Standard EMDR Protocol for Alcohol and Substance Dependence Comorbid With Posttraumatic Stress Disorder: Four Cases With 12-Month Follow-Up

Primary Outcome Measures

The Mini International Neuropsychiatric Interview (MINI) Plus (Sheehan et al., 1997), a structured diagnostic interview, was used to assess for alcohol and substance dependence (past 12 months and lifetime) and alcohol and substance abuse (past 12 months and lifetime). For the purpose of this article and to highlight the positive effect EMDR has on reducing alcohol and substance use, data presented will focus on current (past 12 months) alcohol and substance dependence and abuse.

When completing the MINI Plus, the therapist asks a series of questions relating to each Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.; DSM-IV-TR; American Psychiatric Association, 2000) disorder. For a diagnosis of alcohol and substance dependence, the client must answer “yes” to three or more questions. Examples of a screening question for alcohol dependence includes “In the past 12 months, did you need to drink more in order to get the same effect that you got when you first started drinking?” (Sheehan et al., 1997).

Use of the MINI Plus reflected our aim to screen broadly for comorbid conditions because the MINI Plus is designed to assess and diagnose 23 psychiatric disorders. It is a highly sensitive and specific screening tool adaptable to many clinical and research settings, with excellent reliability and validity (Lecrubier, Sheehan, & Weiller, 1997).

On initial assessment, three participants (Cases 2, 3, and 4) met the DSM-IV diagnosis for current alcohol dependence, and one participant (Case 1) met the DSM-IV diagnosis for current substance dependence.

Participants were assessed again following treatment with EMDR and 12 months following the end of treatment.

The PCL-C is a brief self-report instrument used to assess the reexperiencing, avoidance, and hyperarousal symptoms of PTSD (Blanchard et al., 1996). It is widely used in the clinical setting for tracking symptoms and as a diagnostic tool in research studies. Because the PCL-C does not allow for investigators to confirm that the traumatic event met the Criteria A component of the DSM-IV PTSD diagnosis, it is more useful when followed by a second-tier diagnostic test (such as the MINI Plus; McDonald & Calhoun, 2010). On initial assessment, three of the four participants scored above the threshold of 44 for PTSD diagnosis with a mean score of 55.25.

Screening Tool for EMDR Suitability

The DES was developed by Bernstein and Putnam (1986) as a self-report measure (consisting of 28 items) to assess the degree to which people experience dissociation. Van Ijzendoorn and Schuengel (1996) suggest the DES demonstrates impressive predictive validity, in particular, concerning dissociative disorder and traumatic experiences. In addition, Carlson et al. (1993) found the DES a reliable and valid instrument to measure dissociation in many groups and to have good concurrent validity for detecting severe dissociative disorders. The DES was administered during the assessment phase only because it was used to identify those at risk of dissociation and who would not be suitable for EMDR.

Presentation

WC is a 28-year-old White male, self-employed electrician, living with his de facto partner of 9 years.

He was referred to the PTS Clinic by his treating physician at the hyperbaric unit where he had been receiving hyperbaric treatment for physical complications (poor gait and balance, bowel, and bladder retention) secondary to a scuba diving accident that had occurred 4 months previously. Although now physically recovered, he was experiencing symptoms suggestive of PTSD. He was referred for confirmation of diagnosis and to determine suitability for EMDR therapy.

Client History

WC described himself as a competent scuba diver with 10 years of experience including working as a scuba diving instructor for a tourist company. He reports on the day of the accident he had not been keen to dive but believed it would be stress relieving given the recent increased workload and pressure at work. WC had borrowed his brother-in-law’s equipment, his own needing repair, and was unfamiliar with the aluminium scuba tank, his being made of steel. He describes diving alone, ignoring the recommended and usual safety guidelines of diving alongside a buddy. He recalls losing his weight belt and as a consequence experiencing a rapid ascent, particularly the last 5 m, to the water’s surface. He describes the fear as numbness and loss of feeling spread to his upper and lower extremities. He was unable to signal for help or activate the buoyancy device. He remembers the weight of the scuba tank turning him to the lateral position and his mouth filling with salt water. At this point, he thought he was “going to die.” Seen by fellow divers, he was eventually pulled from the water, but because of altered and loss of consciousness, he only remembers fragments of the 45-minute boat ride to land and the emergency department. At time of assessment, WC describes being troubled by disturbing images and memories of the diving accident, dreams and nightmares (of the diving accident itself as well as sharks, predators of the ocean), anger outbursts, and becoming fearful of others intentions. Since the scuba diving accident, WC had increased his marijuana use, smoking “a joint” usually alone, three to four times a week; this increased from infrequent social use. He believed marijuana “helped take the edge off . . . makes me calmer.” He additionally reported past traumatic events including one episode of childhood sexual abuse (CSA) and bullying at primary school. He had not received any previous treatment for his PTSD symptoms or increased marijuana use.

Initial Assessments

MINI Plus indicated WC met the criteria for PTSD and substance dependence (current). His PCL-C score was 46/85.

Treatment

The initial plan was for WC to receive EMDR on a weekly basis, but his workload resulted in fortnightly appointments, with WC requiring five EMDR therapy sessions. He identified his treatment goals as being “learning to cope with my emotions better following diving accident. Have a better understanding of what’s happening inside my brain.”

Presentation

LK is a 37-year-old divorced White mother of two daughters: a 5-year-old and a 16-year-old. She is employed full-time as a juvenile corrections officer however at time of referral had been on sick leave for 2 weeks. She has been in a supportive relationship with her partner Tom for 5 months.

LK was referred to the PTS Clinic by the duty officer at the local authorized mental health hospital following LK’s crisis presentation to the emergency department where she presented for treatment of a superficial laceration to her left wrist and reporting difficulty coping secondary to traumatic events that had occurred during her childhood and adult years.

Client History

LK reported several traumatic incidences, the earliest and worst, being sexually abused by her maternal grandfather from the age of 6–12 years. She additionally reported being molested by a male stranger when she 12 years old, witnessing multiple episodes of domestic violence between her mother and father as well as being a victim of domestic violence herself in her first marriage. Her latest trauma occurred 2 years previously and over a 2-month period where she was stalked and repeatedly threatened by ex-inmates at the juvenile corrections facility where she worked. LK reported the ex-inmates had gained access to her personal details that resulted in a number of them and their family members breaking and entering LK’s home late at night threatening to rape and kill her and her two daughters. This had prompted LK to seek a violent restraining order. LK reported she had not experienced any PTSD symptoms prior to the latest trauma despite her previous trauma history. Her current symptoms included intrusive memories and nightmares regarding the CSA and the break and enter. She had difficulty falling and staying asleep. She was hypervigilant. On average, she had been consuming half a bottle of wine per night for the last 3 months with quantities even higher for the 12 months previously. She had reduced her alcohol consumption because she was aware of the negative effect this was having on her mood and her relationship with her daughters. She had sought the help of friends to provide additional emotional support during this time. She had not sought any formal treatment for her current alcohol use or PTSD symptoms.

Initial Assessments

MINI Plus indicated LK met the criteria for PTSD and alcohol dependence (current). Her score on the PCL-C was 71/85.

Treatment

Treatment goal: “To feel happier day to day, to be rid of bad dreams, sleep better, get rid of flashbacks and nightmares.”

LK’s first EMDR session focused on the horrific home invasion, the target image being a close-up of one of the male intruder’s face, his snarl, and angry facial expression. “I am in danger” was automatically verbalized as the negative cognition, fear was located in LK’s chest and throat, and her SUDS scored as 9/10. “I am safe” was LK’s positive cognition; however, it achieved a 2/7 for VoC. BLS was commenced using TheraTappers with LK’s emotional and physical arousal reducing throughout the session. Her SUDS reduced to 1/10 and as she stated, “They can’t reach me now . . . I am safe” (VoC = 7/7). A body scan indicated no resistance to this belief and no residual physical discomfort.

Session 2 began with a review of the home invasion, and LK indicated the target image now appeared foggy and “the whole thing doesn’t seem to bother me at all anymore.” As per Shapiro’s standard EMDR, and after discussing at length with LK, it was decided the earliest and worst traumatic memory would be targeted during this session of EMDR. LK reported the image that could best represent the worst memory of CSA was when she was 8 years old and alone with her grandfather in his bathroom. Her negative cognition “I am bad” was accompanied by emotions of fear and shame, which she felt “all over” with a SUDS of “10/10.” Her positive cognition “I was just a kid” held a VoC of 2/7 only.

The therapist commenced BLS using TheraTappers and after two sets observed LK becoming blank and distant. The therapist coached LK back to present using grounding techniques and slow breathing exercises. LK was guided to her safe place and after 5 minutes felt she was “back to her usual self.” LK was keen to recommence EMDR. To avoid the reoccurrence of the aforementioned, the therapist spent time installing resource figures and altered the target image so it would appear as a black and white snapshot. LK successfully processed the said target and other related images and memories of CSA. Her SUDS reduced steadily ending the session with SUDS of 1 and a VoC for her positive cognition of 7/7.

LK attended for weekly EMDR therapy needing four sessions in total. As well as targeting the CSA and break and enter, she targeted the anger she presently held for her mother for “not protecting me from the abuse.” After processing, the positive cognition of “It’s not her fault . . . she did the best she could” spontaneously emerged. Last, future template work was completed targeting the anticipatory anxiety she was experiencing relating to returning to her usual work duties and passing an ex-inmate on the street.

Each week, the therapist returned to the target image previously processed, and each time, LK reported the image was distant and foggy with nil emotional charge. She reported a reduction in her PTSD symptoms and an improvement in her overall functioning. She reported she no longer needed alcohol to dampen her symptoms, and as such, the quantity of alcohol she consumed reduced drastically. Her alcohol dependence had not been targeted during any of the EMDR sessions.

Follow-Up

Although LK required only four sessions of EMDR therapy, she was followed up 2 weeks after completing therapy and then at 6 months and 12 months post-EMDR. She was aware she could contact the PTS Clinic at any time should she require further support or therapy.

Her 12-month follow-up indicated she had maintained improvement with nil return of her PTSD symptoms. She reported she no longer craved alcohol or had consumed alcohol in isolation since treatment. She reported the consumption of alcohol in social situations, on average once a fortnight with one to two standard drinks being consumed, with no episodes of binge drinking or intoxication. She had returned to her usual work duties. Clinical interview combined with results of the MINI Plus and PCL-C (21/85) indicated she no longer met the criteria for current alcohol dependence or PTSD, respectively.

Presentation

RC is a 47-year-old married Australian father of two teenage children. He resides in his family suburban home with his wife of 27 years. His private psychiatrist, for a confirmation diagnosis of PTSD and for assessment to determine his suitability for EMDR therapy, referred him to the PTS Clinic. RC had been on worker’s compensation for 4 months unable to fill his long-term posting with the police helicopter rescue unit.

Client History

RC reports he had been exposed to multiple traumas in the course of his work as a policeman particularly since taking a position with the police helicopter rescue unit in 1991. The “standout” distressing events included the retrieval of four deceased bodies at sea and himself the victim of a helicopter crash while doing a routine visit to a primary school for education purposes. The most distressing incident of all had occurred 14 years previously and was the recovery of the bodies of four fellow policemen (“They were my mates”), who had also worked in the police helicopter rescue unit and who had died as their helicopter crashed into the side of a cliff. RC reported his PTSD symptoms started a month after this event. He had received 12 sessions of “talk therapy” organized through his employer. He reports little benefit from same. He did not divulge to his colleagues or family his experience of PTSD symptoms. His PTSD symptoms became increasing worse. He made excuses and avoided certain activities in the workplace. He started drinking alcohol to combat his anxiety, aid his sleep, and stop the reexperiencing symptoms. At time of assessment, he was drinking alcohol 5 days per week, commencing at 3 p.m. and consuming, on average, one bottle of red wine (750 ml), four “stubbies” (four × 375 ml bottles of beer), and two “shots” of bourbon. He drank alone in his shed but reported he would prioritize his parental/family and home duties over his drinking. He routinely kept Mondays and Tuesdays as alcohol-free days because of a coaching commitment and his son’s sporting activities. He had not sought any treatment, intervention, or therapy for his alcohol dependence either currently or in the past. He was not keen on being referred to alcohol detoxification or rehabilitation services.

Initial Assessments

MINI Plus indicated RC met the criteria for PTSD and alcohol dependence (current). His PCL-C score was 42/85.

Treatment

RC received six EMDR sessions. The first session targeted the most emotionally charged memory—retrieving and identifying the scattered body parts of his colleagues who had died in a helicopter crash. Despite several attempts and a lengthy exploration, RC had difficulty identifying a negative cognition. He described an overwhelming anxiety that presented as “butterflies in my stomach.” He scored his SUDS as 3/10. The therapist immediately questioned the validity and incongruence of the SUDS—how could overwhelming anxiety be felt at such a minimal level? RC admitted to blocking the accompanying sensation and emotion “a protective mechanism . . . habit from the police force.” To avoid further blocking, the therapist spent time emphasizing to RC the importance of connecting with all elements of the memory network to ensure efficient processing, and hence, resolution of the trauma memory could occur. The therapist encouraged RC to connect with all visual, tactile, auditory, and olfactory components of the trauma image, and this time, RC reported his SUDS as 8/10. BLS, in the form of saccadic eye movements occurred for 50 minutes. Several images from past traumatic work experiences emerged—the retrieval of bodies at sea, RC’s own helicopter crash, and attending domestic disputes. RC’s SUDS reduced to 2/10. Because of time restraints, a safe place exercise was used at the end of session.

Session 2 commenced with a review of the target image addressed in Session 1. RC reported this appeared and felt somewhat distant. He did describe residual anxiety that he rated as 4/10, located in his stomach with a negative cognition of “I am not in control . . . I am weak.” Again, BLS in the form of saccadic eye movements were used, successfully processing the target image, reducing the SUDS to 1/10, and a positive cognition “ I will get over this” strengthened from 2/7 to 6/7.

RC attended Session 3 describing an image that had been “troubling me the past week.” He describes a moment during the retrieval of his colleague’s body parts where he and a body bag were being elevated into the helicopter cabin. The body bag had been torn, and a human bone of the deceased had scraped into RC’s leg. During the session, he reported smelling blood and flesh which was making him nauseous and anxious. As a consequence, the therapist used the session to process the said image and accompanying negative cognition “I am unsafe. . . death is around me.” His SUDS score was 9/10, located in his stomach. RC became distressed during the session expressing at one point, “Think I may be sick.” Despite this, he continued to process well, his SUDS reducing steadily, achieving 1/10 and a positive cognition that felt completely true of “I am okay now.”

After three sessions of EMDR, RC reported his anxiety attacks had reduced from six per day to three per day, he experienced less feelings of dread, reported increased social activity including spontaneously going out to restaurants, and a reduction in his reexperiencing symptoms. His urge and desire to consume alcohol had reduced slightly.

Sessions 4 and 5 targeted present triggers—a heavy shopping bag bumped against his leg, triggering a sensation similar to the broken body bag brushing against him; a drive to the beach and the smell of seaweed triggering the smell of dead flesh.

Session 6 addressed his anxiety regarding returning to work, his ability to perform at work, and how he would cope if confronted with similar traumas. The last session was additionally used to review all targets addressed in therapy. RC reported the images now appeared foggy and less vivid that they were “no longer in the forefront of my mind.”

RC’s alcohol dependence was not targeted at any stage during his EMDR therapy.

Follow-Up

RC was followed-up by the PTS Clinic 2 weeks after completing therapy and then at 6 months and 12 months post-EMDR. He was aware he could contact the PTS Clinic at any time should he require further support or therapy. RC remained engaged with his referring private psychiatrist.

At 12-month follow-up, despite meeting the criteria for current alcohol dependence on the MINI Plus, RC reports his craving for alcohol and the volume of alcohol consumed has decreased since EMDR therapy. He additionally reports a reduction in the number of drinking days per week (from 5 to 3 days) and no longer combines spirits, wine, and beer when consuming alcohol. He continues to decline the need for referral to alcohol rehabilitation or detoxification services. He has maintained improvement in his PTSD symptoms achieving a score of 29/85 on the PCL-C (higher than 44 indicative of diagnosis of PTSD). He had not returned to the police force, instead is contemplating a change in career path, specifically purchasing a franchise for a gardening service. He continues to be “happily married” and has started playing veterans water polo.

Presentation

SK is a 53-year-old White male employed full-time as a fire fighter. He has been living with his supportive de facto partner Lisa for 10 years and has two adult children from his first marriage. He was referred to the PTS Clinic by this general practitioner for following worsening of PTSD symptoms that had first appeared 2 years ago, worsening over the last 12 months.

Client History

SK reports being exposed to multiple traumas since being employed as a fireman in 1988. Two years ago, he began experiencing PTSD symptoms including flashbacks, intrusive memories, and nightmares regarding the recovery of deceased and often mutilated bodies. The symptoms had increased in intensity and frequency over the last 12 months. SK used alcohol in attempt to reduce the intrusive and hyperarousal symptoms. He had started binge drinking earlier in the year. He had not sought, been referred, or engage in any therapy or treatment for his alcohol use. His employer had referred him to counseling at Crisis Care—he had four sessions in total.

Initial Assessments

MINI Plus indicated SK met the criteria for PTSD and alcohol dependence (current). His score on the PCL-C was 62/85.

Treatment

SK received six EMDR sessions. His treatment goal were “to stop the thoughts and images from being so intrusive . . . have more control.”

Follow-Up

SK was followed up by the PTS Clinic 3 weeks after completing therapy and then at 6 months and 12 months post-EMDR. Twelve-month follow-up indicated no evidence of PTSD symptoms. He reported the trauma images remained in altered form with no emotional or physiological disturbance. He was planning an extended holiday with his de facto partner. He reported a complete abstinence of alcohol consumption since completing EMDR therapy with no experience of cravings. His MINI Plus indicated he no longer met the diagnostic criteria for PTSD or alcohol dependence. He scored 18/85 on PCL-C (higher than 44 indicative of PTSD).