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January 24, 2005

Little-used PTSD therapy gains fans

Navy psychologist touts method's value for vets
NAVAL HOSPITAL BREMERTON, Wash. -- A Navy psychologist post-traumatic stress disorder that could mean faster and more effective treatment for troops overcome with memories of war's horrors.


By William H. McMichael
Times staff writer

But despite its long-standing use in some Department of Veterans Affairs hospitals and internationally, and a Pentagon endorsement in January, the unique eye-movement therapy has been slow to catch on in the U.S. military.

That may change soon. Given the intense and violent nature of combat in Iraq and Afghanistan -- and the therapy's promising results -- it may have to.

According to a July 2004 Walter Reed Army Institute of Research study on veterans of Iraq and Afghanistan and a 1988 study of Vietnam War veterans, at least 15 percent to 17 percent of returning veterans will likely develop PTSD. And the unconventional warfare of the past year has produced a higher incidence of trauma-inducing events than the initial invasion.

Meanwhile, three other therapies are on the Pentagon's list of those it says can produce "significant benefit" for PTSD victims.

However, all three can require 10 or more sessions and hours of homework by the patient, which leads to high dropout rates.

Repeated controlled studies of eye-movement desensitization and reprocessing, or EMDR, however, have shown that a single traumatic event can be "processed" -- become a mentally manageable event -- within three visits in up to 90 percent of patients, according to the EMDR Institute of Watsonville, Calif.

"It doesn't guarantee it's going to work for every person, and it's not going to work in a single session for every person," said Cmdr. Mark Russell, a clinical psychologist based at Bremerton Naval Hospital, Wash., who claims a success rate of 60 percent to 70 percent. "But if it does work, we usually know within the first session if it's going to ... help or not."

EMDR, developed in 1989, has long been used by certain VA medical centers, and earned the seal of approval of the American Psychological Association in 1998. The Pentagon came aboard in January, clinically noting that EMDR "has been found to be as effective as other treatments in some studies and less effective than other treatments in some other studies."

Training seminars for providers

However, hardly anyone in the U.S. military knows how to perform the therapy. Russell, who was a research assistant to Francine Shapiro, the psychologist who developed the therapy, believes he's the only U.S. military officer qualified to train others on EMDR.

But Russell's spreading the word. In late August, he conducted EMDR training at Madigan Army Medical Center in Tacoma, Wash. In December, a group of Army health-care providers was trained by the VA at Fort Carson, Colo. This month, Russell will lead a regional EMDR training seminar at Bremerton for 80 to 100 participants from all services and VA health-care providers from Washington and Oregon.

Here's what he's teaching them:

In the simplest terms, the brain processes emotions on its right side and rational, logical thought on its left. The right side of a traumatized person's brain is overloaded, with no way to release that trauma.

EMDR tries to patch the right side to the left. If successful, the patient gains a perspective on the trauma that allows for more normal functioning.

To do this, the therapist asks patients to focus on the most vivid visual image connected with the memory or belief that is dominating their thoughts; a negative self-image connected with that memory; and a positive thought about how they'd like to feel.

The patients also rate the intensity of the disturbance on a scale of one to 10, with 10 being intolerable.

Then, in a series of 15- to 20-second sessions, a patient focuses on some sort of back-and-forth stimulus -- a series of blinking lights, soft pinging sounds over headphones or alternate finger taps on the right and left palms. This mimics the rapid eye movements in deep sleep, Russell said.

At the same time, the patient focuses on the image and the negative and positive thoughts with gentle guidance from the therapist. It's not a trance; the patient is completely awake and aware.

After each sequence, the stimulus is halted and the therapist asks the patient what he's thinking. However, the patient isn't required to recount the specific event -- only to comment on his general state of mind. Then, the stimulus continues. At various points, the therapist asks the patient to reassess the intensity of the disturbance.

The goal is to desensitize the experience and get the patient to reprocess the trauma and gain perspective on the event.

"They're never going to feel good about it," Russell said. "But it's helping them adapt to it -- and so, to a point where they can go on with their life and not be saddled by guilt or saddled by the intrusive recollections."

EMDR, like classic psychotherapies, is something of a mystery. "The honest answer is that we don't really know exactly how it works," Russell said.

He first practiced EMDR in 2003 in Rota, Spain, where the deployed Fleet Hospital 8 treated about 1,400 wartime casualties from Iraq and Afghanistan. Nearly all were given a mental-health screening, and 158 were diagnosed with acute stress disorder, a precursor to PTSD.

Troops stayed at Rota no more than three to four days, so the focus was on rapid intervention. Four troops needed immediate intervention, Russell said.

All four reported substantial improvement in one session. One, a soldier, had been traumatized after shooting an Iraqi soldier who didn't die immediately.

The soldier rated that experience a "7" on the disturbance scale. After 10 sets of eye movements, the soldier had lowered that score to a "1," Russell wrote in a paper submitted for professional publication.

When asked what kept the rating from dropping to zero, the soldier told Russell: "Everybody who died was a victim of circumstances. I don't think I will ever feel a zero when I think about it. But ... it doesn't bother me as much as it used to. That's amazing!"

Meanwhile, the therapy has its skeptics.

"The use of eye movements kind of sounds very flaky and doesn't make sense to people," Russell said.

"It doesn't make sense to a lot of scientists because it's not grounded in any current theories of psychological therapy or psychopathology," he said.

The rapid effects being reported with EMDR also "made a lot of people very skeptical and very uneasy -- like this is too good to be true," he said.

However, those rapid effects make EMDR well-suited for military use because troops can return to full duty more quickly, he said.

The therapy also isn't hindered by the widely recognized macho attitude of many troops who see mental problems as a weakness.

In EMDR, Russell said, "You don't have to go into any more detail than you want to share. The therapist doesn't need to know every single thought that you have or how you're feeling about things, or every detail that you've experienced.

"Just enough to keep the processing going."

January 5, 2005

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