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.

1. Treating Traumatic Stress Injuries:
An Overview
Tulane School of Social Work
Mark 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. Schedule
Time Who
Subject (Objective)
9:00 Introductions (1) Both
9:45 Overview of Trauma and Trauma Resilience (1) Figley
10:30 Break
11:00 Overview of Traumatic Stress Injuries (2-3) Russell
11:45 Overview of Treatment Planning (3-4) Both
Noon Lunch
1:00 Overview of EMDR (5) Both
1:45 Demonstration (5) Both
2:30 Break
2:45 Treatment Adaptations for the Spectrum Traumatic Stress Injuries (3-4 & 5) Russell
3:30 Applications to Combat Stress Injuries and the Military Contexts (6-7) Both
4:15 Q&A Both
4:45 Wrap Up

3. Workshop Objectives
1. Provide an overview of resilience, trauma, traumatic
stress, and the traumatic stress injury
2. Identify the spectrum of traumatic stress injuries
3. Clarify the importance of mental health professionals
focusing on human development and injury prevention
and rehabilitation rather than seeking mental illness
treatment
4. Provide an overview of trauma treatment planning
5. Describe contemporary EMDR treatment protocols for
acute stress injuries
6. Discuss unique treatment considerations in working with
military populations
7. Know where to go on the web to review and understand
the research on EMDR treatment of war trauma

4. Introductions
Charles, R. Figley, Ph.D. Mark C. Russell, Ph.D., ABPP,
Tulane University Antioch University Seattle

5. Overview of Trauma and
Trauma Resilience

6. Overview of Traumatic Stress Injuries
Spectrum Mark C. Russell, Ph.D.,

7. What Are Stress “Injuries” and are they
REALLY Injuries?
Dictionary Definition:
Stress- “a physical, chemical, or emotional factor
that causes bodily or mental tension and may be a
factor in disease causation.”
Injury- “an act that damages
or hurts.”
Source. Merriam-Webster at http://www.m-w.com

8. Working Definition of Stress Injury
A severe maladaptive or prolonged stress reaction (e.g., ASR/COSR/CSR) lasting greater than
five days causing substantial functional and/or structural neurophysiological alterations as
evident 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 chronic
activation of the helper’s sympathetic stress response to primary and secondary compassion
stressors which overwhelms the helper’s self-care and resilience capacity.

9. Human Stress Response

10. Universal, Unchanged, Adaptive
Human Stress Response

11. Combat Exposure for OIF Soldiers
Hoge et al. (2004)
Event Army (%) USMC (%)
Attacked/Ambushed 89 95
Being shot at/receiving fire 93/86 97/92
Shooting at enemy 77 87
Killing enemy combatant(s) 48 65
Handling human remains 50 57
Seeing injured women/children 69 83
Seeing dead/injured Americans 65 75
Killing non-combatant(s) 14 28
Being wounded 14 9

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. Perceptual Distortions in Combat
(Grossman, 2007)
85% Diminished Sound 47% Partial Amnesia for Actions
16% Intensified Sounds 40% Dissociation- detachment
80% Tunnel Vision 26% Intrusive Distracting
74% Automatic Pilot Thoughts
(scared speechless) 22% Memory Distortions
65% Slow Motion Time 16% Fast Motion Time
7% Temporary Paralysis
51% Partial Event Amnesia

14. The “Dosage Effect”

16. Walter B. Cannon: “Flight of Fight”

17. Can Stress Cause Actual Injury or Death?

18. Medically Unexplained Physical
Symptoms
Complaint Total Group Combat Veterans Noncombat Troops
Gastrointestinal 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

19. Evidence that Stress Causes Injury
Institute of Medicine (IOM; 2008): “In the brain,
there is evidence of structural and functional
changes resulting directly from chronic or severe
stress. The changes are associated with alterations
of the most profound functions of the brain:
memory and decision-making” (p. 60) and
“profound effects on multiple organ systems…the
continuation of altered physiologic states over
months and years contribute to the accumulation
of adverse long-term health consequences” (p.
66).

20. The Spectrum: Scope of a Mental Health Crisis
Neuropsychiatric 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)3
Behavioral Problem 361,489
(V-Code)
Other Mental Health 318,827 32,268
(Special symptoms)
Diagnoses
26,788
(Sexual Deviations & Disorders)
*TotalNumber of Active 1,780,649 444,505
Military and Veterans
Diagnosed *Not include Mil. Comm. Counseling *Not include data from 300 Vet
Centers, Chaplains, & MFLC Counseling Centers
*Not include est. 657,000 (23%) using contractors
private sector (NCCBH, 2012) **Not include family members
Somatoform and Dissociative 205,181
Disorder2 (Number outpatient visits in 2010- includes
anxiety diagnosis dissociation)
*Co-Morbidity (subtracted from 459,430
above total)

21. 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)3
Adjustment Disorder 471,833 56,633
Post-traumatic Stress Disorder 102,549 239,094
(PTSD)
Depressive Disorder 303,880 184,404
Bipolar Disorder4 8,280
Anxiety Disorder (not PTSD) 187,918 161,510
Substance Use Disorder 306,248 118,438
Traumatic Brain Injury (TBI) 212,742 28,828
Psychotic Disorder (not 15,456 111,199
Schizophrenia) (Affective Psychosis)

22. Understanding & Preventing Stress Injury
Predominant 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.

23. Other Aspects of Spectrum and Crises
Providers 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/OIF
personnel including over 75% reporting fatigue, 70% sleep difficulties, 42% headaches, 50% joint-pain and
23% gastrointestinal symptoms (Hoge, et., al., 2007).
According to the Government Accounting Office (GAO, 2008), DOD data from November 2001, through June
2007, 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 parasuicidal
behaviors, including 1,939 completed suicides, 19,955 received inpatient or outpatient diagnosis of an
intentionally self-inflicted injury or poisoning, and 3,463 were identified as “likely self-harm” after
hospitalization 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 for
moral 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 and
inpatient visits since OEF/OIF (Gorman 2010; Mansfield et al, 2011); 46% spouses reported high stress w/ partner
PTSD (Greentree et al., 2012).
48% of returning Marines threatened physical violence; 26% hit someone (Koffman, 2006);69% reported
injuring a woman or child (Hoge, 2004).

24. Misconduct Stress Behaviors
Misconduct stress behaviors are described by the U.S. Army (2006) as a range of
maladaptive stress reactions from minor to serious violations of military or civilian
law 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 underlying
personality disorder or other character defect, as opposed to evidence of possible
war stress injuries in that “even the good and heroic, under extreme stress may also
engage in misconduct" [Department of the Army (DOA), 2006; p. 1-6).

25. Overview of Treatment Planning
Charles, R. Figley, Ph.D. Mark C. Russell, Ph.D

26. Seven Considerations for Treatment
Planning 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

27. Treatment Planning for TSI Spectrum:
Training & Screening
Training 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

28. Overview of EMDR
Charles, R. Figley, Ph.D. Mark C. Russell, Ph.D.

29. What is EMDR?
EMDR integrates elements of psychotherapy
into standardized set of procedures and clinical
protocols
Consists of two major unique components:
• Dual-focused attention (internal and external
focus) and
• Bilateral (rhythmic) stimulation (BLS) (visual,
auditory, kinesthetic).

30. VA/DoD (2010) PTSD Practice
Guidelines
“The choice of a specific approach should be
based on the severity of the symptoms, clinician
expertise in one or more of these treatment
methods and patient preference, and may
include an exposure-based therapy (e.g.,
Prolonged Exposure), a cognitive-based therapy
(e.g., Cognitive Processing Therapy), Stress
management therapy (e.g., SIT) or Eye
Movement Desensitization and Reprocessing
(EMDR).” (pp. 117-118).

31. Successful therapy requires detailed client self-disclosure XX XX
Successful therapy requires client compliance with daily or XX XX
weekly homework assignments (24-48 hours total)
Therapists frequently engage in extensive challenging of the X XX
client’s cognitive distortions
Therapists teach coping skills in session that clients are .5 XX XX
required to use in vivo outside of sessions
Requires clients to simultaneously pay attention to an internal XX
distressing stimuli and track alternating external stimulus (e.g.,
visually track therapist’s hand movements)
Therapist takes an active, directive stance in implementing the XX XX
treatment protocol

32. Theoretically regards client free associations not linked to XX XX
the target memory during exposure as a form of avoidance
that can derail therapy
Encourages the client to share as little or much of traumatic XX
material as they desire
Same protocol is used to treat symptoms and/or diagnoses XX X X
related to depression, anger, guilt, grief, anxiety, pain, and
other medically unexplained physical symptoms
Requires constant vigilance from the therapist to prevent .5 XX XX
client avoidance behaviors

33. Four Acute Stress Injury Treatment Goals
For treatment planning purposes, assessing military client
suitability for EMDR Standard reprocessing of acute stress
injuries requires matching one of four treatment goals with
the appropriate EMDR early intervention.
Russell and Figley (2013) identified four treatment goals for
utilizing EMDR as an early intervention for acute stress
injuries:
1. Client stabilization
2. Primary symptom reduction
3. Comprehensive reprocessing, and
4. Prevention of compassion-stress injury

34. Treatment Goal 1: Client Stabilization
Purpose: In the immediate aftermath of a traumatic event, the majority of survivors experience
normal ASR/COSR. However, some may require immediate crisis intervention to help manage
intense feelings of panic or grief. Signs of panic are trembling, agitation, rambling speech, and
erratic 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/or
unresponsive to medical or unit personnel. Such clients would present as being conscious and
awake, however, in a state of acute peri-traumatic dissociation or “emotional shock” with
limited or no responsiveness to verbal interchange.
Therapists should attempt to quickly establish therapeutic rapport, ensure the survivor's safety,
acknowledge and validate the survivor's experience, and offer empathy. After all basic safety
needs have been taken care of and medical triage has been completed, medical/ nursing, unit or
command, and/or other emergency personnel may request the therapist to assist with
psychological stabilization in order to medically assess and/or transport to the next echelon of
care.
Recommended EMDR Stabilization Interventions:
(1) Emergency Response Procedure (ERP)
(2) Eye Movement Desensitization (EMD)
(3) Resource Development and Installation (RDI)

35. Emergency Response Procedure (ERP)
Script (Quinn, 2009)
Purpose: Stabilization and triage of client by increasing orientation to present focus. Use in
the following situations: routine attempts to engage blankly staring clients are not
successful; clients are suffering from acute stress reactions; clients are in “shock,” and/or
unresponsive to verbal questions or commands (Quinn, 2009).
1. Calmly speak in the client’s ear to identify yourself, your role in the hospital/setting, and
reassure 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 them
where they are, that they had survived the bombing (or any other incident), and they are
now at a safe place.
3 .After brief periods of the bilateral taps, direct their attention to safety, so that clients can
became responsive to outside stimuli, and be engaged verbally about their medical status
and 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 higher
level of EMDR intervention (symptom reduction, comprehensive reprocessing, or resilience
building).

36. Treatment Goal 2: Primary Symptom
Reduction
Purpose: Limit reprocessing to a single, circumscribed event. A
variety of contexts arise that preclude comprehensive
reprocessing for otherwise stable and suitable military clientele.
Such variables include: time-sensitive constraints (e.g., impending
client or therapist absence, impending client deployment, etc.),
environmental demands (e.g., forward-deployed, operational
settings), and client-stated treatment goals (e.g., expressed desire
to not address earlier foundational experiences other than such as
pre-military incidents), that may lead to the joint decision to
deviate from the standard EMDR protocol after full-informed
consent is provided.
Recommended EMDR Primary Symptom Reduction Interventions:
(1) Eye Movement Desensitization (EMD)
(2) Modified EMD (Mod-EMD)

37. Eye Movement Desensitization (EMD)
(Russell, 2006)
Purpose: Crisis intervention limited to the reduction of primary symptoms
associated with the precipitating event. In the immediate or near-immediate
aftermath of exposure to a severe or potentially traumatic event, clients present
with severe, debilitating ASR/COSR.
Essentially an exposure therapy that adds BLS and does not reinforce free
associations outside of either a single-incident target memory (e.g., primary
presenting complaint), or a representative “worst” memory from a cluster of
memories related to a circumscribed event (e.g., a recent deployment).
Free associations reported outside the treatment parameters require the client to
be 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 where
SUDS are obtained to assess progress of desensitization effect. Repeat process
until target memory has SUDS of “0” is obtained or “1” if ecologically valid.
Installation, body scan, current triggers and future template are not included in
EMD.

38. Potential Advantages of EMD
Allows more strictly controlled reprocessing by reducing chance for generalization to other
memories, which might speed up symptom relief.
When free associations outside of the target occur, the client is immediately returned to the
target memory so that this may prevent client from in-depth exposure to other sources of
emotionally intense material.
May provide clients a mastery experience with EMDR that may open the door for
comprehensive reprocessing with the Standard EMDR Protocol.
Potentially more rapid relief of the most intense symptoms than either modified or standard
EMDR.
Primary symptom reduction may prevent escalation or exacerbation of stress injury and
more 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.

39. Potential Disadvantages of EMD
Desensitization effects may not sustain due to unprocessed
other past, current, and future contributors.
Reduction of primary symptoms may result in client
termination without addressing other contributors.
Increased possibility of stress injury may persist as sub-
chronic, more prone to kindling and relapse, in response to
future acute stress.
Client will probably be exposed, even if fleetingly, to other
negative associations in the maladaptive neural network –
so needs thorough informed consent.

40. Modified-EMD (Mod-EMD) Script
(Russell, 2006)
Purpose: Crisis intervention limited to the reduction of
primary symptoms associated with the precipitating event. In
the immediate or near-immediate aftermath of exposure to
a severe or potentially traumatic event, clients present with
severe, debilitating ASR/COSR.
*Note: See EMD Script with the following modifications:
In Mod-EMD the client’s free associations are limited to
either a single-incident target memory (i.e., the precipitating
event), or within a cluster of memories related to a
circumscribed event (e.g., specific operational mission, a
certain deployment).

41. Treatment Goal 3: Comprehensive
Reprocessing
The essential treatment plan for the eight-phased, Standard
EMDR 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.

42. Treatment Goal 4: Prevention of
Compassion Stress Injury
Purpose: Help process compression stress reactions (CSR) after intense
emotional or trauma-focused sessions. Therapists whose workload
frequently exposes them to highly charged sessions, need to be
particularly mindful of the insidious effects of compassion stress, and take
proactive measures whenever possible to avoid cumulative wear-and-tear
that may lead to compassion-stress injury (CSI).
For therapists with CSI, treatment would be either mod-EMDR that
restricts self-focus attention to particular client(s) or one’s clinical practice,
or the Standard EMDR Protocol to address other past contributors that
increase occupational risk.
Recommended EMDR Compassion Stress Intervention:
(1) Compassion Stress “Protocol” (for CSR)
(2) Standard EMDR Protocol (for CSI)

43. Russell Compassion Stress “Protocol”
(Russell & Figley, 2013)
In addition to traditional self-care (Figley, 2002). Every day
after work before heading home, or after intense session:
1. Put on Neurotek headphones
2. Initiate auditory BLS while recalling
the daily events in mind
3. Image, thoughts, and visceral reactions
are concentrated upon while listening to the BLS
On average, approximately 5-10 minutes a day, or as needed.

44. Demonstration
Charles, 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

45. Treatment Adaptations for the
Spectrum Traumatic Stress Injuries
Mark C. Russell, Ph.D.

46. 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

47. Phantom Limb Pain

48. Medically-Unexplained Physical
Symptoms (Russell, 2008)

49. Traumatic Grief Reaction
29 y.o., married, Hispanic
male
Presenting complaint:
Paternal suicide while
stationed overseas
Second-hand exposure
details imagined

50. Post-traumatic Anger
60
25 y.o. single African
50
American female
40 Presenting complaint:
Baseline
30 Session 3
Sexual assault (date
Post Tx rape) by co-worker
20 2 Mo. F/U after night of drinking
10
Treatment course:
0 8 EMDR sessions w/
IES-R BDI-II DAR TGI mid-tx assessment

51. Substance Abuse
19 y.o. single Asian male
AUDIT
Presenting complaint:
Body recovery off the 3 Mo. F/U
BDI-II
Indonesian coast, referred Post-tx
w/ comorbid substance Baseline
dependence dx
PCL
Treatment course: 0 20 40 60 80
3 EMDR sessions

52. Applications to Combat Stress Injuries
and the Military Contexts
Charles, R. Figley, Ph.D. Mark C. Russell, Ph.D

53. 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 the
diaphragm 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 and
notice 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

54. Acute (Combat) Stress Injury (Russell, 2006)

55. Traumatic Grief Reaction
(Wright & Russell, 2013)

56. Moral Injury
37 y.o., married African American male,
combat decorated Marine Corps SSGT (E- 35
6) with over 11 years of active-duty
service,
30
Presenting complaint: referred due to a
positive post-deployment health 25
rescreening for post-traumatic stress
disorder (PTSD) and major depression
disorder (MDD) symptoms. 20
Baseline
Post-TX
4-Mo. F/U
Treatment course: 3 EMDR sessions. 15
Worst image was the initial sight of the
elderly woman exiting the car with
gaping wounds. Negative cognition (NC) 10
“I killed her,” with ‘tightened’ sensations
around his jaw and eyes, and stomach 5
queasiness coinciding with the primary
emotional response of “extreme guilt,”
rated “10+” SUDS – “Reverse flow” 0
IES BDI-II BHS

57. Moral Injury/Traumatic Grief/
38 y.o., married, Caucasian
male Marine GySgt, OIF vet
Presenting complaint:
Accidental death of 6 year
old son
Treatment overview:
3 sessions, 1 EMDR

58. Comorbid Mild TBI
23 y.o., married, Hispanic
AUDIT
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

59. Web Resources
VA/DoD Clinical Practice Guidelines (CPG)
http://www.healthquality.va.gov/
American Psychiatric Association CPG
http://www.psych.org/practice/clinical-practice-guidelines
Defense and Veterans Brain Injury Center
http://www.dvbic.org/
National Center for PTSD
http://www.ptsd.va.gov/
EMDR Institute
http://www.emdr.com/
Deployment Health Clinical Center
http://www.pdhealth.mil/main.asp

60. Q&A and Wrap-up
Mark C. Russell, Ph.D. Institute of War Stress Injuries
Antioch University Seattle and Social Justice
2326 Sixth Avenue
Seattle, WA 98121-1814
Phone: (206) 268-4837
Fax: (206) 441-3307
Email:
mrussell@antioch.edu www.antiochseattle.edu/institute-
of-war-stress-injuries-social-
justice/