Treating traumatic stress injuries presentation 4-5-13-rev


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This is a Tulane University presentation sponsored by the Traumatology Institute: Treating traumatic stress injuries by Mark Russell, PhD (Antioch University of Seattle) and Charles Figley (Tulane University) that will be delivered Friday, April 5th in New Orleans.

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Treating traumatic stress injuries presentation 4-5-13-rev

  1. 1. Treating Traumatic Stress Injuries: An Overview Tulane School of Social WorkMark C. Russell, Ph.D., ABPP, CDR, USN (Ret.) Antioch University Seattle Charles, R. Figley, Ph.D. Tulane University April 5 2013; 8:30am-5pm (6 CEUs)
  2. 2. ScheduleTime Who Subject (Objective)9:00 Introductions (1) Both9:45 Overview of Trauma and Trauma Resilience (1) Figley10:30 Break11:00 Overview of Traumatic Stress Injuries (2-3) Russell11:45 Overview of Treatment Planning (3-4) BothNoon Lunch1:00 Overview of EMDR (5) Both1:45 Demonstration (5) Both2:30 Break2:45 Treatment Adaptations for the Spectrum Traumatic Stress Injuries (3-4 & 5) Russell3:30 Applications to Combat Stress Injuries and the Military Contexts (6-7) Both4:15 Q&A Both4:45 Wrap Up
  3. 3. Workshop Objectives1. Provide an overview of resilience, trauma, traumatic stress, and the traumatic stress injury2. Identify the spectrum of traumatic stress injuries3. Clarify the importance of mental health professionals focusing on human development and injury prevention and rehabilitation rather than seeking mental illness treatment4. Provide an overview of trauma treatment planning5. Describe contemporary EMDR treatment protocols for acute stress injuries6. Discuss unique treatment considerations in working with military populations7. Know where to go on the web to review and understand the research on EMDR treatment of war trauma
  4. 4. IntroductionsCharles, R. Figley, Ph.D. Mark C. Russell, Ph.D., ABPP,Tulane University Antioch University Seattle
  5. 5. Overview of Trauma and Trauma Resilience
  6. 6. Overview of Traumatic Stress Injuries Spectrum Mark C. Russell, Ph.D.,
  7. 7. What Are Stress “Injuries” and are they REALLY Injuries?Dictionary Definition:Stress- “a physical, chemical, or emotional factorthat causes bodily or mental tension and may be afactor in disease causation.”Injury- “an act that damagesor hurts.”Source. Merriam-Webster at
  8. 8. Working Definition of Stress InjuryA severe maladaptive or prolonged stress reaction (e.g., ASR/COSR/CSR) lasting greater thanfive days causing substantial functional and/or structural neurophysiological alterations asevident by clinically significant changes in one’s mental/physical health, sense of well-being,and/or impaired level of functioning. Maybe Acute or Chronic. Three subtypes:Traumatic Stress Injury (TSI)(1) Acute TSI(2) Chronic TSI (Specific/Developmental/Combined)War (Combat) Stress Injury (WSI)(1) Acute WSI(2) Chronic WSI (Specific/Combined TSI)Compassion Stress Injury (CSI)(1) Acute CSI(2) Chronic CSI (Specific/Combined TSI)Ex. CSI is caused by the cumulative effects of severe or prolonged CSR due to excessive,unregulated empathic responses (e.g., emotional contagion) combined with chronicactivation of the helper’s sympathetic stress response to primary and secondary compassionstressors which overwhelms the helper’s self-care and resilience capacity.
  9. 9. Human Stress Response
  10. 10. Universal, Unchanged, Adaptive Human Stress Response
  11. 11. Combat Exposure for OIF Soldiers Hoge et al. (2004) Event Army (%) USMC (%)Attacked/Ambushed 89 95Being shot at/receiving fire 93/86 97/92Shooting at enemy 77 87Killing enemy combatant(s) 48 65Handling human remains 50 57Seeing injured women/children 69 83Seeing dead/injured Americans 65 75Killing non-combatant(s) 14 28Being wounded 14 9
  12. 12. Normal Combat Reaction (Menninger, 1948) • 50% - pounding heart • 45% - sinking stomach • 30% - cold sweats • 25% - nausea • 25% - shaking/tremors • 25% -muscle stiffness • 20% - vomiting • 20% - general weakness • 10% - involuntary bowel • 6% - involuntary urination
  13. 13. Perceptual Distortions in Combat (Grossman, 2007)85% Diminished Sound 47% Partial Amnesia for Actions16% Intensified Sounds 40% Dissociation- detachment80% Tunnel Vision 26% Intrusive Distracting74% Automatic Pilot Thoughts(scared speechless) 22% Memory Distortions65% Slow Motion Time 16% Fast Motion Time 7% Temporary Paralysis51% Partial Event Amnesia
  14. 14. The “Dosage Effect”
  15. 15. Walter B. Cannon: “Flight of Fight”
  16. 16. Can Stress Cause Actual Injury or Death?
  17. 17. Medically Unexplained Physical SymptomsComplaint Total Group Combat Veterans Noncombat TroopsGastrointestinal 29.7% 85.4% 14.6%Orthopedic 23.5% 88.5% 11.5%Multiple symptoms 17.3% 84.3% 15.7%Cardiovascular 15.9% 88.1% 11.9%Headache 8.1% 86.6% 13.4%Genitourinary 5.4% 80.0% 20.0% Source: Menninger, 1948; p. 156
  18. 18. Evidence that Stress Causes InjuryInstitute of Medicine (IOM; 2008): “In the brain,there is evidence of structural and functionalchanges resulting directly from chronic or severestress. The changes are associated with alterationsof the most profound functions of the brain:memory and decision-making” (p. 60) and “profound effects on multiple organ systems…thecontinuation of altered physiologic states overmonths and years contribute to the accumulationof adverse long-term health consequences” (p.66).
  19. 19. The Spectrum: Scope of a Mental Health CrisisNeuropsychiatric Diagnosis Total Number of Active Military Total Veterans Diagnosed by VA Diagnosed by Military Providers Providers (2000-2011)1 (1st Qtr FY 2002-3rd Qtr FY 2012)3Behavioral Problem 361,489(V-Code)Other Mental Health 318,827 32,268 (Special symptoms)Diagnoses 26,788 (Sexual Deviations & Disorders)*TotalNumber of Active 1,780,649 444,505Military and VeteransDiagnosed *Not include Mil. Comm. Counseling *Not include data from 300 Vet Centers, Chaplains, & MFLC Counseling Centers*Not include est. 657,000 (23%) using contractorsprivate sector (NCCBH, 2012) **Not include family membersSomatoform and Dissociative 205,181Disorder2 (Number outpatient visits in 2010- includes anxiety diagnosis dissociation)*Co-Morbidity (subtracted from 459,430above total)
  20. 20. Neuropsychiatric Diagnosis Total Number of Active Total Number of MILITARY Diagnosed OEF/OIF/OND Veterans by Military Providers Diagnosed by VA Providers (2000-2011)1 (1st Qtr FY 2002-3rd Qtr FY 2012)3Adjustment Disorder 471,833 56,633Post-traumatic Stress Disorder 102,549 239,094(PTSD)Depressive Disorder 303,880 184,404Bipolar Disorder4 8,280Anxiety Disorder (not PTSD) 187,918 161,510Substance Use Disorder 306,248 118,438Traumatic Brain Injury (TBI) 212,742 28,828Psychotic Disorder (not 15,456 111,199Schizophrenia) (Affective Psychosis)
  21. 21. Understanding & Preventing Stress InjuryPredominant Features:• Emotional dysregulation (fear, depression, anxiety, anger) – DSM/ICD diagnoses mood d/o; anxiety d/o; adjustment d/o; anger d/o; alexithymia; impaired love, joy, reflection, humility, & humor.• Cognitive/perceptual dysregulation (attentional bias, beliefs, memory, perception, learning) – DSM/ICD diagnoses brief or atypical psychotic d/o; ASD/PTSD; dissociative d/o; ADD/LD; impaired curiosity, flexibility, efficacy, & mindfulness.• Sleep dysregulation (e.g., parasomnias; nightmare d/o; REM d/o) – impaired sleep hygiene.• Somatic dysregulation (pain, fatigue, cardiovascular, gastrointestinal, neuro, etc.) – DSM/ICD diagnoses somatoform d/o; medically unexplained physical symptoms; immunological d/o; impaired physical activity, diet, relaxation, & wellness behavior.• Behavioral dysregulation (e.g., problems regulating behavior & lifestyle) – DSM/ICD diagnoses suicidal/self-injurious; substance abuse d/o; personality d/o; eating d/o; adjustment d/o; impulse control; sexual d/o; ADHD/ODD/CD; impaired moderation, interests, work, hobbies, & creativity.• Social dysregulation (e.g., interpersonal problems, conflict/violence, isolation) – DSM/ICD diagnoses RAD; adjustment d/o; relational V-codes; personality d/o; impaired other-focused orientation, recreation, altruism, & community involvement.• Identity/moral dysregulation (e.g., moral injury; traumatic grief, survivor guilt; perpetrator trauma; spiritual existential crisis; borderline PD; suicidal/homicidal; “beserking;” atrocity; misconduct stress behaviors; impaired sense of meaning, integrity, purpose & connection.• Empathic dysregulation (e.g., CSI: CF, STS, VT, burnout) – impaired balance & self-care.
  22. 22. Other Aspects of Spectrum and CrisesProviders should also expect that 50 to 80% of patients with PTSD with comorbidity.In 2007 military epidemiologists found a high frequency of somatic complaints in returning OEF/OIFpersonnel including over 75% reporting fatigue, 70% sleep difficulties, 42% headaches, 50% joint-pain and23% gastrointestinal symptoms (Hoge, et., al., 2007).According to the Government Accounting Office (GAO, 2008), DOD data from November 2001, through June2007, revealed that 26,000 service members were separated for personality disorder.During 2001-2010, a total of 25,357 active-duty service members engaged in suicidal or parasuicidalbehaviors, including 1,939 completed suicides, 19,955 received inpatient or outpatient diagnosis of anintentionally self-inflicted injury or poisoning, and 3,463 were identified as “likely self-harm” afterhospitalization for injury or poisoning with a concurrent mental health diagnosis (AFHSC, February, 2012).56.1% of deployed Marines, and 48.4% Soldiers, reported killing combatants in 2010 (MHAT-VII, 2011, risk formoral injury; risk traumatic grief -86% knew a fellow service member shot or wounded (Hoge, et al., 2006).Military children at risk intergenerational effects, increase mental health utilization in outpatient andinpatient visits since OEF/OIF (Gorman 2010; Mansfield et al, 2011); 46% spouses reported high stress w/ partnerPTSD (Greentree et al., 2012).48% of returning Marines threatened physical violence; 26% hit someone (Koffman, 2006);69% reportedinjuring a woman or child (Hoge, 2004).
  23. 23. Misconduct Stress BehaviorsMisconduct stress behaviors are described by the U.S. Army (2006) as a range ofmaladaptive stress reactions from minor to serious violations of military or civilianlaw and the Law of Land Warfare including:• mutilating enemy dead• not taking prisoners• looting, rape, brutality• self-inflicted wounds• "fragging" (killing of one’s own military leaders)• desertion• torture and intentionally killing non-combatants.It is often assumed that misconduct stress behaviors are due to an underlyingpersonality disorder or other character defect, as opposed to evidence of possiblewar stress injuries in that “even the good and heroic, under extreme stress may alsoengage in misconduct" [Department of the Army (DOA), 2006; p. 1-6).
  24. 24. Overview of Treatment PlanningCharles, R. Figley, Ph.D. Mark C. Russell, Ph.D
  25. 25. Seven Considerations for TreatmentPlanning and Adaptation of EMDR to Operational Settings (Russell, Cooke, & Rogers, in press)– Referral Question– Strength of the Therapeutic Alliance– Client Treatment Goals– Timing and Environmental Constraints– Clinical Judgment Regarding Client Safety– Suitability for Standard Trauma-Focused EMDR Reprocessing Protocol– Utilization of Any Adjunctive Intervention and Referral Need
  26. 26. Treatment Planning for TSI Spectrum: Training & ScreeningTraining is essential! Spectrum screening: - History (risks & resilience) - Level of Exposure (single best predictor)-(e.g., CES) - Safety (self/other violence, psychosis) - Physical health, Pain & TBI (e.g., WIA, exercise, diet, medical, recreation, PHQ-15, MACE) - Sleep (e.g., sleep hygiene) - Substance use (e.g., AUDIT, CAGE, Rx & stimulants) - Social (e.g., level of perceived support, family, friends, work, recreation, conflict/violence, transitions) - ASD/PTSD (e.g., PCL, IESR); Depression (e.g., BDI-II; Anxiety (e.g., STAI); Anger, Traumatic Grief, Moral Injury - Level of Functioning
  27. 27. Overview of EMDRCharles, R. Figley, Ph.D. Mark C. Russell, Ph.D.
  28. 28. What is EMDR?EMDR integrates elements of psychotherapyinto standardized set of procedures and clinicalprotocolsConsists of two major unique components:• Dual-focused attention (internal and external focus) and• Bilateral (rhythmic) stimulation (BLS) (visual, auditory, kinesthetic).
  29. 29. VA/DoD (2010) PTSD Practice Guidelines“The choice of a specific approach should bebased on the severity of the symptoms, clinicianexpertise in one or more of these treatmentmethods and patient preference, and mayinclude an exposure-based therapy (e.g.,Prolonged Exposure), a cognitive-based therapy(e.g., Cognitive Processing Therapy), Stressmanagement therapy (e.g., SIT) or EyeMovement Desensitization and Reprocessing(EMDR).” (pp. 117-118).
  30. 30. Successful therapy requires detailed client self-disclosure XX XXSuccessful therapy requires client compliance with daily or XX XXweekly homework assignments (24-48 hours total)Therapists frequently engage in extensive challenging of the X XXclient’s cognitive distortionsTherapists teach coping skills in session that clients are .5 XX XXrequired to use in vivo outside of sessionsRequires clients to simultaneously pay attention to an internal XXdistressing stimuli and track alternating external stimulus (e.g.,visually track therapist’s hand movements)Therapist takes an active, directive stance in implementing the XX XXtreatment protocol
  31. 31. Theoretically regards client free associations not linked to XX XXthe target memory during exposure as a form of avoidancethat can derail therapyEncourages the client to share as little or much of traumatic XXmaterial as they desireSame protocol is used to treat symptoms and/or diagnoses XX X Xrelated to depression, anger, guilt, grief, anxiety, pain, andother medically unexplained physical symptomsRequires constant vigilance from the therapist to prevent .5 XX XXclient avoidance behaviors
  32. 32. Four Acute Stress Injury Treatment GoalsFor treatment planning purposes, assessing military clientsuitability for EMDR Standard reprocessing of acute stressinjuries requires matching one of four treatment goals withthe appropriate EMDR early intervention.Russell and Figley (2013) identified four treatment goals forutilizing EMDR as an early intervention for acute stressinjuries:1. Client stabilization2. Primary symptom reduction3. Comprehensive reprocessing, and4. Prevention of compassion-stress injury
  33. 33. Treatment Goal 1: Client StabilizationPurpose: In the immediate aftermath of a traumatic event, the majority of survivors experiencenormal ASR/COSR. However, some may require immediate crisis intervention to help manageintense feelings of panic or grief. Signs of panic are trembling, agitation, rambling speech, anderratic behavior. Signs of intense grief may be loud wailing, rage, or catatonia.Clients may develop severe, debilitating ASR/COSR that render them un-stable and/orunresponsive to medical or unit personnel. Such clients would present as being conscious andawake, however, in a state of acute peri-traumatic dissociation or “emotional shock” withlimited or no responsiveness to verbal interchange.Therapists should attempt to quickly establish therapeutic rapport, ensure the survivors safety,acknowledge and validate the survivors experience, and offer empathy. After all basic safetyneeds have been taken care of and medical triage has been completed, medical/ nursing, unit orcommand, and/or other emergency personnel may request the therapist to assist withpsychological stabilization in order to medically assess and/or transport to the next echelon ofcare.Recommended EMDR Stabilization Interventions:(1) Emergency Response Procedure (ERP)(2) Eye Movement Desensitization (EMD)(3) Resource Development and Installation (RDI)
  34. 34. Emergency Response Procedure (ERP) Script (Quinn, 2009)Purpose: Stabilization and triage of client by increasing orientation to present focus. Use inthe following situations: routine attempts to engage blankly staring clients are notsuccessful; clients are suffering from acute stress reactions; clients are in “shock,” and/orunresponsive to verbal questions or commands (Quinn, 2009).1. Calmly speak in the client’s ear to identify yourself, your role in the hospital/setting, andreassure the client of their safety in the hospital/setting.2. Inform the client that you are going to tap them gently on the shoulder and remind themwhere they are, that they had survived the bombing (or any other incident), and they arenow at a safe place.3 .After brief periods of the bilateral taps, direct their attention to safety, so that clients canbecame responsive to outside stimuli, and be engaged verbally about their medical statusand so on. (The total intervention time would be measured in minutes Quinn, 2009).4. If stabilized, and deemed appropriate and consent is given, consider suitability for higherlevel of EMDR intervention (symptom reduction, comprehensive reprocessing, or resiliencebuilding).
  35. 35. Treatment Goal 2: Primary Symptom ReductionPurpose: Limit reprocessing to a single, circumscribed event. Avariety of contexts arise that preclude comprehensivereprocessing for otherwise stable and suitable military clientele.Such variables include: time-sensitive constraints (e.g., impendingclient or therapist absence, impending client deployment, etc.),environmental demands (e.g., forward-deployed, operationalsettings), and client-stated treatment goals (e.g., expressed desireto not address earlier foundational experiences other than such aspre-military incidents), that may lead to the joint decision todeviate from the standard EMDR protocol after full-informedconsent is provided.Recommended EMDR Primary Symptom Reduction Interventions:(1) Eye Movement Desensitization (EMD)(2) Modified EMD (Mod-EMD)
  36. 36. Eye Movement Desensitization (EMD) (Russell, 2006)Purpose: Crisis intervention limited to the reduction of primary symptomsassociated with the precipitating event. In the immediate or near-immediateaftermath of exposure to a severe or potentially traumatic event, clients presentwith severe, debilitating ASR/COSR.Essentially an exposure therapy that adds BLS and does not reinforce freeassociations outside of either a single-incident target memory (e.g., primarypresenting complaint), or a representative “worst” memory from a cluster ofmemories related to a circumscribed event (e.g., a recent deployment).Free associations reported outside the treatment parameters require the client tobe returned to target memory whereby SUDS are re-accessed and BLS initiated.Clients may be returned to the target memory at any time by the therapist whereSUDS are obtained to assess progress of desensitization effect. Repeat processuntil target memory has SUDS of “0” is obtained or “1” if ecologically valid.Installation, body scan, current triggers and future template are not included inEMD.
  37. 37. Potential Advantages of EMDAllows more strictly controlled reprocessing by reducing chance for generalization to othermemories, which might speed up symptom relief.When free associations outside of the target occur, the client is immediately returned to thetarget memory so that this may prevent client from in-depth exposure to other sources ofemotionally intense material.May provide clients a mastery experience with EMDR that may open the door forcomprehensive reprocessing with the Standard EMDR Protocol.Potentially more rapid relief of the most intense symptoms than either modified or standardEMDR.Primary symptom reduction may prevent escalation or exacerbation of stress injury andmore readily improve client functioning at least in the short-term.May reassure military clients concerned about culture expectations that emphasize self-control and military readiness in the context of accessing earlier life events.Provides viable option for military clients who otherwise may refuse therapy.
  38. 38. Potential Disadvantages of EMDDesensitization effects may not sustain due to unprocessedother past, current, and future contributors.Reduction of primary symptoms may result in clienttermination without addressing other contributors.Increased possibility of stress injury may persist as sub-chronic, more prone to kindling and relapse, in response tofuture acute stress.Client will probably be exposed, even if fleetingly, to othernegative associations in the maladaptive neural network –so needs thorough informed consent.
  39. 39. Modified-EMD (Mod-EMD) Script (Russell, 2006)Purpose: Crisis intervention limited to the reduction ofprimary symptoms associated with the precipitating event. Inthe immediate or near-immediate aftermath of exposure toa severe or potentially traumatic event, clients present withsevere, debilitating ASR/COSR.*Note: See EMD Script with the following modifications:In Mod-EMD the client’s free associations are limited toeither a single-incident target memory (i.e., the precipitatingevent), or within a cluster of memories related to acircumscribed event (e.g., specific operational mission, acertain deployment).
  40. 40. Treatment Goal 3: Comprehensive ReprocessingThe essential treatment plan for the eight-phased, StandardEMDR Protocol has always consisted of what Shapiro (2001)refers to as the “Three-Pronged Protocol”: – Past traumatic events or other foundational emotionally charged experiential contributors, or small t, as Shapiro puts it (2001), that are etiologic to the presenting complaints or psychopathological condition. – Current internal or external triggers or antecedents that activate the maladaptive neural (memory) network. – Future template, of the client’s anticipatory anxiety, worries, or concerns, and/or needed coping skills or mastery achieved through imaginal or behavioral rehearsal, to prevent relapse, or reactivation of the maladaptive schema.
  41. 41. Treatment Goal 4: Prevention of Compassion Stress InjuryPurpose: Help process compression stress reactions (CSR) after intenseemotional or trauma-focused sessions. Therapists whose workloadfrequently exposes them to highly charged sessions, need to beparticularly mindful of the insidious effects of compassion stress, and takeproactive measures whenever possible to avoid cumulative wear-and-tearthat may lead to compassion-stress injury (CSI).For therapists with CSI, treatment would be either mod-EMDR thatrestricts self-focus attention to particular client(s) or one’s clinical practice,or the Standard EMDR Protocol to address other past contributors thatincrease occupational risk.Recommended EMDR Compassion Stress Intervention:(1) Compassion Stress “Protocol” (for CSR)(2) Standard EMDR Protocol (for CSI)
  42. 42. Russell Compassion Stress “Protocol” (Russell & Figley, 2013)In addition to traditional self-care (Figley, 2002). Every dayafter work before heading home, or after intense session:1. Put on Neurotek headphones2. Initiate auditory BLS while recallingthe daily events in mind3. Image, thoughts, and visceral reactionsare concentrated upon while listening to the BLSOn average, approximately 5-10 minutes a day, or as needed.
  43. 43. DemonstrationCharles, R. Figley, Ph.D. Mark C. Russell, Ph.D.• Emergency Response Protocol (ERP)• Eye Movement Desensitization (EMD)• Modified EMD (Mod-EMD)• Acute Compassion Stress Intervention
  44. 44. Treatment Adaptations for theSpectrum Traumatic Stress Injuries Mark C. Russell, Ph.D.
  45. 45. Chronic PTSD (Russell, Silver, Rogers, & Darnell, 2007)Combat PTSD (n = 48) “Railway Spine” U.K. Client BDI-II 6 Mo. F/U Post-Tx Baseline IES-R 0 20 40 60
  46. 46. Phantom Limb Pain
  47. 47. Medically-Unexplained Physical Symptoms (Russell, 2008)
  48. 48. Traumatic Grief Reaction 29 y.o., married, Hispanic male Presenting complaint: Paternal suicide while stationed overseas Second-hand exposure details imagined
  49. 49. Post-traumatic Anger60 25 y.o. single African50 American female40 Presenting complaint: Baseline30 Session 3 Sexual assault (date Post Tx rape) by co-worker20 2 Mo. F/U after night of drinking10 Treatment course: 0 8 EMDR sessions w/ IES-R BDI-II DAR TGI mid-tx assessment
  50. 50. Substance Abuse19 y.o. single Asian male AUDITPresenting complaint:Body recovery off the 3 Mo. F/U BDI-IIIndonesian coast, referred Post-txw/ comorbid substance Baselinedependence dx PCLTreatment course: 0 20 40 60 803 EMDR sessions
  51. 51. Applications to Combat Stress Injuries and the Military ContextsCharles, R. Figley, Ph.D. Mark C. Russell, Ph.D
  52. 52. Combat/Tactical Breathing Script (Grossman, 2007)Therapist asks the client to sit in a chair and do the following:Say, “Breathe in through your nose with a slow count of four (two, three, four).”Therapist can have clients place their hand on their stomach to see if they are properly filling thediaphragm with air, as evident when their stomach and hand rise.Say, “Place your hand on your stomach, as you breathe in through your nose to the count of four andnotice your stomach and hand rise.”Say, “Hold your breath for a slow count of four (Hold, two, three, four).”Say, “Now, exhale through your mouth for a count of four until all the air is out (two, three, four).”Client’s hand should lower as their stomach lowers.Say, “Now, notice how your hand lowers as your stomach lowers.”Say, “Hold empty for a count of four (Hold, two, three, four).” **Repeat Cycle Three Times
  53. 53. Acute (Combat) Stress Injury (Russell, 2006)
  54. 54. Traumatic Grief Reaction (Wright & Russell, 2013)
  55. 55. Moral Injury37 y.o., married African American male,combat decorated Marine Corps SSGT (E- 356) with over 11 years of active-dutyservice, 30Presenting complaint: referred due to apositive post-deployment health 25rescreening for post-traumatic stressdisorder (PTSD) and major depressiondisorder (MDD) symptoms. 20 Baseline Post-TX 4-Mo. F/UTreatment course: 3 EMDR sessions. 15Worst image was the initial sight of theelderly woman exiting the car withgaping wounds. Negative cognition (NC) 10“I killed her,” with ‘tightened’ sensationsaround his jaw and eyes, and stomach 5queasiness coinciding with the primaryemotional response of “extreme guilt,”rated “10+” SUDS – “Reverse flow” 0 IES BDI-II BHS
  56. 56. Moral Injury/Traumatic Grief/38 y.o., married, Caucasianmale Marine GySgt, OIF vetPresenting complaint:Accidental death of 6 yearold sonTreatment overview:3 sessions, 1 EMDR
  57. 57. Comorbid Mild TBI 23 y.o., married, HispanicAUDIT male, Marine, OIF/OEF vet x 3 Presenting complaint:BDI-II 2 Mo. F/U Multiple IED attack and combat trauma, Post-Tx diagnosed w/ mild TBI 1 PCL Baseline yr. ago Treatment course:MACE Neg. MACE screen; 5 EMDR sessions 0 20 40 60 80
  58. 58. Web ResourcesVA/DoD Clinical Practice Guidelines (CPG) Psychiatric Association CPG and Veterans Brain Injury Center Center for PTSD Institute Health Clinical Center
  59. 59. Q&A and Wrap-upMark C. Russell, Ph.D. Institute of War Stress InjuriesAntioch University Seattle and Social Justice2326 Sixth AvenueSeattle, WA 98121-1814Phone: (206) 268-4837Fax: (206) of-war-stress-injuries-social- justice/