). Of note, a case study by Muller et al. (2018) of a 14-year-old girl treated with CBT for misophonia found that significant tolerance of noise triggers occurred both within and between sessions. The patient achieved concurrent behavioural changes and tolerated a marked reduction in relevant avoidance behaviours. Self-reported and observed psychological and physiological distress diminished when confronted with identified trigger noises, both during conducted in vivo exposures and, more broadly, in the patient’s home and school environments.

Beyond CBT, other case studies suggested possible benefit from other treatment approaches. There is preliminary evidence that EMDR may help reduce the distress and impairment associated with misophonia (Jager et al., 2021). EMDR was originally developed to treat posttraumatic stress but has now been applied to many psychological conditions.

In a study conducted by Jager et al. (2021), participants were either on a waiting list for CBT or non-responders to CBT in a case series design. EMDR was focused on misophonia-related emotionally disturbing memories and was delivered over a mean of 2.6 sessions lasting 60 to 90 minutes each. Pre- and post-treatment, self-assessed ratings of misophonia symptoms were measured using AMISOS-R as the primary outcome. Jager et al. (2021) found a reduction in AMISOS-R scores in a sample of 10 adults and suggested that EMDR may be effective for patients with misophonia who do not respond to CBT. To date, there has been limited research evaluating the effectiveness of EMDR in adolescents with misophonia. Guetta et al. (2024) stated that future research samples should include children, adolescents and underrepresented groups. The current study aims to evaluate EMDR for adolescents experiencing misophonia as a potentially effective treatment approach.

Method

A case series of adolescents with a diagnosis of misophonia treated with EMDR was adopted to evaluate the impact of this intervention on the symptoms of misophonia.

Participant selection

A total of four patients were selected between August 2023 and August 2025 from the outpatient clinic at a national ear, nose and throat hospital. All the patients had been referred to the national specialist centre by local ENT clinicians for treatment of misophonia. Inclusion criteria were a diagnosis of misophonia, being between 12 and 16 years old and having a clear memory of past misophonia experiences. Exclusion criteria include the presence of depression and anxiety as a primary diagnosis, and substance misuse.

Hypotheses

It was hypothesised that a reduction in misophonia symptoms would occur following treatment with EMDR.

EMDR therapy

The EMDR therapy was conducted in accordance with Shapiro’s (2018) eight-phase protocol. Therefore Phase 1 involved history taking and formulation; Phase 2 included preparing and equipping the patient with resources; Phase 3 included identifying the target memory, along with positive and negative cognitions; Phase 4 included desensitisation and reprocessing; Phase 5 included installing more adaptive positive cognition; Phase 6 included a body scan to target any residual physical discomfort; Phase 7 involved closure and debriefing, and Phase 8 involved a re-evaluation, during the following session, to determine if any additional work was required.

Assessments

Participants were assessed at baseline (T1) and post-treatment (T2).

Measures

Misophonia symptoms were measured using the revised Amsterdam Misophonia Scale (AMISOS-R) (Schroder & Spape, 2014), which consists of 10 items with scores ranging from 0 to 40. Higher scores indicate greater symptom severity, classified as follows: 0–10 = normal to subclinical; 11–20 = mild misophonia; 21–30 = moderate to severe misophonia, and 31–40 = severe to extreme misophonia.

The perceived intensity of disturbance or distress associated with an image or an emotional memory being recalled was measured using the Subjective Units of Distress (SUD) scale. This score is indexed on an 11-point Likert-type scale, ranging from 0 (‘no disturbance at all’) to 10 (‘greatest level of disturbance’) (Shapiro, 2018). Participants indicated their SUD score verbally to the therapist for each identified event at the start, during and after EMDR therapy. The SUD scores are presented in Table 3.

Statistical analysis

Because this was a pilot study, no formal sample size calculations were performed. The decrease in symptom severity was tested using a paired t-test, with the AMISOS-R total score as the dependent variable and assessment time points (T1 and T2) as the independent factor. Analyses were based on two-tailed t-tests. For both co-primary and secondary outcomes, P<.05 was considered statistically significant. All results should be interpreted as exploratory. Data were analysed using SPSS Statistics (Version 30).

Participant characteristics

A total of four female patients aged between 12 and 16 years were included in the study.

Table 1. Participant characteristics

Primary outcomes

Table 2. Descriptive statistics for the mean changes between baseline and end of treatment in participants (n = 4)

A paired t-test for the participants’ mean scores on the AMISOS-R showed significant improvement on the primary outcome, t (3) = .7529, p<.05. No adverse outcomes or side effects were reported by any of the participants.

Qualitative outcomes

After treatment, one participant said that their misophonia was not ‘front and centre’; it was now ‘in the background’. Further, she reported that her misophonia no longer bothered her in the same way, and that it had made a ‘huge difference’. She was now able to get a job as a waitress in a restaurant following treatment.

Another participant’s parent noticed they were better able to eat meals together as a family and that she would eat a meal with them in the room, whereas before she would eat separately.

Another participant was able to go on holiday with her girlfriends and sleep in the same room with her friends, when previously their breathing would have bothered her.

Table 3. EMDR treatment information of the four participants with misophonia 

Discussion

This is the first clinical case series to examine the feasibility and effectiveness of EMDR on adolescents with misophonia. The results demonstrated that EMDR targeting emotionally disturbing memories associated with the onset or exacerbation of misophonia symptoms led to a significant reduction in these symptoms. Our positive findings align with those of Jager et al. (2021), who also observed a reduction in misophonia symptoms following EMDR targeting misophonia-related memories. Similarly to the Jager et al. (2021) study used Shapiro’s (2018) future template to help patients successfully visualise themselves managing anticipated future events that involve misophonia triggers.

None of the participants reported any adverse reactions to therapy or side effects of treatment. This suggests that EMDR is an acceptable and tolerable treatment approach for adolescents. This is in contrast with Gregory’s (2024) suggestion that exposure therapy is not acceptable as a treatment approach for adults with misophonia.

Limitations and strengths

As this is a small case series without a control group, it, therefore, has several limitations. The absence of a control group prevents us from assessing the effects of time and non-specific factors on misophonia symptoms. In addition, the small sample size prevents generalisation of the findings.

All participants received EMDR from one therapist, and the evaluator was not blinded to treatment. The treatment fidelity measures were not carried out, possibly leading to bias.

Larger sample sizes with more sophisticated data analyses are needed to confirm the effectiveness of EMDR therapy for adolescents with misophonia, and it would be helpful to use longitudinal sampling to measure effects over a period of time.

However, despite these limitations, our study is, to the best of our knowledge, the first to examine EMDR in the treatment of misophonia in adolescents. A case series design was considered appropriate at this early stage of innovation. Importantly, these findings help to raise awareness within the EMDR and audio-vestibular medicine communities that EMDR may be a viable treatment for adolescents with misophonia.

This study provides preliminary evidence supporting EMDR as a viable and appropriate treatment for misophonia in the adolescent age group, and potentially extends the role of EMDR into the auditory field.

Acknowledgements

We sincerely appreciate the four adolescent participants who entrusted us with providing an alternative therapy approach. This case series underwent a clinical governance review and was approved as an audit within a national ear, nose and throat hospital. All participants received an information sheet and provided written informed consent prior to taking part in the audit.

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Conference announcement   

By Alex Button

EMDR UK Association Annual Hybrid Conference & AGM 

Friday 20^th and Saturday 21^st March 2026 

Delta Hotel, Bristol 

Registration for the EMDR UK annual conference has now opened.  The conference will be held in the Delta Hotel, Bristol.   

CPD points: 12 

With the conferences increasing in size each year and feedback from previous conferences being that delegates wish to have more space; the Delta hotel has been specially selected as it boasts the largest conference facility in the Southwest. With a capacity of 500 in-person delegates, it is ideal for large-scale events.  

The Delta hotel is in a prime central location, just a short distance from Cabot Circus – Bristol’s vibrant shopping and dining hub with over 120 stores, bars and restaurants. There are also excellent transport links; just a 15-minute walk or short bus or taxi ride from Bristol Temple Meads station and access to major roads.  

This is a chance to not only attend this national annual event but also to visit this wonderful city, renowned for its rich maritime history, iconic landmarks like the Clifton Suspension Bridge, vibrant street art and cultural contributions, including being the hometown of the famous artist Banksy.  

We received positive feedback from the Liverpool conference in 2025. The conference was widely praised for its high-quality content, diverse speakers, and engaging presentations.  Many delegates rated sessions as “Excellent,” particularly keynote speeches and workshops on IFS (Internal Family Systems), trauma, and addiction.  Keynote presentations were given by the Association’s new Patron Darren McGarvey, and Aileen Alleyne spoke of generational trauma; both of which were highly appreciated. Matt Wesson’s session on adherence to EMDR evidence base sparked deep discussion and reflection and many workshops were reported to have provided practical recommendations and to have deepened delegates’ insight into specific topics. Many attendees felt the conference was well-organized, and both in-person and online experiences were generally positive.  

There were many helpful suggestions given as to what members wanted to see included in the 2026 conference.  We have commissioned a full programme with international and nationally renowned presenters who will inspire and enrich our knowledge and clinical skills.   

In response to desired future workshops, we are delighted to announce that Dr Karsten Böhm will be presenting on using EMDR to treat sexual, aggressive or religious obsessions in OCD. Nick Adams will be presenting on “The Neurobiology of EMDR: Enhancing practice through neuroscientific understanding.”  Peter Pruyn will be giving a very interactive presentation regarding exploration of clinical choices of interweaves in treating menstrual pain. Silva Neves will be speaking about “Working effectively with LGBTQ+ clients,” and Dr Michel Silvestre will be leading the Child and Adolescent stream, where he will be speaking about the “Impact of trauma on the child and his family, individual injury and relational injury.”   

EMDR UK conferences are now hybrid. This offers greater choice and flexibility to meet the needs of association members, and it reduces the global footprint of national association events.   Whilst the Delta hotel is a large conference venue, we have capped the number of in-person spaces to ensure a comfortable environment for delegates and exhibitors.  Book early if you wish to attend in person or further delegates may choose to attend via our professionally managed online platform, which will enable live participation throughout the conference.  Exhibitors will be present in Bristol, and online delegates will have access via links to their sites. 

We attempt to make the conference venue and presentations accessible for all delegates attending in person or remotely, but we appreciate further considerations may be required. If you have any needs, disabilities or difficulties that may impact your engagement in the event please do let us know and we will endeavour to make reasonable adjustments. Please contact Amy Donohoe by email, emdr@eyas.co.uk or telephone 01243 775561, or if preferred, provide a telephone number so that we can get in contact with you to discuss. 

12 EMDR CPD credits will be awarded for the full conference.  The conference will be recorded and available for registered delegates to view for up to 3 months post conference. 

The EMDR Association has committed to planting a tree for every delegate registered and you will also have the opportunity to participate in this carbon reduction initiative at the point of registration. 

Links for registration, conference programme, presenters’ information and conference venue will be provided in due course.  

Registration link:  Click here to register 

Links to Conference Programme and Presenters’ information 

Conference Venue:  Delta Hotels by Marriott Bristol City Centre 

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EMDR service evaluation: The impact of eye movement desensitisation and reprocessing on symptoms of posttraumatic stress disorder and risk in high secure forensic patients

By Lauren Stewart

Learning objectives

• Understand the high prevalence of PTSD in forensic populations and its association with increased risk of anger, aggression and recidivism.
• Recognise the high comorbidity between trauma, PTSD and psychosis in this group, and how these conditions relate to risk factors such as impulsivity, emotional regulation difficulties and dissociative symptoms.
• Appreciate the potential for EMDR to reduce prolonged maladaptive psychological consequences.
• Provide the reader with feedback on whether this treatment is effective in reducing overall symptoms of PTSD and related risk.

Introduction

Since its development, EMDR has established a clear evidence base in the mental health setting to reduce distress associated with trauma ‘symptomology’ and PTSD through multiple clinical domains. For instance, EMDR has been used to treat combat/war veterans’ critical incidents and current triggers, achieving symptom reductions in anger, depression, anxiety and physical pain (Silver et al., 2008). It has also shown its applicability to individuals with pre-verbal trauma or memory blocks with its use alongside art therapy (Struble & Struble, 2020; Tripp, 2023). Additionally, a systematic literature review of randomised control trials by Valiente-Gómez et al. (2017) found that EMDR improves overall trauma-associated experiences and comorbid psychiatric presentations, such as psychosis and schizophrenia. Furthermore, Shapiro (2001), the founder of EMDR, has provided evidence for the efficacy of EMDR across all clinical samples, with the original theory being consistently empirically reviewed and supported within forensic mental health services (Shapiro, 2012; Susanty et al., 2022). 

Psychosis as a trauma response

The term ‘psychosis’ still lacks a unified definition; however, it denotes a clinical construct characterised by several perceptual disturbances such as delusions, hallucinations and disordered thoughts, accompanied by the loss of an emotional connection with oneself or others and a pervasive sense of fear and lack of safety within daily life (Gaebel & Zielasek, 2015).

There is a well-established association between symptoms of trauma and psychosis (Fleurkens et al., 2018; Mueser et al., 2002). This connection is thought to stem from adverse childhood experiences, which are defined as any highly stressful and potentially traumatic event or situation that occurs during childhood and/or adolescence (McFarlane, 2013; Young Minds, n.d.). Research shows that adverse childhood experiences are thought to have a cumulative effect on the likelihood of psychosis occurring in later life. For example, between 50 and 98% of adults with severe mental disorders (such as psychosis) report at least one traumatising childhood experience, with an average of 3.5 incidents per person (Freuh et al., 2005; Goodman et al., 1997). Another study found that 69% of women and 59% of men with diagnoses of psychosis or schizophrenia were sexually or physically abused during childhood (Read et al., 2005). These studies indicate a clear relationship between severe trauma at a young age, overwhelming biological stress, and altered reality perception, leading to psychosis (Mueser et al., 2002).

This connection is believed to stem from alterations in brain structure and function, as well as the central nervous system’s response to perceived threat, resulting from the overwhelming stress and distorted reality often caused by severe trauma (Shevlin et al., 2008). The ‘dose effect’ is a concept that refers to the relationship between the severity, frequency and accumulation of traumatic experiences and the likelihood of developing psychotic symptoms (Varese et al., 2012). It recognises that with each additional traumatic experience, there is a heightened risk of developing psychosis as a response to overwhelming and prolonged stress. This additionally highlights the importance of trauma-informed approaches in both the understanding and treatment of psychotic disorders.

It is therefore important to recognise psychosis as a response to trauma, as some theories suggest that the treatment of PTSD in individuals with psychosis may lead to improvements not only in their trauma-related distress but also in associated risk behaviours. Examples include auditory verbal hallucinations, delusions, anxiety symptoms, depression symptoms and difficulties with self-esteem – all of which can influence a patient’s vulnerability to risk (Van den Berg et al., 2018).

Trauma in the secure forensic setting

Within the forensic population, mental disorder is considered in the risk assessment literature as an important consideration; for instance, the admission criteria for highly secure hospitals state that the individual must pose a grave danger to themselves or the public. Some patients will have been sentenced under a hospital order, whilst others will have been transferred from prison for assessment and/or treatment that is determined to be required under conditions within a highly secure environment (Nottinghamshire Healthcare, n.d.).

Considering psychosis as a trauma response is crucial, as it may increase the risk of violent behaviour when it’s related to the individual’s perception of threats (McFarlane, 2013; Sweeney et al., 2018). This criterion is supported by the literature, which indicates a complex relationship between initial traumatic experiences and presenting violence (Ardino, 2011; Bentall et al., 2014). Violence is described as a way for a patient to mobilise against unresolved trauma, whereby an individual may re-enact an innate ‘blueprint’ that is protective (e.g., hurting someone else to prevent themselves from becoming hurt) (Porges, 2022). Treating trauma in patients who experience psychosis can reduce symptoms such as hallucinations, delusions, anxiety and depression (Van den Berg et al., 2018). Such treatment can further reduce the likelihood of these individuals engaging in criminogenic behaviours, including violence as a method of coping (The Good Lives Model, Ward et al., 2007).

Considering trauma in risk formulation within high secure forensic populations is therefore critical for understanding the distress and coping mechanisms that contribute to mental health disorders. These mechanisms can include addiction, self-harm and suicidal ideation; understanding these links can guide appropriate interventions and help to minimise the risk of re-traumatisation and re-offending (Cleary et al., 2020).

Furthermore, trauma-informed care posits that this risk factor must be embedded within the relationship and ethos of service delivery, as by acknowledging trauma, risk can be appropriately managed while providing patients with the best possible opportunity for safe and effective care (GOV, 2022; Harris & Fallot, 2001). Trauma and PTSD are essential factors when working and formulating risk in a forensic population, not just to reduce levels of risk to others, but also to reduce the impact of re-traumatisation during hospitalisation and treatment of the patient (Goff et al., 2007; Mental Health Act, 1983).

Rationale

There is limited published data on EMDR therapy within this complex forensic population. Most EMDR evaluations have used self-report measures of satisfaction and progress, semi-structured interviews, and thematic analysis to determine service users’ experiences in NHS high secure services (Every-Palmer et al., 2019; 2023). However, these are not behavioural measures, nor are they reflective of the service from a non-biased perspective. For instance, a robust behavioural measure is important for accurately measuring risk, and, although in most services, patients’ self-reports can be relied upon, those in secure mental health settings may be motivated to under- or over-report the severity of their symptoms for a variety of reasons. Therefore, this evaluation was designed to consider the impact of EMDR on the severity of symptoms of PTSD (as linked to psychosis) and related risk, as recorded by staff in the patients’ notes. This approach allows for the clear exploration of day-to-day stressors and symptoms systematically through the analysis of records relating directly to each patient’s behaviours. Our hypothesis here expects to see a reduction in symptoms following EMDR.

The effect EMDR therapy has on high secure patients remains unclear regarding related risk and practice efficacy. ‘Least restrictive practice’ is a core clinical and ethical principle that underpins guidelines by the National Institute for Health and Care Excellence (NICE, 2005), ensuring that therapy is respectful, person-centred and supportive of patient recovery and progression to less secure environments. This evaluation was therefore in both the service users’ and service providers’ best interest to better understand the effectiveness of EMDR within this population.

Method

This service evaluation consisted of a multiple single-case design using content analysis to compare the case notes of four forensic patients recruited within a high secure hospital. Each patient had completed EMDR at least six months before the start of data collection and had the capacity to consent to participate.

Demographic information, including age, gender, ethnicity and diagnosis of the patients was extracted (see Table 1). No personally identifiable information was included in the data.

Table 1

Demographic information.

This service evaluation was approved by the University of Lincoln School of Psychology ethics committee (2024_17513) and the NHS Trust’s Research and Ethics team. Patients provided informed consent via a form that outlined the usage of EMDR data, their voluntary participation, anonymity and withdrawal rights. No deception occurred, and a support section was included.

Any names or initials within case notes and reports were also anonymised by replacing them with non-related characters (e.g., ‘X’).

The DSM-5 (American Psychiatric Association, 2013; SAMHSA, 2014) diagnostic criteria for PTSD was used as a pre-determined symptom checklist to identify symptoms in each patient’s RiO nursing notes.

To collect the data, the researcher considered a total of 12 months’ worth of nursing notes per patient (six months pre- and post-EMDR) and used the pre-determined symptom checklist to identify the presence of PTSD symptoms in each patient. Whenever the researcher encountered a behaviour or statement in the nursing notes that matched any PTSD symptoms, it was recorded. Additionally, the frequency of incident reports (IR1s) was collected to indicate the presence of aggressive behaviours – verbal, physical or otherwise – that pose a risk to the safety and well-being of patients, staff or others within the hospital environment.

All four patients had the same EMDR-practitioner-accredited therapist who only engaged with these individuals for EMDR therapy when it was deemed appropriate by a multidisciplinary care team and with consideration to their diagnosis. The length of EMDR therapy across the four patients ranged from four to 17 months.

Analytical strategy

Following the extraction of data, an inter-rater reliability check was conducted to confirm the classification of each identified symptom. The total number of reports of symptoms per patient before and after EMDR was then generated to indicate a total quantitative trauma characteristic pre- and post-EMDR for each patient. Additionally, the symptoms with the highest counts and the most prevalence across all four patients were identified.

The extracted numerical data was imported and analysed using non-parametric Wilcoxon tests in R Studio (Version 2024.04.2-764).

Results

There was a variation in the number of symptoms reported across all four patients, with Patient 4 having many more symptoms than the other three. For example, Patient 1 had a total number of 16 identified symptoms of PTSD before EMDR and five after, which was the lowest number of symptoms identified, whereas Patient 4 had 163 symptoms before EMDR and 170 after, indicating that Patient 4 had the highest number of identified symptoms. This is illustrated in Figure 1.

Figure 1

The number of identified PTSD symptoms before and after EMDR for each patient.

On average, patients displayed a higher frequency of symptoms before EMDR (M = 80.5) than after EMDR (M = 62.25), indicating that there was an overall higher level of symptoms of PTSD before EMDR treatment, which is clinically meaningful.

Of the 13 identified symptoms, only four had enough statistically meaningful data to make additional comparisons. This was determined by identifying any symptom that had a frequency count higher than 10 either before or after EMDR.

The four symptoms that met this criterion were ‘hypervigilance,’ ‘impairment in areas of social functioning,’ ‘irritable behaviour and angry outbursts,’ and ‘sleep disturbance.’ Wilcoxon tests revealed no significant differences (Hypervigilance: V = 5, p = 1;Impairment in areas of social functioning: V = 0, p = 0.18;Irritable behaviour and angry outbursts: V = 3, p = 0.37; Sleep disturbance: V = 0, p = 0.18).

These results are shown graphically for each patient in Figure 2:

Figure 2

The total number of symptoms across each patient and each of the four identified symptoms.

Finally, the number of incident reports for each patient before and after EMDR was analysed (see Table 2). These included behaviours that demonstrated recurrent, persistent negative emotional states (e.g., fear, anger and shame), reckless or self-destructive behaviour and/or irritable behaviour resulting in physical or verbal aggression toward other people, and physical arousal or reactivity (e.g., hypervigilance). This number further demonstrated the individualistic needs and characteristics of each patient.

Table 2

Discussion

It was posited that following EMDR, a reduction in PTSD symptoms would be evident due to the well-established connections between trauma, psychosis and PTSD. However, this was not the case across the whole sample, nor when the patients were split according to the four most prevalent symptoms – the influence of EMDR on each of these symptoms was also statistically non-significant. Although these results appear less consistent with the existing research, the trends in the frequencies of the data per patient can suggest that further research may reveal meaningful and clinical implications. For instance, from Figure 1, it appears that Patients 1 and 3 improved, while Patients 2 and 4 did not. In contrast, Figure 2 suggests that although the overall symptom count for Patient 4 stayed consistent, his hypervigilance and irritability got worse, and his sleep and social interactions improved. Additionally, although the p-value was above the conventional threshold, the median number of symptoms before (71.5) and after (37) EMDR indicates there was a clinically meaningful moderate relationship on an ‘individualistic’ level that warrants further investigation and discussion.

It could be posited that the results would support the need for an idiosyncratic approach to EMDR treatment and evaluation. Trauma-informed care already places great emphasis on the importance of trauma in mental health and risk (GOV, 2022), but this does not eliminate the possibility that additional/other factors may have influenced behavioural response (Malvaso et al., 2016). As shown in Figure 2, Patients 2 and 4 saw the largest increase in ‘hypervigilance’ and ‘irritable behaviour and angry outbursts’. However, Patients 2 and 4 moved to medium secure units for a three-month trial leave shortly after the completion of EMDR. This makes the results harder to interpret, as the staff in medium secure units may have very different thresholds for what they regard as ‘worthy’ of recording in a patient’s notes. Moreover, this move to a new facility will likely have increased hypervigilance due to the disrupted feelings of attachment and reinstated feelings of insecurity, abandonment or rejection (McMurran, 2002). It is important to consider protective factors, such as security and safety during the stages of change in a forensic setting, as these factors can be used to help minimise a patient’s fluctuations in hypervigilance and paranoia.

Expanding on this potential alternate factor, there are a multitude of confounding factors why the move to a medium secure unit may have had a destabilising effect on the patient’s rehabilitation. As explained by Attachment Theory (Bowlby, 1982), the consistency of a therapeutic relationship between patient and practitioner is invaluable to the reduction of maladaptive coping mechanisms, aggressive outbursts, and violent behaviours (Alshahrani et al., 2022) as it may have been the first opportunity for a corrective emotional experience in relation to patterns of attachment. Therefore, the move to a medium secure unit may have disrupted feelings of attachment and reinstated feelings of insecurity, abandonment or rejection (McMurran, 2002) and acted as a trigger for a multitude of harmful/maladaptive coping mechanisms. This may explain why Patients 2 and 4 appeared to have deteriorated after treatment, as evidenced by their increase in symptoms and behavioural incidents; Patient 2’s symptoms increased by 68%, and Patient 4’s increased by 83%.

It could also be argued that the transition to a lower-security hospital resulted from a reduction in risk and symptomology, apparent after EMDR treatment, that may not have been captured using the method of data collection. What was clinically evident was a reduction in risk-related treatment needs associated with trauma response, alongside more adaptive functioning in daily living, such as less conflict with peers, adherence to ward rules, greater distress tolerance and emotional regulation. This suggests a positive clinical impact of EMDR, supporting its role in promoting adaptive functioning in individuals with complex trauma histories (Shapiro, 2001; Porges & Dana, 2018).

The use of psychiatric diagnoses may also influence the difference in symptom frequencies. Patients had multiple diagnoses, many with overlapping symptomology; for example, symptoms such as hypervigilance could be identified both as being part of PTSD diagnostic criteria as well as Schizophrenia. This identifies the limitations of using a diagnostic and categorical approach to understanding presenting problems. As such, how staff choose to record behaviours under these categories may vary and therefore influence the data.

It is essential to address the confounding factor of comorbidity when working with a high secure population, due to the complexity of serious mental disorders and the idiosyncratic challenges in treatment. Trauma-informed care and thinking provide a greater understanding of the root causes of problematic behaviours and their links to both mental disorder and risk. Focusing on these aspects, rather than the psychiatric diagnosis, could better capture symptom expression and change (Sweeney et al., 2018).

One key finding from this service evaluation is that it demonstrates a methodology that is both practical and efficient. It accounts for significant variables before and after EMDR and utilises existing data, thereby easing the workload typically required for data collection in inpatient settings. Additionally, the methodology can be used to portray the practitioner’s capacity to tailor treatment to the individuality of the patient. For instance, it identified treatments that took place before EMDR, such as dialectical behavioural therapy (Patient 1) and schema-informed sessions (Patients 2 and 3). This retrospective method supports the evaluation of EMDR’s effectiveness across diverse patient backgrounds and offers insight into the varying lengths of EMDR treatment, hospital stay duration and differences in presentations/levels of dissociation.

Additionally, this methodology highlights the complexity of conducting research in high secure settings and the many confounding factors that are difficult to control when examining pre-recorded data. For instance, moving patients between wards and facilities can destabilise the provision of treatment; changes in psychologists can cause setbacks due to a need for attachment and a reduction in their sense of safety; and it can be problematic to use patient notes and records retrospectively, as patients have already moved on and confounding factors cannot be controlled (Silver et al., 2008; Rodenburg et al., 2009; Porges & Buczyński, 2011).

To mitigate this complexity and confounding factors, a working model of EMDR integrated with the psychological model of understanding is useful to facilitate understanding the individual and unique presentation of each patient. As described by Mueser et al., (2010), patients with PTSD, schizophrenia and psychosis are all likely to have different presentations and triggers based on their individual trauma histories and adverse childhood experiences. However, current NICE guidance focuses on the least restrictive settings and does not seemingly fully consider the additional complexities of patients in high secure services. This emphasises the requirement for EMDR practitioners to act responsively to presenting patient needs rather than adhering to a standard protocol across all cases (Chadwick & Billings, 2022; NICE, 2005).

It has been established that there is a need to adapt common approaches to trauma using EMDR. Given that EMDR is considered a non-directive exposure therapy, as it allows patients to have free associations and quickly move through traumatic memories in a “patient-led” manner (Shapiro, 2001), the need for preparatory work is extensive. Each practitioner should take an individualised approach to formulation to understand the presenting difficulties, resulting coping strategies and threat responses of each patient to appropriately inform treatment goals and approaches (Chadwick & Billings, 2022; Johnstone & Boyle, 2018).

Limitations

Due to the nature of working with vulnerable adults and high secure data, patients had to be selected according to the inclusion/exclusion criteria and give formal consent, which led to a lower participation number. The therapist was a white, British female, and the population in the recruited sample was all white, British and male, thus limiting the generalisability of these results to females and more diverse demographics. Despite a notable timeframe for collecting data, the study was only able to recruit four patients. This was due to the limited number of individuals who had completed EMDR therapy within the service across the six-month pre- and post-timeframe. As noted, a single-case design may have been more informative and reduced the number of confounding factors; however, this would have had implications for the overall generalisability of the results.

Although content analysis has demonstrated rigour among qualitative studies (Strijbos et al., 2006), it requires rigid adherence to predetermined themes – in this case, the DSM-5 diagnostic criteria for PTSD – which can limit the researcher’s ability to respond to unexpected insights or novel aspects of the data (Kalpokas & Hecker, 2024). This approach may have led the researcher to overlook the nuances of individuality between patients or symptoms of trauma that are not conventionally recognised. Furthermore, the use of nursing notes brings a subjective limitation to the collected data. The quality and consistency of nursing notes are likely to vary across different wards, hospitals, and over time due to individual staff variables; for instance, the experiences and subsequent recordings of one staff member may differ significantly from those of another (Font-Jimenez et al., 2020). This could also be an explanation for the increase in symptoms noted when patients have moved facilities, which could be attributed to a difficulty in validating the collected data that is inherently opinion-based and time-relevant.

Summary

This service evaluation adds to the growing literature and evidence base for the application of EMDR in treating trauma, psychosis and related risks. It demonstrates a successful methodology that provides some insight into how patients have changed pre- and post-EMDR and draws attention to the individuality and complexity of high secure patients. Furthermore, with the various models, associated mechanisms and connections from the literature, it is reasonably assumed that due to a reduction in traumatic distress, there has been a reduction in risk following EMDR. This is evident in the increase in adaptive functioning demonstrated by each of the patients moving on from a high secure to a medium secure unit.

It is also recognised that EMDR can clinically influence the frequency of specific symptoms of PTSD in some patients on a single-case basis and, thus, has clinical utility in reducing traumatic distress when therapy is patient-led. Exposure to previous trauma that occurs during EMDR therapy should follow the least direct route possible, addressing original traumatic memories whilst minimising overall distress. This approach supports the effectiveness of EMDR by helping individuals to start to heal unresolved trauma in line with EMDR’s underlying Adaptive Information Processing (AIP) model, reducing the emotional charge of traumatic memories and weakening harmful psychotic experiences and associated behavioural responses. Continued investigation in both clinical practice and research would allow clinicians and services to have the best understanding of how EMDR can help reduce distress that is representative of the manifestations of trauma and associated risk.

Further reading

Every-Palmer, S., Ross, B., Flewett, T., Rutledge, E., Hansby, O., & Bell, E. (2023).  Eye movement desensitisation and reprocessing (EMDR) therapy in prison and forensic services: A qualitative study of lived experience. European Journal of Psychotraumatology, 14(2). 

https://doi.org/10.1080/20008066.2023.2282029

Shapiro, F. (2012). EMDR therapy: An overview of current and future research. European Review of Applied Psychology, 62(4), 193–195.

https://doi.org/10.1016/j.erap.2012.09.005

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“I have to climb mountains”: combining Pilates with EMDR in recovery from chronic lower back pain

By Andrew Keefe

The NICE guideline (2020) for the treatment of non-specific chronic lower back pain (CLBP) –pain lasting for more than twelve weeks, with no identified physical or structural cause – states that clinicians should:

“Consider psychological therapies using a cognitive behavioural approach for managing low back pain with or without sciatica, but only as part of a treatment package including ‘exercise’ (my emphasis) with or without manual therapy (spinal manipulation, mobilisation or soft tissue techniques such as massage).”

There is growing evidence that EMDR is an effective treatment for chronic pain (Grant, 2018; Gerhardt et al., 2016) and that Pilates may be more effective than other forms of exercise for treating and preventing CLBP (Domingues de Freitas et al., 2020; Wells et al., 2014). I am a personal trainer and Pilates teacher specialising in exercise for CLBP as well as an EMDR therapist specialising in trauma-related chronic pain. I run a recovery programme for people living with CLBP, combining individual EMDR sessions with a weekly online Pilates group focusing on improving core strength and spinal flexibility.

This case report regards ‘Sara,’ a former participant in the programme, and explores the question: Can Pilates and EMDR be an effective combination of psychotherapy and exercise for recovery from CLBP?

Sara and the initial consultation

Sara is 30 years old. Seven years ago, while studying for a master’s degree abroad, she had a sudden attack of back pain at an airport while travelling to the UK for a visit. The pain was excruciating and felt in the L4/L5 area of the spine (between the fourth and fifth lumbar vertebrae, counting from the top of the spine, so at the very bottom of the spine, just above the sacrum). The pain became chronic, and Sara had to give up her course and return home. At assessment, she was living with her parents, still in pain and with limited mobility, seven years after the incident at the airport when the pain began.

Sara described a happy childhood, good relationships with family and no major traumas. I administered the Back Bournemouth Questionnaire (Bolton & Humphreys, 2002), a recognised tool for assessing the physical and psychological impact of CLBP, and Sara scored 34 out of a possible 70, indicating moderate but significant levels of pain, anxiety and depression. She described her pain as a “dull ache” rated at 5 out of 10 on a numerical scale (0 = no pain, 10 = the worst pain imaginable). She could only stand for a few minutes and walk for five minutes at a time before the pain increased and she needed to rest.

I talked Sara through Grant’s (2018, p. 253) ‘pendulation’ exercise (where the therapist asks the client to focus on the area in pain, then another part of the body that is not in pain, and ‘gather up’ that more comfortable experience and take it back to the area in pain, and ‘pour it over’ to feel the relief). She reported a small, positive effect on her pain, making her feel more relaxed. This also indicated a psychological element to the pain, and that finding further ways to help Sara relax could be beneficial. I undertook a postural and movement analysis, in line with best practice, when a client joins a Pilates group to better understand how the back pain impacted on her functionally so the session exercises could be made accessible for her.

Initial formulation

Sara was diagnosed originally with an “annular tear” in the L4/L5 area, which meant there was damage to the external, fibrous ring (annulus fibrosus) of the intervertebral disc between L4 and L5. If pressure were placed on the disc concerned (by sitting for too long or through poor posture, for example), part of the disc would push out through the tear in the fibrous ring meant to hold it in place, pressing onto nerves coming out of the spinal column and thus causing pain. The spinal specialists Sara consulted told her the pain was “excessive,” given the current physical condition of her spine. As Sara had become almost house-bound, creating muscle tone loss in the core and stiffness in the spine, she was less able to use her core to support her spine, making the pain worse. Being less mobile affected her confidence: she talked of low mood and anxiety, which also exacerbate pain (Grant, 2018, pp. 39-40; Lalkhen, 2021, p. 15), and had tried several treatments over the years, none of which had a lasting effect, leading to a sense of hopelessness. In the absence of any identified serious early trauma, I believed the experience of the sudden onset of the pain at the airport and its subsequent impact on her life to be worthy of exploration and processing, as the memories of such experiences may well have prolonged the pain.

I believed Sara’s CLBP began with the annular tear, which happened for reasons unknown. The injury took time to heal, and over time, her brain’s pain system became overly sensitised to harm signals from the L4/L5 area. This, together with the stress of the initial incident, its impact on her life and career, and the ongoing stress of being virtually housebound for seven years and not recovering, becoming less and less mobile, as described, exacerbated and maintained the pain.

We agreed Sara would begin weekly EMDR sessions to address the psychological aspects of her pain and join my Pilates group in a few weeks, when the next term began, to improve her core strength, mobility and posture – addressing the physical elements of her condition. Sara accepted my suggestion that she begin the class seated in a chair (chair Pilates), given her limited mobility and the fact that she could only stand for a few minutes at a time, as the class is 60 minutes long.

Course of treatment

As Sara reported no early traumas, I began searching for targets by asking her to ‘listen’ to her back pain (Keefe, 2024). I asked her to close her eyes, slow her breathing and focus on the sensations in the painful areas of her lower back. I then asked her to imagine the pain could speak to her and what it would say. After a minute, Sara responded, “It’s saying, ‘Pay attention to me, I need some attention.’” She was surprised by this, as she felt very well connected to family and friends and believed she had all the attention she needed.

I asked Sara to focus on the “pain itself,” notice any related thoughts, emotions or images, and then let her mind drift back to similar moments in her past (Shapiro, 2001, P. 433).

Sara found a memory from six months after the initial episode at the airport, when the pain began. She was still living in the same country and was lying on her bed, unable to move, when an alarm sounded in the street outside. There were two separate alarm sounds: one to indicate a fire in the neighbourhood and the other to warn of an earthquake. The latter alarm sounded, and Sara was terrified.

Sara’s negative cognitions were “I’m stuck here” and “I will never get home”. Her positive cognition was “I can move, and I can leave,” (VOC = 3). Her emotions were fear and panic (SUD = 7). Sara reported a “panicky feeling” in her body, “like you’re in fight or flight.”

We agreed to begin processing by targeting this memory, and Sara noted she was sitting up more already, with less leaning from side to side (Sara would often rock slightly from side to side when sitting down, as sitting in one position for too long exacerbated the pain).

Processing this memory led, over the next few weeks, to a series of memories related to her experience of CLBP, including: lying in her bed in pain, unable to move but trying to write an essay; being in agony at the end of a long flight home – she was in business class, so could lie down for most of the flight, but had to sit up for thirty minutes while the plane was landing and this caused excruciating pain in her lumbar spine; a time when her back was improving, when she bent down to pick up a heavy pot from a low shelf in her kitchen, which made the condition much worse, leading to seven months of increased pain and reduced mobility (I met Sara at the end of this period); and a Christmas dinner when she was in so much pain she had to lie down upstairs, listening to family and friends enjoying themselves downstairs.

 In other sessions, we processed the pain itself in her lumbar spine directly, as when she had a flare-up after several weeks of progress in reducing pain and increasing mobility and an unidentified but chronic stomach pain that Sara linked to her underlying health anxiety. We also processed Sara’s anxiety about an upcoming train trip to London and her fear of collapsing with pain, needing to go to the hospital by ambulance, and the bodily anxiety she felt when thinking about the future in general.

Technically, memories were processed using the standard protocol and Pain-Itself; the actual physical experience of painwas processed using Grant’s (2018, p. 222) EMDR Pain Protocol by asking Sara to focus on the pain and note what images, negative cognitions, emotions and other bodily sensations she noticed, with the pain being rated on a numerical scale of 0 to10 alongside VOC and SUDs. ‘Float backs’ were used when addressing issues in the present or future to identify the source of the present disturbance: the root of the anxiety about the train trip to London, for instance, was found to be the memory of being in agony at the airport, requiring an ambulance to be called and morphine administered. Sara found ‘time travelling’ (rescue interweaves) particularly helpful, as, when I asked what she would say to her younger self if she could travel back in time to a moment of especially intense pain to help, she said, “I would tell her the pain will never be this bad again and that things will improve.” The positive feelings thus invoked were then installed as a resource, using BLS.

Sara’s negative cognitions expressed themes of helplessness (“I can’t do anything without causing pain,” “I can’t look after myself”), disbelief (“Why me? I don’t have bad luck like this”), self-blame (“Why did I do that? I made the pain worse”) and isolation (“No one understands what this is like for me”).

Her positive cognitions, as ever, acted as antidotes (“I can move, and I can leave,” “I can look after myself,” “I can move safely and without pain,” “I can accept that I am well” or “I can cook dinner for my family and enjoy it”). Sara’s VOCs for these PCs would typically move from 1/7 to 7/7, from Phase 3 to Phase 5, showing a growing sense of agency, confidence and optimism, reflected in her reported material between sets. When processing the earthquake memory, Sara moved from the terror of lying on her bed, thinking she couldn’t move while listening to the alarm signalling the start of an earthquake, to getting out of bed and outside her apartment, where she meets a neighbour who helps her onto the street. There, she meets the building caretaker, who tells her it’s a false alarm. She felt the relief flowing through her body; the SUD went from 6/10 to 0, and the VOC from 2 to 7.

 Sara attended her first session of my weekly Pilates for Chronic Lower Back Pain class after the third EMDR session. Pilates is a progressive, “layer-based exercise system. Participants typically take a twelve-week course, beginning with Level 1, or the simplest, most accessible version of each exercise, spending four weeks practising this level while gradually increasing the number of repetitions, before moving onto Level 2 for four weeks and finally Level 3, provided each layer has been accomplished. I also provided Sara with relevant information and explanations, including the nature and role of fascia in CLBP (Lesondak, 2023), the neurology of pain, and the link between trauma, stress and pain.

Sara talked about her progress in Pilates in her therapy sessions, providing a language to express and track her physical progress. After three sessions, she mentioned feeling a bit more mobile and able to walk further. At week seven, she could stand for longer and bend down to pick something up from nearly floor level, which she couldn’t do before. At week eight, she asked for recordings of the early sessions so she could try the exercises she couldn’t do before. By week nine, she could walk for forty minutes (up from five at week one). She was “wiped out” afterwards, but not in pain. In that week’s Pilates class, she got down onto the floor and lay on her back with both legs in the ‘tabletop’ position (knees over hips, shins parallel to the floor, a staple position in Pilates, from which many exercises begin), which she couldn’t do before.

At week 10, she had “a bit of a setback.” The pain at L4/L5 had increased, and she couldn’t do as much in the Pilates class. However, she wasn’t despondent, saying, “I know there’ll be ups and downs in my recovery; I still have to climb mountains.” She noted that although the pain had gone up, she was less bothered by it. She began to recover within a few days, returning to where she had been before, in terms of Pilates, within three weeks.

Outcomes

At the final session (session 16), Sara’s score on the Bournemouth Back Questionnaire was 22/70, down from 34 at assessment. Her pain score had reduced from 5/10 at assessment to 0.5/10 at week 16. Sara says she feels much better. She had made progress before, like when she went to ‘back school’ and had a mixture of education, movement, physio and group therapy, but the progress never lasted after the intervention ended.

The progress she’s made through Pilates has been more sustained and consistent. In September, she could only do housework in small bursts. However, now (in January), she can cook dinner in one go. At the start, she could only sit for a few minutes but can now manage a couple of hours. She can tolerate the pain much better, which has greatly improved her mood. She now has two new goals of having a nine-to-five job and travelling to socialise. She can sit and type for about 10 minutes without any pain and can take a break then, if needed. She feels more comfortable if upright or reclining.

At assessment, Sara had very limited flexion/extension (rolling down and up again) and rotation mobility in her spine, and as she could only stand for a few minutes, she did the first couple of Pilates classes sitting down, using adapted, ‘chair-based’ versions of the exercises, followed by the rest of the class. She could not get onto the floor and back up without the aid of a chair. The Pilates classes built her core, upper and lower body strength, and improved her spinal flexibility, and I encouraged her to walk every day, gradually increasing the distance and hence time spent walking. By the end of the programme, she could do the whole routine of nine exercises either standing or on the mat as appropriate. She could also walk for 40 minutes, up from five minutes at the start of the programme. The progressive nature of the Pilates classes gave Sara a ladder to climb up. Her confidence improved as she could do more and more of the routine, and this complemented and supported the cognitive change (the movement from helplessness and pessimism to agency and optimism about the future described above).

Discussion

Research literature on the effectiveness of EMDR in the treatment of chronic pain in general and CLBP specifically is growing (Grant, 2018; Gerhardt et al., 2016),and the mechanisms by which this happens are clearly explained (Grant, 2018), therefore, Sara’s progress after 16 sessions of EMDR was to be expected, to some extent. The novel factor in this case study is the Pilates programme Sara undertook alongside EMDR, raising the question of whether the Pilates contributed to the reduction in her pain, and if so, how.

Pilates is a system of exercise developed by Joseph Pilates in the 1920s (Steel, 2020), promoting core and whole-body strength and flexibility. A systematic review by Wells et al (2014) concluded that findings from the studies concerned show Pilates is effective in the treatment of CLBP and more effective than other forms of exercise.  The teaching and practice of Pilates are based on the six principles of breath, concentration, centring, control, precision and smooth, flowing movement, which all contribute to addressing the ‘physical’ causes of CLBP, but two of the principles (smooth, flowing movement and concentration) also address the psychological elements.

In a Pilates session, one is taught to move smoothly, with flow – not to rush but to move with control and precision. Pilates teachers encourage participants to concentrate on the movement, letting go of all other thoughts. Breath sets the rhythm of movement (usually one inhales to prepare, moves on the exhale, and returns on the inhale). This engages the parasympathetic nervous system, as does Yoga (Emerson & Hopper, 2011), calming and relaxing the body. Focusing mindfully on this smooth movement engages interoception, which is the process of the nervous system informing the brain of ‘how’ the body is. (Myers, 2014, p. 281). The brain receives messages that the body is moving smoothly, without impediment. To live with CLBP is to be beset with maladaptive cognitions: “If I move, the pain gets worse ”, “I can’t move without pain.” Pilates counters these thoughts with more adaptive information generated by this combination of focusing on the smoothly moving body, contributing to, and enhancing AIP (Shapiro, 2001, P. 456).

This process counteracts the ‘centralisation’ effect, often a significant factor in the development and maintenance of CLBP. When there is a physical cause for the pain (such as Sara’s annular tear), harm signals are sent from the site of the damage to the pain system in the brain. The brain analyses the signals, decides there is a risk of further damage unless the harm is attended to, and induces the sensation of pain in the relevant area to alert the conscious brain into action. If the damage takes time to heal, the harm signals will continue, and the pain system will become overly sensitive to them, continuing to send out pain signals, even though the harm signals are weakening as the damage slowly heals.

Sometimes the brain continues to send out pain signals even after the damage has healed and the harm signals have ceased – the mechanism through which phantom limb pain can develop (Doidge, 2007, pp. 184-186). Put another way, one part of the brain will be aware that the damage has healed and there is no need to feel pain, while another part still thinks there is harm in the lumbar spine, so it continues to send out pain signals. Ultimately, it is the brain’s decision whether something should hurt. In making the decision, the brain not only considers information received from the body through the nervous system, as discussed, but also how the person feels, including how stressed, depressed, anxious or traumatised they may be (Lalkhen, 2021, pp. 16-18).

Norman Doidge (2007, p. 192) quotes neurologist and expert on phantom limb pain, V. S. Ramachandran: “Pain is an opinion on the organism’s health, rather than a reflexive response to injury.” The more emotionally distressed someone is, the more likely it is their brain will send them pain. Depression and anxiety also lead to a fall in serotonin levels in the blood, which acts both as a painkiller and a mood regulator. (Lalkhen, 2021, p. 15).

Melzack and Wall’s groundbreaking work on the “Gate Control Theory of Pain,” published in 1965 (as cited in Lalkhen, 2021, pp. 153-54), showed that even where there is physical damage, the brain can stop the body feeling pain if this would be unhelpful under the circumstances. For example, if a soldier is wounded in a battle, they may not feel pain until the fighting is over and they have reached safety. If the brain had let them feel pain at the time, they would have stopped fighting and could have been killed. The brain does this by releasing endorphins and other painkillers to close a series of ‘gates’ along the nerves running up and down the spinal column, preventing pain signals from passing through them.

Psycho-education on this process, and the brain’s role in deciding whether the body should feel pain, helps clients understand how Bi-Lateral Stimulation (BLS )can address pain by stimulating AIP, promoting flow of information around the brain, so that the pain centre, which still thinks the body is damaged, can receive updated information about the healing of the injury concerned. However, such interventions need to be delivered sensitively and carefully to avoid the client believing you are telling them that “it’s all in your head” or “you’re making this up,” reminding them of unhelpful encounters with previous clinicians. In some cases, this can repeat patterns from childhood where expressing emotion was discouraged and emotional pain was unconsciously converted into physical pain to make it feel more manageable. This dynamic is recognised as a risk factor for the development of chronic pain in adulthood. (Grant, 2018, pp. 214-215; Keefe, 2024).

The EMDR/AIP approach promotes the flow of information around the brain through BLS, so the news that the original damage has healed can reach the part of the brain that thinks the lumbar spine hasn’t healed yet. Pilates contributes to this process by sending information to the brain (through proprioception and interoception) about the moving spine, which is getting stronger.

Walking (Pocovi et al  2024) is an effective method of reducing and preventing CLBP, and as Sara was keen to walk more, it gave us another metric (alongside pain measurements and progress through the Pilates programme) to measure her progress, i.e., tracking the number of minutes she could walk each day.

Sara’s responses to BLS showed her moving from being a passive recipient of pain at the start, to gaining a sense that she has control over the pain by sessions 15 and 16. This change could be seen within sessions, such as when we processed the memory of the earthquake alarm. At the start she felt terrified and helpless, but she then remembered getting out of her flat to find help. She also remembered more traumatic moments of the story than she was in touch with at assessment, enabling these to be processed too. This takes the view that traumatic memory is sometimes stored in the body as chronic pain, the processing can cause more experience to be converted back into memory, allowing it to be processed.

Education around the role of fascia in spinal health (Lesondak, 2023) aided Sara’s understanding of the condition, again helping her feel less helpless and more in control. This shift helped Sara take a positive approach to the increase in pain she experienced around week 10, regarding it as due to becoming more mobile during her recovery, rather than as a problem. She reached the point where she could distinguish between the pain itself – the actual physical sensation of pain – and the emotional experience of it, and how much she was bothered or disturbed by it. This is an important milestone in the recovery journey. As you become less emotionally disturbed by the pain, feelings of overwhelm reduce and agency returns. The fear that moving will exacerbate the pain decreases, and you become more physically and socially active, more engaged in the world again and less isolated by it. More physical movement and having other things to do and think about, to distract yourself with, all contribute to lower pain (Grant, 2018, p. 246).

Conclusion

Returning to the question asked at the start of this paper: Can Pilates and EMDR be an effective combination of psychotherapy and exercise for recovery from CLBP?

By the end of the combined Pilates and EMDR programme described, Sara’s CLBP had improved considerably. Her pain level had reduced from 5/10 to 0.5/10, she was more mobile and she was able to walk for forty minutes at a time compared to just five minutes as at the start. She could also stand for longer periods, including long enough to cook for herself and her family.

As noted, there is growing evidence that EMDR is an effective treatment for chronic pain; therefore, it is important to question whether this improvement would have happened anyway, without the Pilates or whether the exercise programme contributed to and enhanced the process of recovery. Clearly, there is a need for further research, as this is only a single case study.

 I believe the Pilates programme added several elements to the recovery process that were not provided by EMDR alone. Firstly, to the extent that there was still physical damage to the intervertebral disc with the annular tear, Pilates will have assisted with the physical resolution of the issue by strengthening Sara’s core and improving her posture, enabling her deep core/spinal stabiliser muscles to lengthen her spine, pulling the L4 vertebrae upwards, lessening pressure on the disc that sits below it and above L5. There would therefore be less pressure on the gel-like, inner part of the disc (nucleus pulposus) to push out through the tear in the outer ring and put pressure on spinal nerves, reducing the physical elements of the pain.

Secondly, Pilates is a form of AIP. Sensory data gathered through focusing on the smoothly moving body becomes part of the ‘adaptive information’ that BLS processes, updating the brain’s pain centre regarding the true condition of the lumbar spine.

Thirdly, Pilates provides the participant a ladder to climb up: the layered approach of Pilates, gradually increasing the difficulty of each exercise and the number of repetitions, allows participants to understand that they are making progress and Sara found this very helpful. Each EMDR session would begin with a brief update on how she had found that week’s Pilates session. Sara’s progress, from sitting in a chair to fully participating in classes (standing and lying on the mat), translated into improvements in her activities of daily living (ADLs). This gave her greater confidence and contributed to the shift from negative to positive beliefs noted earlier, which was a key feature of her recovery.

This experience can be used as a resource. As Sara became stronger and more mobile, I was able to ask her to visualise herself performing an exercise such as the Roll Down (see Table 1), to notice her emotions and where she felt them in her body and then use BLS to install the resource. When Sara had the setback at week 10, this knowledge sustained her and helped her view the increase in pain as temporary and probably just caused by increased fatigue, as becoming more active put more strain on her muscles.

Finally, offering a Pilates programme alongside therapy and making space in the therapy to reflect on Sara’s experience of Pilates is a powerful way of taking the physical reality of the pain seriously and avoiding the pitfalls of focusing exclusively on the psychological aspects (Keefe, 2024).

The overall effect of the Pilates programme complemented the AIP work of the EMDR sessions themselves in targeting traumatic memories underlying and generating the pain and the pain itself (Grant, 2018). Sara was courageous and determined to recover. Pilates gave her something she could actively do to contribute to her recovery, rather than being a passive recipient of therapy, and this was also a major factor.

Although not all EMDR therapists aspire to become Pilates teachers, increasing awareness of spinal anatomy and how core stability and increasing flexibility in the spine can reduce and prevent CLBP can help therapists to understand why the NICE guideline recommends the combined approach and explain this to clients. The more you understand about what happens in a Pilates session, the more you can understand the progress a client is making, which you can then use in therapy sessions to resource the client. Rather than being an adjunctive therapy, I regard exercise and Pilates as an essential element of the therapy itself, which greatly assists recovery from CLBP.

Statement of consent 

I can confirm that the client who is the subject of this case study has given their full consent: they gave consent for me to begin work on the article and have read this finished version. They are aware that the article is aimed at publication in the EMDR Therapy Quarterly and are content for it to be published. 

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Research News

By Anthea Sutton

EMDR Publications Database

A selected summary of recent research added to the EMDR Publications Database

We begin this update with a retrospective study published by Professor Jaime Delgadillo (King’s College London) and Dr Thomas Richardson (University of Southampton) on the associations between neighbourhood socio-economic deprivation, PTSD severity and treatment response (Delgadillo & Richardson, 2025).  The study analysed 2,064 electronic health records of patients treated for PTSD across 16 psychological therapy services in England. It revealed that patients seeking psychological therapy (TF-CBT or EMDR) living in socio-economically deprived neighbourhoods had more severe PTSD symptoms before therapy compared to those living in more economically advantaged neighbourhoods. Additionally, they demonstrated a poorer response to treatment unless they received lengthier interventions.

There are new RCTs in this update, including:

• Laurian Hafkemeijer, Simon Hofman and colleagues have published two publications relating to results from the TEMPO study (Trauma-focused EMDR for personality disorders among outpatients) (Hofman et al., 2022). One publication reports on the effectiveness of EMDR on PTSD symptoms and diagnostic status in patients with a personality disorder (Hafkemeijer et al., 2025). This research paper concluded that EMDR significantly reduced PTSD symptoms and was effective for a range of adverse event memories, irrespective of their baseline PTSD diagnosis. The companion publication evaluates the effectiveness of EMDR therapy in reducing personality disorder symptoms compared with a waiting list, regardless of PTSD status. This research paper reported that EMDR was superior to a waiting-list control condition in reducing personality disorder symptoms and improving personality functioning and emotion regulation, resulting in 44.1% (n=30) of participants achieving personality disorder diagnostic remission.
• An RCT, also from the Netherlands (Dr Yvette Hendrix and colleagues), investigated the effectiveness and safety of early EMDR in reducing symptoms and incidence of PTSD at nine weeks postpartum in women with a traumatic birth experience, compared with care as usual (Hendrix et al., 2025). The study included 151 participants (76 in the treatment group and 75 in the control group) and found that EMDR reduced PTSD symptom severity and associated psychological distress (including depression, bonding difficulties and fear of childbirth).
• An RCT on the effect of EMDR on the intensity of primary dysmenorrhea with 88 participants (Valedi et al., 2025) found that EMDR significantly reduced the severity of dysmenorrhea symptoms, including pain intensity, menstrual distress and the need for analgesics, with effects sustained up to two months post-intervention, in comparison to no intervention.

Two new RCT protocols for ongoing research have been added to the database:

• EMpower Parents: Effectiveness of EMDR treatment for parental PTSD related to a child’s medical condition (Vesseur et al., 2025)
• EMDR as a potential treatment for substance use disorders (Sanchez et al., 2025)

There are two published studies relating to parents of children with autism spectrum disorder in this update. An RCT conducted in Iran with 60 parents of autistic children found that EMDR therapy significantly and immediately reduced depression in the parents, with the effect maintained one month later (Rashidi et al., 2025). Anne Stekkinger-de Vries and colleagues have published a single-case design study of EMDR for child-related PTSD in parents of adolescents with autism spectrum disorder and severe emotional dysregulation (Stekkinger-de Vries et al., 2025). The study included seven parents (of six adolescents) and found that all parents showed a reduction of PTSD symptoms after EMDR therapy, both immediately after treatment and at 30-day follow-up. This was compared with the control group, which received no intervention.

Military and veteran populations

An observational study from the United States examined treatment outcomes for 2,717 military-affiliated clients (veterans, active duty service members and their adult family members) receiving treatment for PTSD within a community health network (Lancaster et al., 2025). The percentage of clients who achieved clinically significant change, defined as a PCL-5 score reduction of 18 points or more, was substantial for EMDR. Specifically, 47.8% of clients who completed four or more EMDR sessions met this threshold. When restricting the analysis to clients who screened positive for PTSD at intake (PCL-5 score > 32), it was found that 53.6% of those receiving EMDR achieved clinically significant change. Furthermore, the study found that cognitive processing therapy, EMDR and prolonged exposure were all beneficial in real-world settings and demonstrated comparable large effect sizes. 

Psychosis

Two systematic reviews relating to EMDR for psychosis have been added to the database this quarter. Ahmed and colleagues included four RCTs (a total of 275 participants) and found that EMDR was generally superior to treatment as usual and wait-list and was particularly effective in reducing psychotic negative symptoms and paranoid thinking. However, improvements in delusions and auditory hallucinations were mostly insignificant (Ahmed et al., 2025). A broader systematic review on trauma-focused treatment for psychosis (Hellen et al., 2025) included six EMDR studies that reported outcomes related to psychosis symptoms, with four of the studies reporting positive outcomes in relation to the reduction in symptoms such as hallucinations, delusions and paranoid ideations. 

We are also pleased to announce that Aline Hardwick’s qualitative research, “Stepping into the trauma memory scene” with EMDR: What is it like for adults with psychosis?, which was featured in a poster at this year’s annual conference in Liverpool, has now been published in the journal Psychosis (Hardwick et al., 2025). Aline’s doctoral research is supervised by Dr Susannah Colbert, a member of the EMDR UK Scientific Research Committee (SRC), at the Salomons Institute for Applied Psychology, Canterbury Christ Church University.

Other studies by UK authors

Dr Sarah Cope and colleagues have published the results of the MODIFI feasibility randomised controlled trial (50 participants, two groups – EMDR and neuropsychiatric care (NPC) or NPC alone) (Cope et al., 2025). EMDR therapy, adapted for functional neurological disorder, was both feasible and acceptable to participants. The EMDR group showed greater patient satisfaction and reported greater improvements in functional neurological disorder symptoms and related outcomes, including reductions in PTSD, depression, anxiety, disability and healthcare use, compared to the group receiving standard care alone. The authors conclude that the results warrant a full-scale trial.

Researchers from the Division of Psychiatry at University College London have published a review of systematic reviews outlining the current treatments and debates relating to PTSD and complex PTSD (Billings & Nicholls, 2025).

What else has been added to the database this quarter?

The most recent update to the database was in October 2025, when 42 new publications were added. Newly added publications can be easily viewed by clicking on the ‘NEW’ tag. Within the NEW tag, you can then select further tags of interest to see what has recently been added for specific topics and research types. Table 1 provides an overview of the topics and study designs added to the database this quarter. Please note that topic areas are not mutually exclusive; some publications may appear in more than one category.

Table 1: New research by topic and study design

How we populate the database (methods)

The EMDR Publications Database is developed collaboratively with the Sheffield Centre for Health and Related Research (SCHARR) and is provided as a free resource for Association members. If you have not yet accessed this useful resource, you can find out how to do so in the members’ area of the EMDR UK website.

The EMDR Publications Database is a collection of peer-reviewed research and dissertations/theses focusing on EMDR. It contains over 2000 references, many of which have access to the full text. The references are categorised by ‘tags’ (keywords) relating to the clinical area and study type, allowing for easy browsing. The database can also be searched using specific terms of interest.

Searches to populate the database are conducted on the following international databases: MEDLINE, Embase, PsycINFO, ProQuest Dissertations & Theses, and PTSDpubs.

The next update of the publications database will be in January 2026, but in the meantime, if you have any queries or comments, you are welcome to get in touch at: a.sutton@emdrassociation.org.uk.

If you are an EMDR UK member and wish to request access to the database, please email the team at the University of Sheffield: emdrdatabase@sheffield.ac.uk

Disclaimer: this update reports study findings only; the research included in the database has not been assessed for quality, and we recommend that evidence users do so before applying recommendations into practice. You can find out more about critical appraisal of research here: EMDR UK Association research webinars: Developing critical analytic skills – EMDR Therapy Quarterly

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Scientific and Research Committee update

By Anthea Sutton

Anthea Sutton (Academic and Research Liaison)

Jonathan Hutchins (Chair of the Scientific and Research Committee)

Annual Conference 2026

As we move into the last quarter of 2025, we start looking ahead to 2026 and the annual conference, taking place in Bristol on March 20-21, please save the date.  The Scientific and Research Committee will be in attendance and will provide an update over the course of the two days, there will be a research keynote speaker, and *new for 2026* “lightning talks” from the poster presenters – 60 seconds to summarise their research.  We received a high number of poster abstracts and are currently assessing these. If you submitted a poster, you will hear a decision from us in due course, but in the meantime, please get in touch if you have any queries: researchofficer@emdrassociation.org.uk

Conference registration will open on 10 November, so please look out for further announcements, and we look forward to seeing you there.

Veterans Network

Now moving back to 2025, and our current activities, the Scientific and Research Committee has recently been forming a veterans collaborative network with stakeholders in academic institutions, clinical settings, charities, and people with lived experience.  The Veterans Research Network has been established to address the significant evidence gap regarding the use of EMDR for military-related trauma, by building a coordinated research community specifically focused on EMDR for veterans’ health and wellbeing.  If you are interested in the current research available in veteran populations, please see the EMDR Publications Database.  You can read all about the latest update here.

Randomised Controlled Trial in progress

A randomised controlled trial (RCT) comparing EMDR with treatment as usual for adults with depression in primary care has been funded by the NIHR (National Institute for Health and Care Research).  Led by Professor Nicola Wiles (University of Bristol), the trial started in March 2025 and is due to complete in April 2029, further details are on the NIHR website here. 

NICE Guidelines

The Rehabilitation for chronic neurological disorders including acquired brain injury guideline has now been published, see: https://www.nice.org.uk/guidance/ng252 The guidance states:

“If the person has low mood or anxiety, or is distressed by, or having difficulties adjusting to, the impact of their neurological condition, consider cognitive behavioural therapy (CBT), mindfulness-based talking therapy or acceptance-based interventions.” (Section 1.17.12 p145)

“If the person has difficulty engaging in talking therapy because of cognitive or communication problems, or if speaking is not the person’s preferred way of communicating, consider creative therapy (for example, music, art or drama therapy).” (Section 1.17.15 p145)

EMDR UK is a registered stakeholder in the guideline, and the association responded to the guideline consultation.  You can read the comments and the NICE response here: https://www.nice.org.uk/guidance/ng252/documents/consultation-comments-and-responses-2

Of note, on page 57, in response to our comment:

“Eye Movement Desensitisation and Reprocessing/EMDR was not included in the intervention search terms, therefore there is a risk that potential studies to include have not been retrieved. For example, the MODIFI trial protocol may not have been retrieved: Cope et al. (2023). MODIFI: protocol for randomised feasibility study of eye-movement desensitisation and reprocessing therapy (EMDR) for functional neurological disorder (FND). BMJ open, 13(6), e073727. Although an ongoing study and therefore may not be included (although this is not totally clear from the eligibility criteria), it suggests the search is not as comprehensive as it could be.”

NICE responded:

“Thank you for your comment. The list of interventions under adjustment and engagement in the protocol wasn’t an exhaustive list, although EMDR wasn’t listed as an intervention to improve adjustment and engagement, if it was designed to improve adjustment and engagement the study would have been captured in the search strategy and included in the review. In relation to Cope et al 2023, as this is an ongoing study it would have not been included in our current evidence review, however given the current research on the use of EMDR in FND this is something that would be taken into consideration in any future updates of this guideline.”

The SRC continue to engage with NICE.  If this is an area you are interested in, particularly regarding to responding to consultations and/or applying to join a NICE committee, please get in touch: researchofficer@emdrassociation.org.uk

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Update from the Equality, Diversity and Inclusion Committee

By Emma Mullins-Crocker

We are now in autumn, a season that has brought with it many global developments. Many people are feeling displaced and unsafe. Once again, we are reminded that those who are marginalised are often the most vulnerable, and they continue to experience this reality across the world.

We acknowledge the recent demonstration and the broader conversation it has sparked around equity, justice and the lived experiences of people of colour in the UK. These events have deeply affected many in our community, including our members, clients and colleagues.

As an association dedicated to equality, diversity and inclusion, we reaffirm our stance against all forms of discrimination and injustice. We stand in solidarity with those impacted and recognise the importance of creating safe, respectful and inclusive spaces for healing and dialogue.

We would like to take this moment to reiterate our:

• EDI Policy: Our commitment to fostering equality, diversity and inclusion across all levels of our work. 
• Statement of Respect and Wellbeing: Our dedication to ensuring psychological safety and mutual respect for all. 
• Diversity and Cultural Awareness: Our ongoing efforts to challenge systemic inequities and promote cultural humility.

Statements

Our mission is to alleviate suffering and promote personal growth in those who have experienced trauma and other adverse life events by providing skilful, compassionate and effective EMDR therapy. Many members, both individually and collectively, have met with us and contact us, including a collective letter from 80 Association members regarding how the Association should comment on the conflict in Gaza. We appreciate and value members’ contact and time in collaborative working. The Board is trying to work collectively with our members, with guidance from our legal team in this area. As a charity, it is important that we do not take a political stance, but we also want to be able to support our members. Fiona Corbett, a member of the EDI Committee, has collated a list of resources for those impacted by or supporting those impacted by the conflict in Gaza. These can be found on the forum. The Board has also issued a statement regarding the Israel-Palestine conflict. Aisha Docrat is also working with some members of the Association to deliver a webinar relating to this complex area, providing a place and space for collaborative dialogue.  

Multimedia approach and having a voice

As you are aware, we aim to take a multimedia approach to both support and listen to our membership. The committee continues to source and deliver a multimedia approach, with a particular focus on working with marginalised and underserved groups, adapting and developing our EMDR practice. If this is something you could offer and you are an EMDR therapist, practitioner, consultant or trainer, we would be delighted to hear from you.

Please reach out to:

• Dean Whybrow with contributions or to share ideas for publication in the ETQ.
• Heena Chudasama for webinar ideas and conference contributions.
• Russ Hurn for podcast ideas.

We would also like to hear about what you would like to see at the conference, including topics and speakers regarding equality, diversity, inclusion and social justice. Please contact Heena Chudasama.

CPD

A number of CPD events are available, which you can access here.

Regional groups (RGs) and special interest groups (SIGs)

Please connect with us to discuss collaborations in events that align with your SIG and RG.

Awareness days

We aim to work with SIGs to highlight awareness days and months. SIGs and RGs have already shared the events they would like to promote. Aisha Docrat will be leading this with SIGs and RGs. While we may not be able to promote every suggested event, we will rotate the highlighted topic.

In the meantime, please contact Emma Mullins Crocker with any questions. Katy Bell and David Leck will also be working with the Association to support and promote the work in this area.

Bursary to come

The Association has agreed to offer some bursaries to support access to standard EMDR training, child and adolescent EMDR training, relevant books and clinical supervision. We are currently developing a process and would welcome support from any member with experience of bursary and grant application procedures. Please email Heena Chudasama.

Accessible event guidance

Guidance on accessible event planning has been shared on the forum. Where possible, this will be added to the EDI webpage along with other resources.

Forum

The EMDR UK Forum is a great place to share ideas, experiences and resources. The Association aims to develop a safe space to explore issues relating to EDI, while working towards fully integrating EDI throughout the forum. Fiona Corbett and Karen Crowe regularly share resources on the EDI section of the forum.

Join the Board

It is now time to start considering nominations for joining the EMDR UK Association Board. I asked members to start thinking about this as a real option. It is important that the Board represents the diversity of our membership, and as such, I request that members volunteer to join the Board. The Board secretary, Louise Mackinney, will send an invitation for nominations to all Association members. I would urge you to apply.

Accessible answerphone

To increase accessibility to the Association, an answerphone has been live since May 2023.

Accessible answerphone number: 0151 372 6802

This is an accessible answerphone line for those who cannot email the Association. The answerphone will not be monitored on weekends and during holiday periods. Please be mindful that queries will be responded to as soon as possible but may take a few days. If you are able to email, please do so at admin@emdrassocation.org.uk.

Please be aware there is a process of reasonable adjustments and mitigating circumstances that members can access. Please contact admin@emdrassociation.org.uk to be directed to the right person in relation to your query.

If you have any thoughts or concerns, or would like to contribute to the conversations, please get in contact or share your voice via:
 

Forum

Chair of the EDI committee: Emma Mullins Crocker

Heena Chudasama (She/Her)

HChudasama@emdrassociation.org.uk

Past Chair of the Equality, Diversity and Inclusion Committee

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Navigating Police Culture: Cultural competence in EMDR therapy with UK law enforcement. A narrative review

By Carolyn Langlands

Learning objectives: How does the review add to existing knowledge in this area?

This narrative review aims to synthesise literature on cultural issues and challenges in UK law enforcement affecting engagement with therapeutic interventions, specifically cultural competence in EMDR therapy.

Introduction

Eye Movement Desensitisation and Reprocessing Therapy (EMDR), originally founded and developed by Shapiro (2018), has provided strong empirical evidence in treating posttraumatic stress disorder and has also been found as an effective, transdiagnostic and integrative treatment approach for a wide range of diagnoses in a variety of contexts and treatment settings with diverse cultural populations (Laliotis et al., 2021), including working with the uniformed services. Shapiro (2018) considered culture as an essential component within the EMDR standard protocol enhancing the AIP model, which establishes the approach as a holistic therapy; an elevated level of training and clinician skill is therefore required for the delivery of EMDR treatment, especially in the face of increasingly complex trauma presentations in UK law enforcement.

The UK police force responds to millions of calls annually, and trauma rehabilitation with law enforcement frontline responders is growing worldwide (Syed et al., 2020). The latest figures state that approximately 17,000 officers across England and Wales were either on recuperative duties, long-term sickness or in adjusted posts due to mental health issues, and this has increased from 10,000 since 2017 (Phythian et al., 2022). Many of these officers, diagnosed with PTSD or CPTSD, require significant and appropriate rehabilitation. Brewin et al. (2022) also identified that police officers in the UK were more likely to develop CPTSD, described in the revised ICD-11 as the core six PTSD symptoms, clustered into avoidance, arousal and re-experience with the addition of disorder of self-organisation (Cloitre et al., 2018); the latter presentation is dependent on the volume of cumulative workplace incidents having occurred as well as any ACEs identified in assessments with officers.

Recent EMDR interventions have shown promising outcomes. An observational cohort study, conducted by Biggs et al. (2021), using clinical data from a trauma support service in the UK, found positive outcomes for personnel in the UK who received EMDR therapy from therapists in a six-to-eight-session model. Intensive treatments have also been developed rapidly over recent years, with excellent outcomes reported for police officers by Police Care UK (Rogers, 2023). The service evaluation showed promising preliminary results, with 93% of officers returning to work, as well as an 87% reduction in diagnoses of CPTSD or PTSD. They also reported a significant improvement in quality of life for those who undertook this residential programme.    

Despite these successful outcomes, changing attitudes and awareness of the effects of trauma on police officers, there still seem to be ongoing issues of stigma, which can affect officer engagement at every level of policing (Porter & Lee, 2024). The purpose of this review is to consider the recent literature on the barriers EMDR therapists face when working with this cohort, hoping that suggestions in the literature can help increase engagement moving forward.  

Police culture

Stigma is one aspect of police culture that has been covered substantially in research over the last few decades, presenting law enforcement well-being services with significant challenges. Royle et al. (2009) described stigma as a barrier to engagement in mental health services for first responders, the reason being that accessing any form of mental health intervention to assist in rehabilitation for police personnel means that there would be an admission of their inability to cope. Bullock and Garland (2017) added that stigma and social identity issues can drive difficulties in mental health presentation in police personnel, impacting the success of trauma interventions, including the quality of the interventions and the number of police personnel accessing services. 

The existing literature acknowledges that rehabilitation with police personnel involves balancing issues around police culture, such as operational stressors, organisational expectations and outside stressors (such as stigma), combined with internal individual factors such as self-stigma. These factors challenge engagement in rehabilitation, which affects therapeutic outcomes (Ben-Zeev et al., 2012; Edwards & Kotera 2020; Simmons-Beauchamp & Sharpe, 2022). Porter and Lee (2024) agree and include more specific reasons for these difficulties, such as machoism, gender differences, generational differences, work-life balance, public perception, resilience levels and the nature of the job – all of which can affect engagement.

Cultural competence in EMDR therapy

Cultural competence is essential in EMDR therapy, particularly when working with law enforcement, as it helps address challenges posed by police culture and mental health issues. Therapists must possess multicultural beliefs and skills to effectively engage with clients from diverse backgrounds, ensuring they understand the cultural impacts on the client group they are working with (Constantine & Ladany, 2001). Tervalon and Murray-Garcia (1998) present a concept of cultural humility that emphasises the importance of lifelong reflection and an awareness of cultural biases, which is crucial for building a therapeutic relationship, supporting the need for EMDR therapists to bridge the gap between themselves and law enforcement clients (Royle, 2023). McLeod (2025) also suggests focusing on the client’s cultural ‘niche’ – an individual’s unique social and cultural context – which can enhance rehabilitation efforts.

Various cultural competency models, including Relational-Cultural Theory and the ASK model, can guide therapists in designing culturally appropriate interventions (Frey, 2013; Nickerson, 2023). Additionally, the therapeutic alliance and attunement are critical factors in successful EMDR therapy, as noted by Marich et al. (2020), who emphasise the importance of flexibility, intuition and cultural awareness in addressing the client’s unique needs. This knowledge and skill set empowers therapists to embrace the officer’s current reality and historical background to overcome barriers such as stigma and self-stigma in the therapeutic setting (Levis, 2017).

Method

A narrative review was chosen, as this is a reasonably new line of enquiry in EMDR therapy. Information was synthesised from interdisciplinary sources, giving a unique insight into what may be considered a gap in EMDR therapy research (Chaney, 2021). The synthesis process reflects the hourglass model describing the inversion of the research process, where the ending of one phase provides the beginning for another. This strategy is helpful for a researcher where there is a clinical problem that may be of concern to practitioners, and some of the possible answers may be based on a theoretical framework and/or a clinical hunch as to how these issues could be addressed (Rowland & Goss, 2000). The articles selected build on each other regarding theory and findings, and clinical ideas emerge as possible thoughts for future research. 

The research databases consulted were APA PsychArticles, Academic Search Complete via the EBSCO search host, the Meta database and Google Scholar (Renner et al., 2022). Boolean search terms included: Law Enforcement AND Culture AND Mental Health; Police AND Mental Health AND Stigma AND UK; EMDR AND Police Identity; EMDR AND Cultural Competence.

The inclusion criteria comprised peer-reviewed articles, RCTs, literature reviews, other qualitative enquiries, book chapters and international and British research published between 2019 and 2024. The exclusion criteria comprised dissertations, magazine articles and conference papers. Theoretical depth was considered, whereby each article was screened using a backwards search representing the review of citations in the identified literature (Renner et al., 2022), revealing specific standard citations expected for research in this area. PsychInfo and Academic Search Complete provided more specific findings for this review. Google Scholar was considered supplementary to the principal research systems, focusing on recently published research. Systems such as Google Scholar have been reported to fail query tests, and do not support the Boolean search functionality, resulting in less specific findings when conducting a database search (Gusenbauer & Haddaway, 2020). However, some useful recent articles were sourced in this case. Below are the number of articles accessed through each search engine: 

Table 1. Number of articles accessed

The Critical Appraisal Skills Programme (CASP, 2022) analytical tool was used to analyse the quality of each of the 24 articles chosen after initial screening using the qualitative checklist. CASP is the most used tool to check for quality in qualitative evidence in health sciences and has an endorsement from the Cochrane Qualitative and Implementation Methods Group (Long et al, 2020). Five articles were chosen from this list, and findings from this process are shown in Appendix 1.   

Results

Awareness and knowledge of police culture, including stigma and identity theory

The main findings of the Soomro and Yanos (2019) study concurs with much of the previous literature on stigma regarding lack of engagement and negative stereotypical attitudes to mental health in policing. Stigma and self-stigma appear to be higher among police officers compared with the general public, especially officers diagnosed with PTSD. This is an important finding, as it potentially forms a baseline of attitudes to, and engagement, with mental health services and could increase challenges to rehabilitation in the more severe cases. Ben-Zeev et al. (2012) description of stigma may explain why this happens in policing. More specifically, public stigma, where the individual is aware of the stereotypes held by the public, or in this case, the wider attitudes in the police force about those who engage with mental health interventions, therefore leading to self-stigma. The individual consequently applies these stereotypes to themselves, leading to a more internalised form of devaluing themselves, which can prevent them from trying to achieve their personal goals. Other influences, such as the ‘why try effect’ identified by Corrigan et al. (2016), are explained as a sense of futility that occurs when individuals apply mental illness stereotypes to themselves. This hampers their belief in achieving personal goals, increasing feelings of helplessness and, therefore, engagement in rehabilitation (Ben–Zeev et al., 2012).

Royle et al. (2009) also explained the concept of cognitive separation occurring within the individual into categories of ‘them and us’ regarding mental health. This manifests when an officer feels it is too risky to access or engage in help, fearing they will be perceived as weak within their group. They ultimately avoid shame by not accessing or engaging with therapy. Label avoidance, therefore manifests in avoidance or no acknowledgement of symptoms to avoid any form of stigma associated with mental health intervention (Ben-Zeev et al, 2012).

Soomro and Yanos (2019) also noted that wider police culture potentially needed investigating as a potential trigger to stigma amongst officers, aligning with findings by Turner and Jenkins (2019), who found that while officers recognised the seriousness of psychological distress, they often attributed it to bureaucratic issues, which reportedly discouraged openness about vulnerability. Higher PTSD scores correlated with greater self-stigma, affecting engagement in support services. Although the Soomro and Yanos (2019) study was carried out in the United States, there is a worldwide consensus that social support and occupational stress (including police culture and stigma) result in difficult coping strategies and contribute to mental health difficulties, and therefore findings are considered relevant to the UK (Syed et al., 2020). 

Edwards and Kotera (2020) found that the wider police culture in the UK played a much more significant role in mental health attitudes. Results from five officers concurred with previous stigma findings, highlighting self-stigma and stigma at an institutional level rather than the impact of the job itself (Bullock & Garland, 2017). This reportedly affected police officers in disclosing their mental distress due to perceived peer judgement and a fear of not being supported in the workplace, bringing a whole host of worries for their career in policing, including the consequences of taking time out.

Machoism and masculinity (as a part of broader police culture) continue to be regular descriptions of policing culture in the UK. They are often perceived as negative, which was supported by more recent findings by Porter and Lee (2024). As part of exploring gender beliefs across genders in policing, Silvestri (2017) found that displaying emotion was perceived as a weakness, and emotional detachment was valued for the most part across all genders. Bell and Eski (2016) also considered the positive effect of canteen culture, which embraced machoism, and how it helped police personnel carry out challenging duties. They described canteen culture as a form of emotional support, despite it exacerbating stigmatised beliefs about mental health. Due to the scrapping of canteens, increased workload and pressure to address stigma, access to this form of interaction was reduced, and although it is generally now regarded as more negative than positive, a void was left in support for officers.

Key findings from Demou et al. (2020) in Scotland also acknowledged that operational trauma existed, but that organisational issues were equally as problematic in perpetuating mental health issues. The stigma around mental health had reportedly lessened but still prevented some officers from seeking help. Overall, it was suggested that it was essential to acknowledge police culture moving forward and that police organisational culture constructed police identity and practice.

The results appeared more favourable regarding the effectiveness of some well-being interventions on stigma. This is supported by Porter and Lee (2024), who found improvements in engagement and attitudes towards mental health in British policing; however, added factors such as generational influences and length of service emerged as an additional concern. Younger officers were reported to have different perspectives on work-life balance, leading to tensions with older cohorts, who sometimes viewed their younger counterparts as less resilient, partly due to limited experience and time served in the job.

Edwards and Kotera (2020) continued to emphasise the need for more research on interventions to measure outcomes for preventing and managing mental health issues. They recommended involving occupational health, and recent research acknowledges that most occupational health departments in the UK now offer short-term counselling and trauma interventions. (Rogers, 2023).

The research broadly indicates that stigma surrounding mental health issues remains prevalent among UK police officers, despite initiatives like Oskar Kilo (Phythian et al., 2022) aimed at breaking down mental health taboos in forces across the country. Bell et al. (2022) further broke down wider organisational challenges, including relationships with supervisors, occupational health and policies on performance and sick leave, potentially discouraging officers from seeking help for their mental health concerns. While some progress seems to have been made in reducing stigma in UK policing, it appears there is still some distance to cover in ensuring a robust support system for officers, as there appears to be inconclusive evidence on how cultural issues are perceived across UK forces. Insight into police identity may offer some insight into assisting this process for EMDR therapists.

Identity theory

Royle (2023) discusses police culture through the lens of social identity theory, highlighting the importance of in-group/out-group dynamics and cultural norms for police officers. The key norms identified include mission focus, control focus, commitment, action, decisiveness and pragmatism, which help officers navigate chaotic situations and maintain a sense of competence. However, when officers experience PTSD and CPTSD, negative thinking can undermine these internal constructs that once kept them functioning, potentially leading to a deep existential crisis where they dramatically question their lives and existence. The tension between culture, identity and stigma, therefore, increases and poses challenges to the EMDR therapist in engaging with and facilitating recovery for affected officers.

Richards et al. (2021) challenged social identity theory as the only explanation in the context of considering help-seeking behaviour through a social cognitive theory lens, questioning the in-group/out-group notion as a stand-alone explanation. Determinants for seeking mental health support were measured through social and environmental factors, such as family support, departmental culture and societal views; behavioural outcomes, such as harm to career and stigma; and self-efficacy considerations, such as education and awareness, perception of services and personality factors.

It was considered why someone may or may not seek help and/or engage with a psychological intervention to ensure the best outcome in recovery. The findings suggested that mental health support also varied between police organisations and locations, which hampered the effectiveness of trauma interventions.

These findings concur with Drew and Martin (2021), suggesting that the relationship between help-seeking behaviour and culture/stigma may be more complex than first thought, as various studies provided contradictory results on the tolerance and perception of stigma in policing (Bell et al., 2022; Demou et al 2020). Notably, these studies were conducted in different parts of the UK, suggesting that differing cultural norms and expectations in policing groups are potentially evident, depending on the area.

This presents a challenge when applying identity theory across the board. It suggests that policing in the UK is not homogeneous and diversity within UK policing, including differences in rank, role, and exposure can affect engagement. A tailored approach to research, well-being support and rehabilitation that considers regional and individual cultural differences, may therefore be more effective (Foley et al., 2021).

Cultural competence with law enforcement and the EMDR eight-phase protocol

Royle (2023) describes how cultural theory can be integrated into the EMDR therapy protocol with law enforcement. Practical considerations during history taking and the preparation phase in working with this cohort are clearly considered, with an emphasis on framing, reframing, justification, and, importantly, collaboration in case conceptualisation in the early phases of treatment.    

The preparation and assessment phase needs to be tailored culturally in a sensitive way. Once underway, the desensitisation phase may call for culturally sensitive interweaves to move the process on, of which there are helpful suggestions. Most importantly, understanding police cultural identity can help therapists build rapport with this group and help the shift from loss of group identity to regaining their cultural identity, thereby breaking down the stigma around mental illness.

If identity theory is important in helping to navigate police culture in the rehabilitation process, viewing identity as a multilayered construct could be helpful. Hecht’s (2014) Communication Theory of Identity (CTI) views identity as a complex, dynamic and layered concept that is shaped and expressed through communication. The theory contains four identity layers: persona (self-perceptions and the internal sense of self), relational (identity through personal relationships), enacted (identity in their day-to-day communications) and communal (identity influenced by society, culture and organisational affiliations). Police identity could be explored by therapists with their clients using these layers to help the officer negotiate, express and experience their identities through communication within the various contexts they find themselves in. Identity is reported to be layered and multifaceted, evolving through communication and interaction. Essentially, communication can help the officer to express, maintain and modify their identity. This could be helpful for the EMDR therapist to consider (instead of what Hecht regards as simpler theories of identity, such as Tajfel’s social identity theory and Bandura’s social cognitive theory) and could provide a more realistic platform from which to engage with law enforcement so that culture is navigated carefully in a deeper relational way (Hecht, 2014).

Relational attunement has long been considered imperative when delivering EMDR therapy. The neurobiological aspects of relational work in therapeutic interventions like EMDR therapy focus on appraisal, arousal and attunement, which are crucial for both the clinician and the client. Effective appraisal and internal clarity enhance the therapist’s ability to attune, allowing the client to engage deeply in trauma work (Dworkin, 2006).

Unlike other therapies, EMDR therapy features a dynamic shift in the power of the therapeutic relationship throughout the protocol. In the initial and closing phases (1-2 and 5-8), the therapist’s power is greater due to directive interventions, whereas in Phase 4 (desensitisation), relational power increases, making attunement essential. If a client feels unsafe, processing may be hindered due to activating memories. Deep empathic attunement – where the therapist remains grounded yet open to the client’s feelings – is vital for successful processing (Parnell, 2013). Additionally, attentiveness to interweaves during Phase 4 is key for maintaining connection and addressing blocks. Therapists should use culturally sensitive language and responses to enhance effectiveness, particularly concerning clients’ cultural identities during Phase 4, and when it comes to police officers, paying attention to these considerations is crucial as their identities form a key part of their day-to-day lives (Royle, 2023).

Cultural competence in EMDR therapists

Findings by DiNardo and Marotta-Walters (2019) provided a helpful starting point in considering the current state of cultural competence in EMDR therapists in general. They emphasised the need for therapists to consider the universal, group and individual identities of clients as part of the Tripartite Model (Sue & Sue, 2012). Intersectionality also provides a nuanced explanation of the complexity around cultural identity constructs. Police culture could be described as an example of an occupational culture comprising its own subcultural or micro world with its own set of values and ways of relating. Utilising the concept of intersectionality, therapists may get closer to the unique combination of identities and values exhibited by individual police clients, irrespective of their group identity. The invitation to be curious about the range of cultural identities and memberships that matter to the client is said to enhance the therapeutic process and was considered valuable in relation to working with clients who experienced cumulative stigmatisation, marginalisation and oppression arising from intersecting identities (McCleod, 2025).

DiNardo and Marotta-Walters’ (2019) research also revealed that more than 50% of practitioners view EMDR as a universal therapy rooted in neurobiology, suggesting a lack of depth in acknowledging cultural aspects. The meaning of these findings challenges the conscious attitude towards the importance of cultural considerations in rehabilitation within EMDR therapy, as cultural research has explicitly suggested that correctly harnessed cultural intuition can greatly empower clients both in and out of therapy (Levis, 2017).  

The nuanced implicit findings of DiNardo and Marotta-Walterss’ (2019) research found that practitioners mostly used Germanic-origin words when describing different aspects of the protocol pre- and post-processing. These words were reported as a more authentic way to communicate, aiding the therapeutic relationship, which would help engagement in therapy during history taking and the preparation phases of EMDR therapy.

Relational-Cultural Theory supports the importance of therapist responsiveness and authenticity and using culturally sensitive language, the police officer’s social/cultural unconscious can be navigated effectively, which can guide group and individual communication and behaviour (Frey, 2013; Weinberg, 2007). 

Cultural communication is important in addressing issues such as transference and resistance in therapy. Resistance from police officers can signify a disconnection or dissociation that, when reframed, serves to protect their integrity and identity (Frey, 2013). Understanding this resistance can facilitate authentic connection and change in clients to address cultural issues more explicitly in EMDR therapy.   

Discussion

The importance of cultural competence and the focus on how to navigate relationships with police personnel is complex; however, the research clearly shows there are ways for EMDR therapists to address this.

Resistance encountered in sessions with police officers, for example, was described as a form of disconnection or dissociation (Frey, 2013) and could be viewed in strength-based terms; reframing that resistance is there to protect them from authentic connection could be explored. In the case of policing, self-revolution strategies could help the officer understand the function of their resistance as a preservation of their integrity, identity, viability and agency. Specific strategies can help individuals address connection and mutual empowerment in relationships, rather than relying solely on independence and self-sufficiency. This encourages officers to actively cultivate relationships in their private lives and at work, and to challenge limiting beliefs about themselves and others. They are also encouraged to recognise the cultural influence on current relational patterns. Working with resistance in this way enables clients to find a new way of maintaining their self-integrity and changing their person, not their problem, although the resistance naturally falls away as they become more aware of it (Frankel & Levitt, 2006).

Relational-Cultural Theory impacts at the individual and socio-cultural level, and it is these socio-cultural dynamics that inflict disconnection, silence, shame and isolation in marginalised groups. Police officers experiencing mental health disorders fall into this category; as Royle (2023) notes, they have been separated from their cultural identity. The theory and interventions considered here have significant implications for how EMDR therapists integrate cultural constructs into their work with police officers. 

Summary, limitations and future learning

Clearly stigma remains significant in policing across the UK. Additionally, cultural attitudes towards mental health have been shown to be complex and disparate across the country in the findings presented. Organisational issues have also been found to play a big part in perpetuating negative stereotypes in the mental health arena. Programmes to change these attitudes, such as Oskar Kilo (Phythian et al., 2022), have had an impact to date, but the extent is still difficult to determine. Training and research in law enforcement rehabilitation need to be more targeted so EMDR therapists understand what they face when working with law enforcement.

Alongside research into the integration of relational psychotherapy models as a benefit to facilitating increased engagement of police officers in rehabilitation in EMDR therapy, more cohesive research into police culture across the UK would be valuable. This could start with a systematic literature review followed by further broader-based qualitative research, as current findings are contradictory in this narrative review, which only addressed a few relevant articles. Targeted EMDR research into the experiences of therapists working with police officers in the UK could investigate current cultural competence, assess awareness of cultural issues, and support the development of specific culturally informed interventions within the EMDR protocol.

Acknowledgement

Professor Derek Farrell

Appendix 1

Details of research studies

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Using EMDR to treat combat-related trauma: A prison-based clinical case study

By Paul Greenall

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

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.

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