TREATMENT OF PTSD WITH EMDR 1. Running head: TREATMENT OF PTSD WITH EMDR

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1 TREATMENT OF PTSD WITH EMDR 1 Running head: TREATMENT OF PTSD WITH EMDR A Literature Review of Treatment for Post-Traumatic Stress Disorder (PTSD) in Post-Combat Veterans Using Eye Movement Desensitization and Reprocessing (EMDR) Derek Rutter Wake Forest University

2 TREATMENT OF PTSD WITH EMDR 2 Abstract As an ever-growing number of post-combat veterans are returning from conflicts around the world and being diagnosed with post-traumatic stress disorder (PTSD), the need for efficacious treatments of this disorder is as necessary as ever. Eye-Movement Desensitization and Reprocessing (EMDR) has been demonstrated in various studies to bring about relief of PTSD symptoms from a variety of traumas in both civilian and military populations. Despite recommendation by the Department of Veterans Affairs and Department of Defense, controversy surrounding EMDR and the research supporting this treatment has limited EMDR s adoption. This review examines seven case-studies to look at the efficacy of treating post-combat veterans with EMDR. This review also examines one meta-analysis and two follow-up evaluation studies regarding this same topic. A discussion of these cases-studies and issues of future research conclude this review.

3 TREATMENT OF PTSD WITH EMDR 3 Introduction When we look at the number of veterans that are returning from conflicts around the world with mental health concerns, there is little room for doubt that attention must be paid to this population. According to a 2008 Department of Veterans Affairs (VA) study cited by Albright and Thyer (2009), from 2002 until January of 2008, the VA diagnosed 40% of OEF (Operation Enduring Freedom) and OIF (Operation Iraqi Freedom) veterans with possible mental health disorders. This number includes 60,000 veterans diagnosed with possible post-traumatic stress disorder (PTSD). By the fourth quarter of 2008, a follow-up report revealed that those numbers had grown to 44.6% of veterans with possible mental health diagnoses and 92,998 veterans with possible PTSD (Department of Veteran Affairs, 2009). This is an increase of nearly three thousand possible PTSD diagnoses in only ten months. Today, it is October of 2012, four years after these numbers were released and during which time American troops have remained in these conflict regions in both Iraq and Afghanistan. Undoubtedly, these numbers have since risen. PTSD is defined by the Diagnostic and Statistical Manual of Mental Health Disorders- IV-TR (American Psychiatric Association, 2000) as: the development of characteristic symptoms following exposure to an extreme traumatic stressor involving direct personal experience of an event that involves actual or threatened death or serious injury, or other threat to one s physical integrity; or witnessing an event that involves death, injury, or threat to the physical integrity of another person; or learning about unexpected or violent death, serious harm, or threat of death or injury experienced by a family member or other close associate (p. 463).

4 TREATMENT OF PTSD WITH EMDR 4 Furthermore, the DSM-IV-TR (2000) states that characteristic symptoms of PTSD include intense fear, helplessness, or horror re-experiencing of the traumatic event, persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness, and persistent symptoms of increased arousal (American Psychiatric Association, 2000, p. 463). EMDR is an eight-phase psychotherapy that targets maladaptive information processing resulting from negative experiences. Specifically, EMDR works on memories associated with negative experiences that have not been properly processed, so as to integrate them into greater memory and processing networks (Shapiro, 2001). The goal of EMDR, according to Silver, Rogers, and Russell (2008), is not the retrieval of the trauma memory or any other particular memories, but rather a process of assimilation and accommodation of the disturbing experience with the individual s cognitive structures (p. 948). Whereas most experiences assimilate normally, the disturbing experiences of those suffering from PTSD are unable to gain resolution (Silver, Rogers, & Russell, 2008). Shapiro and Maxfield (2002) suggest that by accelerating information processing, EMDR facilitates the resolution of traumatic memories. The efficacy of treating PTSD with EMDR has been the subject of many studies (Albright & Thyer, 2010). Considerable debate has also surrounded this issue, with particular attention to whether or not EMDR is a form of exposure therapy (Welch & Beere, 2002) and to the necessity and contribution of bilateral eye movements (Seidler & Wagner, 2006). Nevertheless, there is, at this point, a general conclusion that EMDR does bring about moderate improvement to PTSD symptomology (Albright & Thyer, 2010). Furthermore, EMDR has been recommended by various entities, including the EMDR Institute and the Department of Veteran Affairs (DVA) and Department of Defense (DoD), as an efficacious treatment. In 2010, the DVA/DoD released clinical practice guidelines for the treatment of PTSD, which stated:

5 TREATMENT OF PTSD WITH EMDR 5 Overall, argument can reasonably be made that there are sufficient controlled studies that have sufficient methodological integrity to judge EMDR as effective treatment for PTSD (p. I-26). The report also mentioned the immediacy of EMDR and the lack of necessity to reveal the traumatic event as potential strengths of EMDR (Department of Veterans Affairs and Department of Defense, 2010). A complete review of all studies regarding the efficacy of EMDR in treatment of postcombat PTSD is well beyond the scope of this work. Specifically, this review hopes to shed light on research in the form of case-studies published since January Specifically, 7 case studies are examined. In addition, a meta-analysis and two follow-up studies, also published after January 2000, will be briefly examined so as to provide a more complete picture of the treatment of PTSD in post-combat veterans with EMDR. A discussion of the results of the case-studies as well as pertinent issues facing future research will conclude this review. EMDR According to Shapiro (2001), phase-one of EMDR focuses on information gathering, which includes identifying the initial precipitating event, current triggers or stimuli that evoke the event, and cognitive structures that may inhibit future functioning. Phase-two is used to educate the client on EMDR, develop basic relaxation and tension reduction techniques, and obtain outside information that may be helpful in the client s resolution. Phase-three is used for assessment of the initial event, including representative imagery, the current cognition of the event, negative emotions, physical sensations, and identification of a desired future cognition regarding the event. Phase-four is the desensitization phase, during which time the patient recalls issues from the assessment while experiencing bilateral stimulation in the form of eye

6 TREATMENT OF PTSD WITH EMDR 6 movements, physical taps, or sounds. Phase-five begins once desensitization is complete. The goal of this phase is to install positive cognitions in association with the precipitating event. This is accomplished by bringing these positive cognitions to mind while again receiving bilateral stimulation. Phase-six involves doing a body scan while examining the initial event and the new positive cognition. If any negative physical sensations arise, they are focused on while bilateral stimulation is once again employed. Phase-seven is devoted to closure during which time guided imagery is used to ensure client stability between sessions. Phase-eight is for reevaluation during which time previous treatments are reexamined, progress is assessed, and future goals are created. Methods Research conducted to find information regarding PTSD in post-combat veterans, as well as the treatment of such cases using EMDR was conducted through Wake Forest University s Z. Smith Reynolds Library website as well as through Google Scholar. The primary focus of this research was on peer reviewed, scientifically based research articles as published in scholarly journals, as well as one book made available through Interlibrary Loan. Through the ZSR website, multiple databases were accessed for the search. These databases included PubMed (also known as MEDLINE), PsychINFO, and ProQuest. Beyond focusing primarily on journal articles, the other major restriction placed on searches was regarding the date of publication. While substantial data was available for research conducted throughout the 1990 s, the focus of this review is limited to those published during or after January of Finally, searches were also limited to those published in English. Key words and phrases that were used for searches and provided the best results included post-combat PTSD and EMDR, post-war PTSD and EMDR, veteran PTSD and EMDR, and post-deployment PTSD and EMDR. Beyond

7 TREATMENT OF PTSD WITH EMDR 7 simply relying on the results of searches, the reference lists of pertinent articles that were discovered in early searches where examined for references not revealed through database searches. New articles discovered through this method were then searched for within the ZSR website using the exact title, typically providing positive results. The best results found through keyword searches came from Google Scholar, for this search engine seemed to more successfully pull together results that were related to keywords, even if they did not match that which was searched for exactly. All articles discovered through Google Scholar were searched for again by specific title through the ZSR website, so as to ensure access to full text. Results Case-studies. In a multiple case study utilizing EMDR, Russell (2006) offers a detailed account of administering EMDR treatment to four United States soldiers wounded in Iraq at the evacuation hospital in Rota, Spain. These soldiers were experiencing symptoms of Acute Stress Disorder (ASD) and PTSD so strongly that they feared returning to the United States and requested immediate non-pharmaceutical treatment. Patients were informed of about all treatment options available to them, both medication and psychotherapy, and chose EMDR. Based on the author s awareness of the limitations of the alternatives, his clinical experience, and his knowledge of the trauma research base, he decided to administer EMDR treatment to these soldiers (Russell, 2006, p. 2). A Structured Clinical Interview (SCI) was used initially to measure symptoms. In addition, the Impact of Events Scale (IES) and the Subjective Units of Disturbance Scale (SUDS) were also used to measure pre-treatment and post-treatment symptoms and disturbance. All patients received one session of EMDR, as well as a follow-up visit to assess for future treatment. Patients received an additional visit prior to evacuation.

8 TREATMENT OF PTSD WITH EMDR 8 Unlike, standard protocol EMDR in which all stressors are addressed, these single session treatments focused solely on the most immediate, acutely disturbing stressors. The one EMDR processing session was used primarily to focus on the assessment and desensitization phases of treatment (Russell, 2006, p. 6). Participant 1 (P1) was a 23-year-old lance corporal Marine who had participated in the shooting of a vehicle that attempted drive a road block. After the shooting, it was discovered that the car was driven by a mother and her three-year-old son, both of whom were killed. P1 reported moderate symptomology (31) on the IES, endorsed 23 of 27 items during the SCI, and a SUDS rating of 10, all which indicated a diagnosis of PTSD accompanied with extreme disturbance. During the follow-up evaluation two days after the single-session EMDR treatment, P1 reported a SUDS level of 1, noting that he had slept better than he had since his deployment to the Gulf (Russell, 2006, p. 8). A final IES score of 5 indicated that his symptoms where no longer in the clinical range. Participant 2 (P2) was 22-year-old corporal Marine who had been injured by shrapnel in an ambush and witnessed his buddy being terribly mutilated by an RPG. P2 reported an IES score of 38, endorsed 15 symptom questions on the SCI, and had a SUDS rating of 8, indicating a PTSD diagnosis with high disturbance. At reevaluation, P2 had as SUDS level of 2, and IES score of 15, and reported sleeping well for the first time in a long time (Russell, 2006, p. 9). Participant 3 (P3) met criteria for diagnosis of Acute Stress Disorder (ASD), but not PTSD. Participant 4 (P4) was a 32-year-old U.S. Army staff sergeant who had been injured by mortar shrapnel and had witnessed a mass gravesite where he saw a dog eating a corpse. P2 reported severe symptomology (44) on the IES, endorsed 20 items on the SCI, and had a SUDS

9 TREATMENT OF PTSD WITH EMDR 9 level of 10. At follow-up, P4 reported a SUDS level of 1 and an IES score of 10, both indicating mild symptomology below the clinical range. Russell (2006) acknowledges that both single-trauma and multiple-trauma PTSD require more sessions than these single-session EMDR treatments in order to be considered comprehensive. The author also acknowledges that this may potentially limit the breadth of symptoms affected and the longevity of their resolution. Nevertheless, the observation that all four patients suffering from either ACD or acute PTSD could receive substantial benefit after one EMDR session indicates a potentially important addition to standard treatment for frontline personnel (Russell, 2006, p. 12). Russell (2006) also suggests that future research may benefit from investigating the variable of time as well as the number and type of trauma involved in post-combat PTSD. In another case-study that focuses on early intervention with EMDR RE (a variation of EMDR protocol designed for the treatment of recent events), Wesson and Gould (2009) describe treating, John, a 27-year-old active-duty U.K. soldier while in theater. John, a medic, presented to field mental health services five days after delivering first aid to a colleague who stepped on a landmine and later died from the injury. John completed four self-report questionnaires at pretreatment, post-treatment, and 18-month follow-up: the PTSD Checklist-Civilian Version (PCL-C), the Impact of Event Scale-Revised (IES-R), the Hospital Anxiety and Depression Scale (HADS), and the Beck Depression Inventory (DBI). John also rated his anxiety using the SUDS. At pretreatment, John scored around the threshold on the PCL-C and IES-R, and SUDS level of 6, suggesting significant disturbance. His HADS and BDI results suggested anxiety without depression.

10 TREATMENT OF PTSD WITH EMDR 10 John received four sessions of EMDR after which he reported a dramatic reduction is symptoms. These results remained consistent during two sessions one month after the last of the initial sessions was completed. At one year posttreatment, these reductions remained consistent and were reflected by all self-report measures; John planned to redeploy at this time. Further reduction was reported in all self-report measures at an 18-month follow-up, and John reported feeling very positive about his EMDR treatments as well as his return to the frontline. Wesson and Gould (2009) acknowledge the possibility of John simply recovering over time, as well as shortcomings of this study, which include single-case study design and generalization. The authors also suggest John had characteristics particularly suited to treatment including a stable background, supportive commanders, high levels of motivation, and a willingness to seek help, all of which most likely contributed to his success in treatment. Nevertheless, this case provides some evidence that the EMDR RE protocol could benefit military personnel on operations and early after a traumatic event (Wesson & Gould, 2009, p. 95). Furthermore, this case illustrates the potential for using EMDR in theater. In a 2008 study conducted by Silver, Rogers, and Russell, two case-studies involving the use of EMDR on post-combat veterans are investigated. The first case involved a 22-year-old, George, who had completed two tours in Iraq and was honorably discharged after a suicide attempt. After multiple subsequent suicide attempts, George was diagnosed with PTSD and admitted to a Veterans Administration PTSD inpatient treatment program. George identified four potential memories for processing: shooting an Iraqi combatant, the death of a friend, being injured by shrapnel from a mortar, and his fiancée breaking off their wedding. Over the course of four sessions all four disturbing memories were addressed, including additional anxiety associated with being in public places. At a 3-month follow-up George reported that he no longer

11 TREATMENT OF PTSD WITH EMDR 11 experienced disturbances regarding the targeted memories. With all treatments being completed within two weeks, this is yet another example of the immediacy with which EMDR delivers relief of PTSD symptoms. The second case involved a 73-year-old Vietnam veteran, Bob, who suffered from a number of aliments including myoclonic movements and PTSD. Bob experienced suicidal ideation from his symptoms, which in the past he addressed with medication and alcohol, ultimately costing him his marriage. Bob identified five traumatic memories to be addressed, which included being left alone and unarmed in a field at night and escorting his cousin s remains home after his return from the war. After two sessions of EMDR, Bob reported that his myoclonic movements and all other symptoms had ceased, which remained consistent at 1- month and 6-month follow-ups. Again, these single-case studies are not necessarily generalizable to all Veterans. Still, the work of Silver, Rogers, and Russell (2008) offers a valuable juxtaposition of the potential for EMDR to address both recent and long-standing cases of post-combat PTSD, as well as the potential for addressing both Iraqi and Vietnam veterans. Furthermore, the case of Bob offers evidence for the relief of psychosomatic symptoms resulting from PTSD. The final case-study examined in this review is that of Russell (2008b), in which EMDR treatment was used to address combat-related PTSD with medically unexplained symptoms (MUS). This case focused on Jerry, a 40-year-old master gunnery sergeant who served 19 years of active-duty and completed two tours in Iraq. While Jerry denied intrusive PTSD symptoms, he suffered from variety physical, mood, sleep, and anxiety symptoms associated with stress that began after his second tour of Iraq. Aside from Iraq, Jerry also served in Afghanistan, Bosnia, and Somalia. Throughout these deployments Jerry witnessed many traumatic events, however,

12 TREATMENT OF PTSD WITH EMDR 12 the loss of his best friend during his second tour in Iraq was his greatest source of disturbance. At pretreatment Jerry reported a SUDS score of 8 and a perceived health status of 1 ( 0 being the lowest in the latter). Over the course of five sessions, all of Jerry s symptoms psychological, emotional, and physical greatly reduced. At his 1-month, 3-month, and 6-month follow-ups he reported a SUDS score of 2 and a perceived health status of 8. The author notes that shortly after experiencing changes during and after EMDR, he [Jerry] was convinced it helped him gain a new perspective on life (Russell, 2008b, p. 221). This case is particularly interesting because of the inclusion of so many psychosomatic symptoms, which were effectively relieved through EMDR treatment. Furthermore, Jerry s long and diverse service that included multiple and varied traumatic experiences seems to be a potentially challenging case that was, nevertheless, successful. In particular, the immediacy of treatment, lack of necessary disclosure, and lack of homework associated with EMDR all seemed to be well suited to Jerry, potentially contributing to his successful treatment (Russell, 2008b). Meta-analysis. In a meta-analysis conducted by Albright and Thyer (2010), six experimental and three quasi-experimental studies were summarized and examined. The results of this meta-analysis suggest that limited evidence was discovered in support the use of EMDR in the treatment of post-combat PTSD. While the studies examined appear to hold up methodologically, the authors note that all nine studies are of limited sample size and precision, as well as lacking detail and transparency. Furthermore, the all nine studies have the potential to be affected by issues regarding self-reporting. Finally, all nine studies examined were limited to Vietnam veterans, an issue of particular interest to this this review, since the focus here is primarily on OEF and OEI veterans (Albright & Thyer, 2010). It seems relevant to future

13 TREATMENT OF PTSD WITH EMDR 13 research to examine if there is a measurable difference in the efficacy of EMDR in the treatment of PTSD as applied to Vietnam veterans versus OEF and OEI veterans. If so, examination and comparison of cohort issues regarding these two populations of veterans may warrant deeper examination. Follow-up evaluations. Macklin, Metzger, Lasko, Berry, Orr, and Pittman (2000) conducted a five-year follow-up study examining the results of 13 Vietnam combat veterans with chronic PTSD who had previously received EMDR treatment. In this study, pretreatment and follow-up outcomes were compared; these results were compared to a control group consisting of similar Vietnam veterans who had also participated in initial and follow-up evaluations but did not receive EMDR treatment. The authors report that the results of this 5-year follow-up indicate that approximately 10 weekly sessions of EMDR, although initially yielding some benefits, did not produce long-lasting improvement in the overall severity of PTSD symptomology (Macklin et al., 2000, p. 26) Furthermore, the authors report that PTSD symptomology worsened in both the treated and control group veterans. However, much like the studies analyzed by Albright and Thyer (2009), this study relies on a small sample size. Furthermore, in this study, there is no mention of subject selection being randomized or blind, nor is there evidence of multiple therapists being used to control for potential bias. This report also lacks fidelity in regards to exact EMDR protocol used, and even mentions that only half of all treatments involved bilateral eye movement stimulation. Aside, from these potential weaknesses in methodology, once again cohort issues regarding the use of Vietnam veterans may possibly be affecting the outcomes of this study. Considering, the potential for bias and error within this study, the value of these results remains questionable.

14 TREATMENT OF PTSD WITH EMDR 14 In a separate follow-up study conducted by Zimmerman, Biesold, Barre, and Lanczik (2007), 89 German soldiers who received in-patient treatment for PTSD between 1998 and 2003 were retrospectively evaluated. Patients were nonrandomly assigned to two groups: those who received EMDR and those who received general hospital treatment and relaxation techniques. Interestingly, this study focused on German soldiers whose PTSD was not the result of combat. This is valuable to the discussion here, because all other studies pertaining to non-combat related PTSD that were able to be found consisted of civilian populations. Better understanding the efficacy of EMDR in treating PTSD as resulting from combat versus non-combat events within a military population allows us to better understand potential cohort issues specific to soldiers, which may or may not pertain to civilians. Zimmerman et al. (2007) state that Combat exposure and trauma severity are closely related and are factors that can substantially influence the prognosis of PTSD patients whether or not they received trauma treatment (p. 456). The results of this study appear to be in accordance with this statement. The authors report that after 29 months, all patients who received EMDR showed significant improvement on the IES (Impact of Event Scale) when compared with pretreatment scores (Zimmerman et al., 2007, p. 458). Furthermore, this report notes that all participants who encountered death in their precipitating event showed significantly poorer improvements as compared to those who did not encounter death, which may be related to duration of treatment. Once again methodological concerns were present including small sample size and a lack of random assignment. Furthermore, there was a lack of standardization of the number of sessions, the conditions of treatment, and length of treatment between the EMDR treated groups and control group. Nevertheless, this study indicates that EMDR can bring about positive outcomes in treating non-combat related PTSD in soldiers, however, traumatic events involving

15 TREATMENT OF PTSD WITH EMDR 15 death do not appear to respond significantly to treatment lasting only a few weeks (Zimmerman et al., 2007). Considering the potential for trauma involving death within the context of military combat, this report seems to suggest future research regarding the use of EMDR to treat postcombat PTSD should pay particular attention to the duration of treatment. This also suggests the possibility that insufficient treatment time may be a significant variable affecting the results of other research examining the use of EMDR in treating post-combat PTSD. Discussion As this review has addressed, the need for efficacious treatment of combat-related PTSD certainly exists. EMDR, as we have seen, attempts to addresses this need. Furthermore, EMDR seems particularly well-suited for treating PTSD in combat soldiers and veterans for a number of reasons: the immediacy of results; the lack of necessary self-disclosure during treatment; the lack of homework; the ability to be used in a variety of settings, including in-theater; the application to recent and distant-past trauma; the application to single and multiple-trauma disturbances (Department of Veterans Affairs and Department of Defense, 2010; Russell, 2006; Wesson & Gould, 2009). While the case-studies examined in this review predominantly demonstrate the efficacy of EMDR, generalizability cannot be assumed from these studies alone. If anything, these cases set the stage upon which future research may be directed. As the works of Albright and Thyer (2010) and Macklin et al. (2000) have illustrated, future research comparing EMDR treatments of Vietnam veterans to veterans of more recent conflicts may offer valuable insight into populations best served by EMDR. The work of Russell (2006) points out a need for future investigation into the variable of time and type of trauma in regards to combat PTSD as treated

16 TREATMENT OF PTSD WITH EMDR 16 by EMDR. Also, comparing combat and non-combat associated PTSD within soldier and veteran populations may expand our understanding of the efficacy of EMDR as suggested by Zimmerman et al. (2007). As Wesson and Gould (2009) illustrate, EMDR has potential for successful use within a variety of venues, including in theater, and future research may benefit from comparing the success of different therapeutic contexts. Beyond the specific issues examined in these cases, a number of research issues lay before EMDR. While these case-studies provide valuable qualitative information, more quantitative research would undoubtedly be valuable. Shapiro (2009) notes that except for a one one-session process analysis, there have been no randomized studies directly comparing EMDR and CBT treatments with U.S. combat veterans (p. 226). According to Russell (2008a) the importance of such research cannot be overstated, as he asserts there is ample evidence that resistance to EMDR has been extensively fueled by challenging the dominant substantive CBT concepts (p. 1741). Further empirical support for the efficacy of EMDR versus CBT would help delineate the debate between efforts made to provide the most efficacious treatment and those made to maintain the current CBT-dominated paradigm. Furthermore, it seems the debate surrounding the efficacy of EMDR has not always been aided by research. According to Shapiro (2009), substantial research on EMDR has been conducted, however, much of the early research is problematic, because it lacks fidelity regarding EMDR protocol and clinician competency. Shapiro (2009) also notes that few studies conducted have used the standard number of EMDR treatments dictated by protocol. It basically meant that we had no idea what we knew, and that became an issue in terms of EMDR research (Shapiro, 2009, P. 221). Maxfield and Hyer (2002) echo this sentiment, suggesting future

17 TREATMENT OF PTSD WITH EMDR 17 research would greatly benefit from increased attention to efficacy and methodology, and in particular assessment reliability and treatment fidelity. Ultimately, as suggested by Russell and Freidberg (2009), the controversy surrounding EMDR appears to be an on-going obstacle to increasing its availability within the DoD (p. 29). Nevertheless, as the results of cases reviewed in this document suggest, EMDR appears to have provided positive outcomes for some individuals suffering from post-combat PTSD, encouraging future research into the efficacy of EMDR treatment in serving this population.

18 TREATMENT OF PTSD WITH EMDR 18 References Albright, D. L., & Thyer, B. (2010). Does EMDR reduce post-traumatic stress disorder symptomatology in combat veterans? Behavioral Interventions, 25(1), American Psychiatric Association (2000). Diagnostic and Statistical Manual of Mental Disorders (4 th ed., Text Revision). Washington, DC: Author. Department of Veterans Affairs. (2009). VHA office of public health and environmental hazards, analysis of VA health care utilization among US global war on terrorism (GWOT) veterans: Operation Enduring freedom, Operation Iraqi Freedom, January Retrieved from Department of Veterans Affairs and Department of Defense. (2010). VA/DoD clinical practice guideline for the management of post-traumatic stress. Version 1.0. Washington, DC: Department of Veterans Affairs and Department of Defense. Retrieved from Luber, M., & Shapiro, F. (2009). Interview with Francine Shapiro: Historical overview, present issues, and future directions of EMDR. Journal of EMDR Practice & Research, 3(4), doi: / Macklin, M. L., Metzger, L. J., Lasko, N. B., Berry, N. J., Orr, S. P., & Pitman, R. K. (2000). Fiveyear follow-up study of eye movement desensitization and reprocessing therapy for combatrelated posttraumatic stress disorder. Comprehensive Psychiatry, 41(1), doi: /s x(00) Maxfield, L., & Hyer, L. (2002). The relationship between efficacy and methodology in studies investigating EMDR treatment of PTSD. Journal of Clinical Psychology, 58(1), doi: /jclp.1127

19 TREATMENT OF PTSD WITH EMDR 19 Russell, M. C. (2006). Treating combat-related stress disorders: A multiple case study utilizing eye movement desensitization and reprocessing (EMDR) with battlefield casualties from the Iraqi war. Military Psychology, 18(1), doi: /s mp1801_1 Russell, M. C. (2008a). Scientific resistance to research, training and utilization of eye movement desensitization and reprocessing (EMDR) therapy in treating post-war disorders. Social science & medicine (1982), 67(11), doi: /j.socscimed Russell, M. C. (2008b). War-related medically unexplained symptoms, prevalence, and treatment: Utilizing EMDR within the armed services. Journal of EMDR Practice & Research, 2(3), doi: / Russell, M. C., & Friedberg, F. (2009). Training, treatment access, and research on trauma intervention in the armed services. Journal of EMDR Practice & Research, 3(1), doi: / Seidler, G. H., & Wagner, F. E. (2006). Comparing the efficacy of EMDR and trauma-focused cognitive-behavioral therapy in the treatment of PTSD: A meta-analytic study. Psychological Medicine, 36(11), doi: /s Shapiro, F. (2001). Eye movement desensitization and reprocessing : basic principles, protocols, and procedures / (2nd ed.). Guilford Press,. Shapiro, F., & Maxfield, L. (2002). Eye movement desensitization and reprocessing (EMDR): Information processing in the treatment of trauma. Journal of Clinical Psychology, 58(8), doi: /jclp Silver, S. M., Rogers, S., & Russell, M. (2008). Eye movement desensitization and reprocessing (EMDR) in the treatment of war veterans. Journal of clinical psychology, 64(8), doi: /jclp.20510

20 TREATMENT OF PTSD WITH EMDR 20 Welch, K. L., & Beere, D. B. (2002). Eye movement desensitization and reprocessing: A treatment efficacy model. Clinical Psychology & Psychotherapy, 9(3), doi: /cpp.323 Wesson, M., & Gould, M. (2009). Intervening early with EMDR on military operations. Journal of EMDR Practice & Research, 3(2), doi: / Zimmermann, P., Biesold, K. H., Barre, K., & Lanczik, M. (2007). Long-term course of posttraumatic stress disorder (PTSD) in German soldiers: Effects of inpatient eye movement desensitization and reprocessing therapy and specific trauma characteristics in patients with noncombat-related PTSD. Military medicine, 172(5),