Portraits in Healing:
Clinical Study on the Neurological Outcomes of EMDR in the Treatment for
Cumulative PTSD in Police Officers
By: Karen Lansing, MFT, BCETS, & Daniel Amen, M.D.
The purpose of this study was to observe the changes that occurred with five clients diagnosed with Posttraumatic Stress Disorder through an entire course of treatment that included the use of EMDR. Special interest was given to two points of reference (1) measurements of neurological changes (observed before, during and after EMDR through brain imaging) and, (2) the clients own self report of their symptomology before the utilization of EMDR and then at the end of the segment of their treatment which incorporated EMDR.
The subjects for this study were chosen from a client base comprising of police officers. All had been involved in shootings. Each subject was evaluated by an independent clinician who was not involved in this study before EMDR was introduced as well as at the end of the course of treatment. The purpose for this was to confirm (or rule out) a diagnosis of PTSD and to identify the severity of each subject’s condition. These outside evaluators each specialize in the treatment of trauma. The Foa Posttraumatic Stress Diagnostic Scale (PDS), a standardized evaluative tool for the measurement of PTSD was used by these clinicians as well as session interviews. Several subjects had seen a psychotherapist prior to entering this study for extended periods of time while others had not received any therapy before coming into the study.
In addition to the aforementioned outside evaluations, pre and post EMDR
SPECT brain images were taken of all five subjects prior to their first
EMDR session and then at the end of the segment of treatment where EMDR
was utilized. Additionally
four out of five subjects were given brain images during their very first
Each of the five subjects completed therapy successfully and experienced
a dramatic improvement in their symptoms. All but one were able to return to a pre-morbid level of
functioning in terms of executive functioning.
Neurological changes were seen consistently in several sectors in
the brain (cingulate gyrus, basal ganglia, the deep limbic system, and the
cerebellum). Prior to the use
of EMDR these sectors were overactive.
Following the utilization of EMDR these areas became less active.
Additional drops in activity occurred in the Prefrontal Cortex.
All of the brain images corresponded with the standardized PDS
evaluations recording the client’s own self reports in the outside
clinical evaluations. A
dramatic diminishing of their PTSD symptoms was reflected in both the PDS
as well as in the opinions of the outside therapist evaluators.
Individuals in Law Enforcement experience more trauma in one month than
the average citizen will see in the course of a lifetime.
Cumulative PTSD with delayed onset is the most common type of case
that this population will present with.
In such cases, it’s not merely one traumatic event but numerous
ones that require effective resolution.
Without complete recovery, officers can experience dramatic drops
in their ability to contend with the chronic stress and dangers inherent
in their jobs. For this
reason, it is imperative that those providing therapy to treat
duty-induced trauma be effective. This
study observes the progress and outcomes of 5 officers involved in on-duty
shootings. All had cumulative
PTSD for one year or longer by the time they entered into treatment.
Partial funding for this study was rendered by the EMDR Institute that
helped to pay for 15 SPECT images. The
design of this study was formulated solely by Karen Lansing, MFT and Dr. Errore. Il segnalibro non č definito..
Clients that were chosen for this study had to meet the following criteria:
These research subjects all came in for the treatment of PTSD due to duty related trauma. All had been in officer-involved shootings but had also accumulated at least two or more other traumatic events over the course of performing their duties. Two clients had never been in therapy before, and three clients had already been involved in treatment using talk therapy as the mode of treatment. One of these clients had been through a complete course of treatment while the remaining two had seen a therapist and had been referred. Talk therapy was the model of treatment with the preceding therapists in all of these cases. Prior to entering into this research, Client #1 had been in therapy for eight months, Client #2 had been in therapy for ten months and client #4 had been in therapy for five months. Session content with the previous therapists had included discussion of their respective traumas in some detail as well as some focus on family issues.
The choice of officers involved in on-duty shootings was made for several reasons. First, this is a population that the treating psychotherapist specializes in. Additionally, because police officers are highly trained, once they’ve had to revert to their training in a critical incident, they tend to dissociate from their affective reactions to things in order to survive or, protect others (i.e. they may not be aware of any sense of fear/terror/horror even though they are reacting due to such internal reactions). The fact that an officer has been in a situation that’s caused him/her to not only have drawn a weapon, but to have fired, is a confirmation that s/he was afraid for personal safety and/or for the safety of others. Additionally, officers who have had to fire at another (always with the intent to kill), often suffer from increased risks if they remain/return to duty. The inability to perform this same act again out on patrol can be one deadly bi-product of such trauma but there are other debilitating after effects that can occur as well… not the leaste of which is PTSD (Grossman, 1995; Herman, 1992; van der Kolk, et al (1996).
Course of treatment:
Upon entry into treatment, intake was conducted taking a family history,
client history and trauma history. These
clients were then asked if they would be interested in taking part in this
study. If they were
interested they were informed of what this would involve with regards to
time, travel and brain imaging. Outside
clinicians conducted the following evaluations on all subjects: The PDS was administered along with an interview, which would
set out to (1) define and describe the symptoms each client was
experiencing, (2) the nature
of their traumas and (3) to confirm that each had a viable case of PTSD.
If the diagnosis of PTSD was confirmed informed consent was given
to each research client by the treating therapist, and a second form was
included in the patient information paperwork for their review and
signature at the Amen Clinic detailing the process and elements involved
in receiving SPECT imaging.
Treatment Protocol: Treatment format for all clients proceeded as follows:
#1. Administrative Phase: Initial intakes are done including genogram, personal history and trauma history. Coping mechanisms are taught. These include, (1) the identification of one’s support network (or if necessary the formation of one) (2) an agreement to refrain from self medication with non-prescribed substances, (3) teaching the client how to use containment techniques when/if flashbacks and/or disturbing memories erupt, (4) a routine of stress reduction activities are initiated as well which usually include exercise on a regular basis, social interaction with friends and/or family, etc. (5) Logging is taught whereby a client makes note of reactions s/he is experiencing (i.e. flashbacks, memories of the scene that come to mind, strong emotional responses to things, nightmares, etc.) These are to be noted and rated on a 0-10 scale (0=no reaction---10=as extreme/intense as could be). Additionally, the client is instructed on how to refine his ability to clearly identify underlying emotions. For example, male clients will often times log a reaction of anger to any given distressful situation. If asked what lies beneath the anger he may find that it is fear or sadness. This logging is preparation for EMDR which is done in the second phase. (6) Resource Installation: Called “Going to Baseline” whereby the client is taught to recall a good memory or event in his/her life when disturbing memories or reactions come up.
Traumatic events are inventoried and ranked in intensity for later reference regarding EMDR targets in the second phase of treatment. Additionally, client safety is evaluated regarding risk to self / others, need for medication and stability of living environment.
#2. Working Phase: Once the client has been stabilized and has been making use of the resources put in to place in Phase #1, s/he is ready to begin focused and in-depth trauma work.
The focal point of this segment in treatment is EMDR. Due to the mental fatigue that this technique will cause, the frequency of EMDR sessions (which typically run from 2-3 hours in length) is dictated by the client’s individual recuperation time. Generally, it is done three to four weeks apart. Due to officer safety concerns, it was necessary to time EMDR sessions for the beginning of his/her three day off-duty time, and to allow for recovery from mental fatigue before going into the next EMDR session. In the case of the one officer who was on medication while in treatment, there was a slower recovery time noted after EMDR sessions. Sessions between the EMDR sessions are one hour long and are used to facilitate any insights and connections that had been made both during and after these sessions. Changes in the intensity and frequency of symptoms were also reviewed.
At the end of Phase #2 (one month following the last EMDR session) the final SPECT was taken. This time between the last EMDR session and final SPECT allowed the brain to recover from mental fatigue that was caused by the EMDR.
Each of the subjects had gone through initial intake, the complete
course of education and training listed in Phase #1 and the outside
clinical evaluation prior to their first SPECT scan.
The outside evaluations were done anywhere from 1-42 days prior to
the SPECT scan. The two
clients with the most severe PTSD symptomology were purposefully put on
extreme ends of this timeline to see if Phase #1 could drop their symptom
intensity and overactive neurological conditions.
SPECT scans still indicated a high degree of PTSD induced over
activity in both of these clients. While
all five of the clients following Phase #1 were more able to mediate their
symptom clusters and had more skills to make use of for self-care, their
symptomology had not abated measurably.
Dramatic drops in symptomology as well as changes in brain function
occurred after the clients had completed the second phase of treatment
where EMDR had been used (when final SPECT images were taken).
The choice was made to have the Connor CPT Concentration Test utilized
for the “at concentration” pre and post EMDR SPECT images.
This was in the interest of (1) having the subjects engaged in a
uniform activity, and (2) to insure that they were not thinking about
their traumatic events during the imaging.
This allowed the view of PTSD “running in the background” when
the thoughts/images of their incidents were not foremost in their minds.
More importantly, was the goal to “render no harm” to these
officers as we observed their progress through treatment.
The SPECT images cannot be taken any sooner than 30 hours apart
(due to the half life of the ink which is injected).
As it was, the pre and during EMDR brain images were done one week
apart. There were concerns
that in doing an initial SPECT image that required the subjects to recall
their shootings, or to have them listen to the dispatch tapes of their
incidents, this could intensify their PTSD conditions.
Not all of these officers were on disability leave and so were
still working out on patrol with guns.
EMDR was conducted according to the techniques taught through the EMDR
Institute. The use of the
TheraTapper during EMDR segments allowed the subjects to go through the
traumatic scenes with their eyes closed.
Even so, it was noted that at various times all subject’s eyes
would move back and forth even though they remained closed.
These subjects were unaware of this when asked about it.
Brain Imaging Parameters:
The brain SPECT studies were performed in the following manner.
The subject was placed in a dimly lit, quiet room.
Intravenous access was obtained via small gauge butterfly.
The subject remained quiet for several minutes with his/her eyes
open to allow his/her mental state to acclimate to the environment.
For both the pre and post EMDR brain images, the subject was given a
standardized concentration test to perform.
The Conner’s Continuous Performance Task is a 15 minute
computerized test of attention. Three
minutes into performing the task HMPAO was injected into the I.V. port.
The subject then completed the task.
In the “during” EMDR brain images, the Conner’s Continuous
Performance Task was replaced by EMDR.
Subjects were set up with the Iv port prior to commencement of EMDR.
Once EMDR was under way, the injection was given (always during the
first review of the traumatic scene).
In all cases, a tomographic brain image was then performed approximately
45 minutes later using a high resolution Picker Prism 3000 gama camera
with fan beam collimators. Data
was acquired in 128 X 128 matrices. One
hundred twenty images with 3 degrees of separation spanning 360 degrees
rotation were obtained. The
data was prefiltered using a low pass filter with a high cutoff.
Attenuation correction was performed using a linear method.
Coronal, sagittal and transaxial tomographs were parallel to the
The tomographs were displayed using a standardized linear color scale. The studies were read by visual inspection in all three planes and in 3 dimensional surface brain maps (looking at the most active 45% of brain activity) and 3 dimensional active brain maps (comparing average activity with the most active 15% of brain activity). All of the brain areas were rated on a scale of 0 (normal activity) to 4 (+) increased or 4 (-) decreased activity.
Eye Movement Desensitization and Reprocessing (Shapiro, 1989, 1995) is a
treatment modality that combines key aspects of major theoretical
orientations (e.g. cognitive behavioral, psychodynamic, client-centered
and interactional) along with bi-lateral stimulation. This technique can be integrated into a comprehensive
treatment plan by appropriately trained clinicians in order to address and
neutralize the effects of distressing life events and traumas. EMDR consists of a procedural protocol including eight phases
designed to address specific complaints that bring clients in for
treatment (i.e. mood disturbances, insomnia/hypersomnia, increased anger,
depression, isolation, avoidant behaviors, panic/anxiety attacks, etc.).
Initially eye movement was the modality used to accomplish the
increased vivification of scenes that were disturbing.
Over the course of time, it has been discovered that various other
types of bi-lateral stimulation (i.e. tapping or tones) can also
Various theories exist regarding how and why EMDR works. Dyck (1993)
correlates the EMDR protocol to that of classical conditioning.
Another theory is that eye movement or kinesthetic tapping can
reduce the intensity of overpowering affective reactions when recalling a
traumatic event (Commons, 2000).
While the basal ganglia do tend to drop in over activity during EMDR the
increase of fear, helplessness, horror, etc. were uniformly a part of the
process in the earlier sets. As
already mentioned, the modality for bi-lateral stimulation used during
EMDR was hand tapping with the “TheraTapper.”
In each set of EMDR the focus was on facilitating the most intense
re-experiencing of the traumatic scene.
The clients who had previously been in talk therapy voiced concerns
that they would not be able to recount their traumatic scenes fully, or
experience any improvements since they had discussed them in some detail
on numerous occasions with prior clinicians.
In all of these cases their concerns were unfounded.
These same subjects voiced surprise at the intensity of not only
the scenes, but also their affective reactions to them (especially those
of fear and sadness) as they worked through these during EMDR.
Additionally, in most cases, fragments of memory were recounted
(i.e. why a gun had not fired properly, or the presence of bystanders
who’d been near the line of fire that the officer had not recalled being
there, or, why radio transmission had not occurred). The subjects who had
not been in therapy prior to entering this study had the similar
experiences as well.
All five subjects also reported a change in the nature of their memories
as the EMDR process proceeded. Perceptive
changes were noted and volunteered by the subjects where they described
initially feeling as though they’d been back in the scene.
One client without realizing it, had actually lifted her hands (as
though aiming her gun). As the scene was revisited in each EMDR segment, the subjects
began to experience it more as spectators watching the scene playing out.
One of the subjects who’d come into this study with severe PTSD (according
to the PDS and his brain image) had never before been able to discuss his
shooting without coming to tears. After the completion of his EMDR session,
for the first time, he was able to tell the story from beginning to end
without becoming overwhelmed.
In all of the initial brain images similar patterns of neurological
activity were observed. Over
activity (to varying degrees) was found in the cingulated gyrus, the basal
ganglia, the deep limbic region and in the cerebellum.
Upon completion of the second phase of treatment where EMDR was
used, these regions became measurably less active or returned to normal
levels of activity. Along
with this, the prefrontal cortex (PFC) was also found to drop in activity.
Typically this PFC drop would indicate a diminishing of ability to
sustain attention, to filter out distractions and a drop in cognitive
function. However, all but
one subject reported marked improvements in these areas along with an
increase in their sense of safety, ability and control while on duty. Prior to EMDR all had experienced difficulties in things such
as multitasking (i.e. driving out on patrol, listening to radio traffic,
verbal responses on the radio and watching the activity out on the streets).
After treatment, multitasking returned to a pre-morbid level of
functioning. The one officer
who was an exception to this had suffered several traumatic head injuries
over the course of her career prior to treatment.
Two officers (subjects 2 & 5) reported still having some residual
anxiety in their PDS. Both saw measurable drops in neurological over
activity in all the aforementioned regions of their brains with the
exception of the basal ganglia. These
two officers had concerns regarding possible retribution after their
respective shootings in the communities that they served. Despite that
however, both felt that their anxiety was manageable while on duty.
Even so, symptoms such as nightmares, sleep disturbances, mood
disruptions (i.e. disproportionate anger reactions) all disappeared.
All subjects reported dramatic improvements in mood, sleep, and
relationships in the wake of EMDR utilization.
Their brain images corresponded with their self-reports in the
final PDS intakes.
While this study was designed as a means to observe the normal clinical
progression of subjects being treated for complicated PTSD with the
utilization of EMDR, the hope is that it can add to the research which has
already been done. Further
studies of this type using other treatment models can only help to
facilitate our understanding of what treatment modalities can best assist
in the process of healing. Even
so, as is always the case, improvements in research design are always
possible and this modest study is no exception.
One aspect of study along with the standardized evaluations and
brain imagines that could further add to such endeavors would involved the
measurements of stress hormones before, during and after EMDR has been
utilized. Due to funding
restrictions this was an aspect of investigation that was not an option.
In the future perhaps this can be added to the matrix.
and Post EMDR PDS Evaluation Scores:
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