Law Enforcement, PTSD and EDMR
BY LINDA OUELLETTE


There are nearly a million Americans serving in law enforcement. It is estimated that the incidence of current, duty-related Posttraumatic Stress Disorder (PTSD) in law enforcement personnel varies between 5.9-22% (Flannery, 2015).  In addition, there are likely many officers that may have symptoms of PTSD but fail to meet the full diagnostic criteria. Their symptoms still are disturbing or debilitating.

Since 2001, police have had to add dealing with the imminent threat of terrorist attacks to their responsibilities.  Law enforcement personnel, and other first responders, are exposed daily to acute stress and trauma. These incidents have a cumulative effect.  In someone susceptible to developing PTSD, there is no time to recover from one event before they are facing the next one.

The Diagnostic and Statistical Manual of Psychiatric Disorders (5th ed., 2013) defines PTSD as “Exposure to actual or threatened death, serious injury, or sexual violence in one (or more) of the following ways:” Directly experiencing the traumatic event or witnessing it, in person, learning that the event happened to a family member or close friend, or experiencing repeated or extreme exposure to aversive details of the traumatic event.

There are many pretrauma factors that influence whether or not one is vulnerable to developing PTSD or is resilient. There are genetic susceptibilities. Demographic variables play a role. Women tend to be more likely to develop PTSD than men. Whether the officer has a previous trauma history, including childhood trauma is important to consider. Is there a history of psychiatric illness? How well adjusted is the person? What is their intellectual functioning? How well do they cope with other stressful events?

Then, there is the traumatic incident itself. The degree of life threat may influence responses to the critical incident. There are psychological and biological responses at the time, and shortly after the event. The reactions during or in the immediate aftermath of the trauma are called peritraumatic reactions.  These reactions and one’s perception of life threat have a strong association with PTSD symptoms. If left untreated, these overpowering symptoms may last indefinitely.

Historically, two problems in dealing with PTSD in first responders are under-reporting and under-recognition . In under-reporting, the trauma survivors themselves exhibit a lack of trust, a fear of being seen as “weak” or even a failure to recognize the symptoms. While most of us consider first responders to be “tough” and resilient, many suffer in silence. There has also been under-recognition of the traumatic symptoms by health care providers. These problems were described by Harris in 2001. In the past 15 years, the healthcare field has traveled light years in their understanding and recognition of trauma. “Trauma-informed care” is the new standard that agencies and healthcare organizations, including mental health groups, aspire to.

We now understand that trauma is not the actual event or even our memory of that event. Trauma is how the nervous system responds to the event.  Bessel van der Kolk, an internationally acclaimed clinician, educator and researcher with over 40-years of experience in working with and treating people who have experienced trauma describes trauma; “From my vantage point as a researcher we know that the impact of trauma is upon the survival or animal part of the brain. That means that our automatic danger signals are disturbed, and we become hyper- or hypo-active: aroused or numbed out. We become like frightened animals. We cannot reason ourselves out of being frightened or upset. Of course, talking can be very helpful in acknowledging the reality about what’s happened and how it’s affected you, but talking about it doesn’t put it behind you because it doesn’t go deep enough into the survival brain.” The reaction to trauma causes chemical changes in the body, on the hormonal level, which make it impossible to “just get over it.” These chemical changes produce two of the major symptoms of PTSD – hyperarousal and hypoarousal. With hyperarousal comes anxiety, agitation, sleep difficulties, intrusive memories (flashbacks) and nightmares. Hypoarousal, on the other hand, involves the shutting down of sensations and emotions, or what they call “psychic numbing.” This shutting down also effects the cognitive area of the brain which results in having trouble concentrating, remembering things, making decisions and talking about what happened to them. Ironically, this shutting down, under typical circumstances, is what makes them so good at their job. They train themselves to not see what they are seeing. If they are not able, afterwards, to “turn back on” when with family or friends, PTSD has arrived.

One of the more familiar treatments for critical incidents is the Critical Incident Stress Debriefing (CISD). These debriefings have been common practice for first responders, their value has not been scientifically evaluated. The World Health Organization, for instance, says a psychological debriefing “should not be used for people exposed recently to a traumatic event” and may do more harm than good.

The efficacy of EMDR, on the other hand, has been well documented. The EMDR International Association (EMDRIA) defines EMDR (Eye Movement Desensitization and Reprocessing) as an “evidence-based psychotherapy for Posttraumatic Stress Disorder (PTSD).” Francine Shapiro, the originator of EMDR, discusses the AIP, or Adaptive Information Processing model. The premise is that PTSD symptoms today are due to traumatic or disturbing adverse life experiences which are maladaptively encoded or incompletely processed in the brain. EMDR facilitates the resumption of normal information processing and integration. Present symptoms are alleviated and distress from the disturbing memory is decreased or eliminated. The client has an improved view of the self and relief from bodily disturbance.

In typical memory processes, new experiences process through an information system that allows the current situation to link with adaptive memory networks associated with similar experiences in the past. Thus, the person develops a knowledge base with perceptions, attitudes, emotions, sensations and action tendencies that will assimilate more similar experiences in the future.

Traumatic events are stored maladaptively in memory, such that they cannot link with memory networks that have more adaptive information. Memories then become susceptible to fragmented recall that is not functional in terms of time, place and context.  New information or positive experiences cannot connect with the disturbing memory, as it is now in its own memory network, separate from the adaptive memory networks.

There are 8 phases in the treatment of PTSD with EMDR, that will proceed over several sessions. Phase 1 is Client History and Treatment Planning. In PTSD in a first responder this is likely to confine itself more to the history of the actual traumatic event(s). As past trauma, even from childhood, can impact someone’s susceptibility to developing PTSD, that will be discussed as needed. Treatment planning consists of developing a list of “targets,” or memories/events to process. Phase 2 is Preparation. The person will be oriented to the EMDR definitions and processes, so they can give informed consent. The first responder needs to master self-soothing, and adaptive resources prior to dealing with the disturbing memories. You need to learn how to step on the brake, before you step on the accelerator. In Phase 3, the Assessment phase, the clinician and client establish a particular memory to target, and establish a baseline of their current response to the intensity of that memory. The client is asked first to imagine a picture of the worst part of the experience. Then they reveal a negative irrational belief they have about themselves now that goes with that event. With first responders those negative beliefs are likely to be things like, “I am in danger,” or “I should have done something more,” or “It’s my fault.” 
Then they are asked about a positive belief they would like to have about themselves now instead, things like “It’s over. I’m safe now,” “I did everything I could,” “It is not my fault.” They rate how true the positive belief feels to them at this time (scale of 1-7). They are then asked what emotions they feel, how disturbing the memory seems to them now (scale of 0-10) and what physical sensations they are noticing.

During Desensitization (Phase 4) the memory is accessed and the client is asked to notice his/her experiences while the clinician provides alternating bilateral stimulation, eye movements, tones or taps. The client then reports what they experience. Once the disturbance is at or near zero, the desired positive belief is mentally paired with the disturbing event and this is processed until that belief feels completely true. Then the client does a mental body scan (Phase 6), where they are looking for any tension or tightness that might be lingering. The session is closed (Phase 7) with information about getting support between sessions, and with accessing some of the self-soothing skills they learned in Preparation. Phase 8, Reevaluation, takes place at the beginning of the next session, where the target memory is evaluated to see if any disturbance remains. Each memory or disturbing image of the traumatic event is processed with this protocol.

There are some variations to this standard protocol which, with additional EMDR training, can be used with more recent traumatic events, and early EMDR interventions.  There is a protocol that has been developed to be used by paraprofessionals in crisis situations. There is an Emergency Response Protocol to help people who are severely affected by an event, such that they are shaking, in shock, perhaps even unable to speak right away. Much of this would apply to first responders. Many randomized, controlled trials have demonstrated the efficacy of EMDR for the treatment of PTSD. If they are willing to seek help, first responders no longer have to suffer in silence.

ABOUT THE AUTHOR:  Linda Ouellette, MA, LPC lives in Tucson, AZ and shares her time between EMDR and clinical supervision at Sierra Tucson, a world-renowned behavioral health treatment center, and her private practice, Awakenings Counseling. She is certified in EMDR, and helps train others. She is in awe of the power of EMDR and how it can truly change lives.

References:
EMDR information compiled from www.emdria.org
Flannery, R. (2015, June). Treating psychological trauma in first responders: A multi-modal paradigm. Psychiatric Quarterly, 86 (2) 261-267.
Harris, M. and Fallot, R. (2001). Envisioning a trauma-informed service system: A vital paradigm shift. New Directions for Mental Health Services, 89, 3-21.
Jarero, I. et al., Journal of EMDR Practice and Research, Vol 7, Nbr 2, 2013, pp. 55-64.
Keenan, P., & Royle, L. (2007, Fall). Vicarious trauma and first responders: a case study utilizing eye movement desensitization and reprocessing (EMDR)as the primary treatment modality. International Journal of Emergency Mental Health, 9 (4). 291-298.
Luber, M (Ed.), Implementing EMDR early mental health interventions for man-made and natural disasters (pp.371-382). New York, NY: Springer Publishing Co.
Marmar, Charles, et al (2006). Ann.N.Y. Acad Sci 1071:1018 doi:10.1196/annals.1364.001
Stone, Adam (9/30/2013). http://www.emergencymgmt.com/training/Beyond-Debriefing-Responders-Emotional-Health.html?
Usadi, Eva, MA, BCD. http://www.traumaandresiliencyresources.org/resources/trr-resources/42-an-open-letter-to-first-responders-on-trauma.html
Van der Kolk. http://www.psychotherapy.net/interview/Bessel-van-der-kolk-trauma 



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