Military Behavioral Health

ISSN: 2163-5781 (Print) 2163-5803 (Online) Journal homepage: http://www.tandfonline.com/loi/umbh20

Eye Movement Desensitization and Reprocessing

(EMDR) as Treatment for Combat-Related PTSD: A
Meta-Analysis
Sietse Verstrael , Peter van der Wurff & Eric Vermetten
To cite this article: Sietse Verstrael , Peter van der Wurff & Eric Vermetten (2013) Eye
Movement Desensitization and Reprocessing (EMDR) as Treatment for Combat-Related PTSD:
A Meta-Analysis, Military Behavioral Health, 1:2, 68-73, DOI: 10.1080/21635781.2013.827088
To link to this article: http://dx.doi.org/10.1080/21635781.2013.827088

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MILITARY BEHAVIORAL HEALTH, 1: 6873, 2013

C Taylor & Francis Group, LLC
Copyright 
ISSN: 2163-5781 / 2163-5803 online
DOI: 10.1080/21635781.2013.827088

Eye Movement Desensitization and Reprocessing

(EMDR) as Treatment for Combat-Related PTSD:
A Meta-Analysis
Sietse Verstrael and Peter van der Wurff
Military Rehabilitation Center, Ministry of Defence, Doorn, The Netherlands

Eric Vermetten

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Military Mental Health Research, Ministry of Defence, Utrecht, The Netherlands; Arq Psychotrauma Expert Group;
and Leiden University Medical Center, Leiden, The Netherlands

Although the symptom presentation of post-traumatic stress disorder (PTSD) in the general
and military population is very similar, combat-related PTSD is typically thought to be more
severe due to repeated and prolonged exposure to traumatic events. One of the treatments
of choice, eye-movement desensitization and reprocessing (EMDR) has, however, not been
validated for the military population. A meta-analysis was carried out on literature ranging
back to 1987. The analysis thus far resulted in a failure to support the effectiveness of EMDR
in treating PTSD in the military population. Several possible explanations are given, of which
the limited number of well-designed randomized controlled trials (RCTs) seems to be the most
important one. Until more research is done, EMDR as treatment of choice for combat-related
PTSD should be used only if other treatment protocols have proven unsuccessful.

Keywords: PTSD, EMDR, meta-analysis, combat, military, RCT, psychotherapy, CBT,

treatment

BACKGROUND
It is generally believed and empirically supported that
exposure-based therapies are most effective in treating combat-related post-traumatic stress disorder (PTSD)
(Sharpless & Barber, 2011). Among these types, traumafocused cognitive behavioral therapy (tf-CBT) and eyemovement desensitization and reprocessing (EMDR) are
considered to be the first-line therapies of choice (e.g., National Institute for Health and Clinical Excellence [NICE],
2005), but other therapeutic approaches such as narrative exposure therapy (NET) and brief eclectic psychotherapy for
PTSD (BEPP) are also starting to gain momentum, illustrating some divergence from the NICE guidance and evidence
of professionals within specialized settings tailoring therapeutic practices to the perceived needs of individual clients.
Both tf-CBT and EMDR therapies are, however, considered
to be evidence based. EMDR has further been recommended
Address correspondence to Prof dr Col Eric Vermetten, Military Mental
Health-Research, Ministry of Defense, Lundlaan 1, 3500 EZ, Utrecht, The
Netherlands. E-mail: hgjm.vermetten@mindef.nl

in the treatment guidelines by the International Society for

Traumatic Stress Studies (Foa, Keane, Friedman, & Cohen,
2009), the U.S. Department of Veterans Affairs/Department
of Defense (Management of Post-Traumatic Stress Working Group, 2010), and the American Psychiatric Association
(APA; 2004).
TF-CBT is a so-called talking therapy, in which patients are encouraged to search for irrational and distressing
thoughts and feelings about the event. These irrationalities
are then replaced by corrective thoughts that are more balanced. TF-CBT has been proven effective in the treatment of
PTSD in the general population (Bisson & Andrew, 2009)
as well as the military population (for a review, see Harvey,
Bryant, & Tarrier, 2003; Goodson et al., 2011). EMDR is
being piloted in disorders beyond PTSD and other anxiety
disorders, ranging from psychosis (Van den Berg & van der
Gaag, 2012) to borderline personality disorder (Mosquera &
Gonzalez-Vazquez, 2012).
No single theory has explained the effectivity of EMDR.
Many favor the explanation that EMDR is based on the
working memory theory, which states that working memory
has limited resources. If a dual task uses some of those

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EMDR AS TREATMENT FOR COMBAT-RELATED PTSD

resources, less will be available for memory processes so

the recollection of memories will be less vivid and less
emotional. In EMDR this dual task consists of bilateral
stimulation. It is generally believed that eye movement is
essential to the therapy (Jeffries & Davis, 2013; Van den
Hout et al., 2012).
Compared to TF-CBT, EMDR is more debatedmostly
because it is still uncertain whether the effects of EMDR
are due to the unique therapy approach (for an overview, see
Sikes & Sikes, 2003; Russell, 2008). In EMDR, the patient is
typically instructed to imagine a distressing event and to rate
how distressing the event is on a Subjective Units of Distress
(SUD) scale. A type of rapidly alternating and bilateral stimulation is given when the affect is maximal (in most cases
the subject is invited to follow a horizontally moving object
with the eyes). This is performed in repeating cycles lasting
for the duration of a therapy session. Afterward, the patient is
instructed to identify distressing thoughts and feelings about
this event and rate them on a Validity of Cognitions (VoC)
scale, which is again followed by bilateral stimulation. The
VoC scale is a self-rated measure of the validity of ones
thoughts (whether or not the thoughts are true).
Several meta-analyses have shown the effectiveness of
EMDR in the general population (e.g., Bisson & Andrew,
2009; Davidson & Parker, 2001; Van Etten & Taylor, 1998).
Some therapists believe this is the result of the imagined exposure and the cognitive behavioral components of EMDR
and not of the bilateral stimulation. However, bilateral stimulation has been demonstrated to have a positive effect on the
retrieval of episodic memories (Christman, Garvey, Phaneuf,
& Propper, 2003).
The effectiveness of EMDR in the military population is,
however, still unclear (for a review, see Albright & Thyer,
2010; Goodson et al., 2011). There is some evidence that it
is useful but not nearly enough to be considered evidence
based. This is especially notable because PTSD as a disorder
was first conceptualized to be a syndrome most applicable
to war veterans. PTSD in the military population is believed
to be markedly different from PTSD in other populations,
due to the prolonged and repeated exposure to the traumatic
events that occur during combat. This form of PTSD is more
commonly known as combat-related PTSD.
Despite several research studies on the applicability and
therapeutic effect of EMDR in cases of combat-related PTSD
dating back to 1995, no meta-analysis on the effectiveness
of EMDR in this population has been published to date. This
article is aimed at filling that gap by conducting a metaanalysis on published studies on this topic.
METHODS
Study Selection
PubMed, the Cochrane Library, and Utrecht Universitys
Omega were used to search for relevant articles, using the
following search parameters: the terms (PTSD or posttraumatic stress disorder) AND (EMDR or eye move-

69

ment desensitization and reprocessing) AND (veteran or

soldier or military personnel or combat or war),
spanning a publication date range of 25 years, between 1987
(start of EMDR) and March 2012. Only articles with original
data, with only combat-related PTSD and using standardized
PTSD-specific measures were of interest for this analysis.
Articles that did not meet these criteria are not reported here.
Search Results
Only seven articles met the inclusion criteria. In two articles
(Silver, Brooks, & Obenchain, 1995; Macklin et al., 2000)
insufficient data were presented to calculate effect sizes, and
one article (Wada, 2000) was written in Japanese and was
therefore excluded. Authors of these studies were contacted
in order to receive additional data, but no response was obtained. Included studies are listed in Table 1, with several
characteristics.
Materials
For all studies, a Platinum Scale (PS; Hertlein & Ricci, 2004)
score was calculated. The Platinum Scale is an instrument
that evaluates the study on criteria such as the use of the
original EMDR protocol, appropriate training of the therapist
and assessors, and other factors. PS scores indicate how well
the study was designed and performed, with higher scores
indicating better study designs.
The PS score was calculated by three raters. First, all raters
judged the articles independently, then afterward a consensus
meeting was held. After this meeting, only 2 of 156 scores (13
PS items 4 articles 3 raters) were debated, and this was
within a single item. The ratings in Table 1 represent the
score the majority of raters (2 out of 3) agreed with. The PS
score was used to calculate the weight of the study for use in
a cumulative meta-analysis.
Measures
PTSD symptoms are often measured using a variety of
tests. These tests can be divided into primary and secondary
outcome measures. Primary outcome measures are used to
identify and evaluate PTSD symptomatology, whereas secondary measures are used to identify and evaluate non-PTSDspecific symptoms, such as depression. The sections that follow present very short descriptions of the tests used in the
included studies.

Primary Measures
The Clinician-Administered PTSD Scale (CAPS; Blake
et al., 1995) is a structured interview in which the criteria
from the American Psychiatric Associations Diagnostic and
Statistical Manual of Mental Disorders (DSM) relating to
PTSD are assessed and the severity of both frequency and
intensity are rated by the interviewer on a 5-point Likert scale.
The ratings are given based on the month prior to assessment.
The Mississippi Scale for Combat-Related PTSD (MPTSD; Keane, Caddell, & Taylor, 1988) is a 35-item

70

S. VERSTRAEL ET AL.
TABLE 1
Characteristics of Studies Included in Analysis

Study
Carlson, Chemtob,
Rusnak, Hedlund,
& Muraoka, 1998

EMDR (n = 10),
Biofeedback (n = 13),
Care as usual (n = 12)

DSM-IV

Devilly, Spence,
& Rapee, 1998

EMDR (n = 19),
REDDR (n = 16),
Care as usual (n = 16)
EMDR (n = 25) Control
(n = variable per measure)

Jensen, 1994

Rogers et al., 1999

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Sample

PTSD
Classification

EMDR (n = 6),
Exposure (n = 6)

PTSD Outcome
Measurea

Secondary
Outcome Measurea

Mean Effect Sizeb

d(var)

Platinum
Standard Total
Scorea,b

STAI, BDI

1.7263
(0.3030)

10.5

DSM-III-R

M-PTSD
PSS
IES
CAPS
M-PTSD

BDI, PPD

0.3562
(0.1693)

DSM-III-R

SI-PTSD

1.5653

7.5

DSM-III-R

M-PTSD (only
posttreatment)
IES

(0.1045)

0.7879
(0.3592)

aSee section on measures; bMean effect size, calculated with Hedges d for pre- versus immediate posttreatment in EMDR condition; a negative value
represents a drop in the measures used and thus a decline in PTSD symptomatology.
Note. CAPS = Clinician-Administered PTSD Scale; M-PTSD = Mississippi Scale for Combat-Related PTSD; SI-PTSD = Structured Interview for PTSD;
IES = Impact of Events Scale; PSS = PTSD Symptom Scale; STAI = Spielbergers State Trait Anxiety Index; BDI = Becks Depression Inventory; PPD =
Personal Problem Definition.

self-report measure in which PTSD symptoms and associated features are rated on a 5-point Likert scale.
The Structured Interview for PTSD (SI-PTSD; Davidson,
Kudler, & Smith, 1990) assesses PTSD symptoms as described in the DSM (depending on the edition of the manual
that is used by the interviewer). The interviewer rates the
severity of both frequency and intensity of these symptoms
on a 5-point Likert scale. It differs from the CAPS in the time
frame used. In the SI-PTSD, subjects are asked to rate their
worst ever symptomatology, whereas in the CAPS a time
frame of a month is used.
The Impact of Events Scale (IES; Horowitz, Wilner, &
Alvarez, 1979) is a 15-item self-report measure that assesses
subjective stress caused by traumatic events. A revised version (IES-R; Weiss & Marmar, 1996) with 22 items was used
by Rogers and colleagues (1999).
The PTSD Symptom Scale (PSS), as used by Carlson,
Chemtob, Rusnak, Hedlund, and Muraoka (1998), was a
self-report measure with an 11-point global scale. This was
devised by the authors and should not be confused with the
PTSD Symptom ScaleSelf-Report version (PSS-SR) by
Foa, Cashman, Jaycox, and Perry (1997).

Secondary Measures
The State-Trait Anxiety Index (STAI; Spielberger, Gorsuch, & Lushene, 1970) is a test that measures anxiety in two
distinct ways: state (current) anxiety and trait anxiety (personal characteristic). It also gives an indication of the overall
level of anxiety and its severity.
Becs Depression Inventory (BDI; Beck, Ward, Mendelson, Mock, & Erbaugh, 1961) is the most-used test to measure
depression. It is composed of 21 items with a 4-point Likert

scale. It is unclear which versions were used in the included

studies.
The Personal Problem Definition (PPD; Devilly, Creamer,
& Gournay, in preparation) asks subjects to identify five
problems that they perceive to be interfering with their daily
lives. They then rate those problems on a 9-point Likert scale.
Procedure
All analyses were performed using MetaWin, Version 2.0
(Rosenberg, Adams, & Gurevitch, 1999). Effect sizes were
calculated for the means of the pre- and posttreatment scores
on the tests used in the corresponding studies. The effectsize estimate used was Hedges d, which is a standardized
mean difference that accounts for the nonequality of sampling variances. When multiple PTSD measures were used
in one study, a fixed-effect model was adopted to estimate the
mean effect size of the total study. A random effects model
was adopted to calculate the meta-analytic effect size.
Comparisons were made on EMDR groups pre- and posttreatment, on both primary (PTSD) measures and secondary
measures (see Table 1). Physiological measures such as heart
rate are excluded. Also, SUD and VoC scores are not taken
into account, because they are an integral part of EMDR and
are used only to identify progress in the context of EMDR
therapy.
Due to the low number of studies and participants, no
comparisons were made between EMDR and controls, or
between EMDR and other treatments.
Results
A total of 60 patients with combat-related PTSD received
EMDR therapy. Although one study reported more PTSD
symptoms after EMDR therapy (Jensen, 1994), no serious

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EMDR AS TREATMENT FOR COMBAT-RELATED PTSD

FIGURE 1

71

Normal Quantile Plot, with 95% Confidence Intervals.

adverse reactions (e.g., hospitalization) were reported. A random model was used to assess the effect of EMDR on primary
outcomes, as measured pre- and immediately posttreatment.
The test for heterogeneity was not significant (Qt = 2.73, p
= 0.43, with df = 3), which implies that the variance among
effect sizes was not greater than was to be expected from
sampling error. The estimated effect size was 0.51 [95%
confidence interval (CI): 2.09 to 1.07]. This indicates a
nonsignificant medium decrease in PTSD symptoms. A normal quantile plot (Figure 1) was created to assess publication
bias, which indicated there were no irregularities. There are,
however, too few studies included to conclude that no publication bias exists.
A cumulative meta-analysis was then performed on the
primary outcomes, with the PS score used as the sorting
variable. The test for heterogeneity was nonsignificant (Qt =
2.60, p = 0.48, with df = 3), so the variance was not greater
than was to be expected from sampling error. The analysis

FIGURE 2

yielded an nonsignificant result, with a medium effect size

of 0.61 [95% CI: 2.29 to 1.07].
A random effects model meta-analysis (Figure 2) on the
secondary measures resulted in a large nonsignificant effect
size of 1.05 [95% CI: 6.42 to 4.32]. The test for heterogeneity was not significant (Qt = 1.00, p = 0.32, df =
1). Jensen (1994) and Rogers and colleagues (1999) did not
report relevant secondary measures other than SUD and VoC
scores and were therefore not included in this analysis.
DISCUSSION
The research question in this study, whether EMDR is effective in reducing problems associated with combat-related
PTSD in the military population, could be answered positively for neither primary nor secondary measures. As results indicate, a nonsignificant medium effect was found on
the primary measures and a nonsignificant small effect was

Cumulative Meta-Analysis of Studies.

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72

S. VERSTRAEL ET AL.

determined on the secondary measures. This analysis thus

fails to support the effectiveness of EMDR in the treatment
of combat-related PTSD in the military population.
This is a remarkable result, because meta-analyses on
EMDR in the general population tend to support its effectiveness, with reported effect sizes of 1.51 (Bisson &
Andrew, 2009), 1.43 (Bradley, Greene, Russ, Dutra, &
Westen, 2005) and 1.24 (Van Etten, & Taylor, 1998). These
reported effect sizes are much larger than those found in this
meta-analysis. There are several possible explanations for
this result. First, it could be that EMDR really is not effective
in the military population. The notion that combat-related
PTSD may be different from normal PTSD still holds.
This could have contributed to the result of this analysis, in
that combat-related PTSD is more difficult to address, because combat veterans with PTSD often have been exposed
to a greater number of traumas than civilians with PTSD,
so their symptoms may be more resistant to treatment. This
explanation, however, does not align with the results of most
experimental studies (e.g., see Albright & Thyer, 2010). Also,
the results of our meta-analyses tended to indicate a medium
to large symptom-reducing effect, although not significant.
The only included study in this analysis that does not support EMDR effectiveness is the Jensen (1994) study, which
found that symptoms increased after therapy. A problem
with Jensens study is that only two EMDR sessions were
provided. Although some articles claim very significant improvements after only a few sessions (e.g., Russell, 2006),
it is clear that more sessions are needed in most cases. The
Platinum Scale guideline is that 11 or more EMDR sessions are needed to fully study its effects (Hertlein & Ricci,
2004). The other included studies also used sessions numbers
that would be considered too few, with the exception of the
Carlson and colleagues (1998) study, in which 12 sessions
were administered.
Another explanation is that PTSD severity could have
been a factor that caused differences in the effect EMDR had
on the patients. Symptom severity is known to be a marker
of poorer outcome in psychotherapy (Goodson et al., 2011).
One can hypothesize that more severely afflicted individuals were affected less (or more) by EMDR than those with
less severe PTSD. Due to the use of different tests, it is not
possible to compare the severity of the PTSD in the samples
of the included studies. It thus remains speculation whether
this factor could have had an impact on the effectiveness of
EMDR.
Chronicity of disease associated with combat-related
PTSD may also adversely affect veterans responses to treatment. Disease chronicity may also be particularly relevant to
Vietnam veterans, many of whom have been living with persistent symptoms of PTSD for decades. With chronicity, veterans with PTSD are also more likely to present with comorbid physical and psychiatric conditions, which may pose additional treatment challenges (Forbes, Creamer, Hawthorne,
Allen, & McHugh, 2003). Also, treatment of veterans with
combat-related PTSD may be hindered by factors specific to

such combat-related trauma as guilt and shame about their

combat-related actions, rendering symptoms less amenable
to treatment interventions (Foa & Meadows, 1997).
The included studies varied widely on the Platinum Standard scores (range 6.0 to 10.5), which indicates that the
methodological strength was not comparable. This is an important notion, especially because Maxfield and Hyer (2002)
found that more methodologically rigorous studies (as rated
on the Gold Standard, a predecessor of the Platinum Standard) report larger effect sizes. This is not the case in this
meta-analysis. It could, however, mean that if more methodologically rigorous studies are included, the effect sizes
would be larger, probably because of the lower occurrence of
random errors. Future studies should therefore be as rigorous
as possible, to give a better estimate of the real effectiveness
of EMDR.
Furthermore, the number of studies was very low, and all
included small groups of participants. It is indeed a problem that so few studies have been conducted on the use of
EMDR in this population. Russell (2008) identified several
reasons for and ways in which there is scientific resistance to
properly research EMDR, despite the fact that larger RCTs
on this topic are very much needed. He states that continued resistance to fully researching, training and using EMDR
does not serve the best interest of science and beneficiaries,
predominantly combat veterans (p. 1744). It is therefore of
utmost importance that this topic is further investigated.
Based on these results, to conclude that EMDR is a treatment of choice for returning veterans affected by PTSD
seems premature. It is clear that more research is needed
before any hard conclusions about its effectiveness can be
made. Use of EMDR with veterans suffering from combatrelated PTSD should be postponed as treatment of choice until other treatment protocols (e.g., tf-CBT) have been proven
unsuccessful or until larger and more rigorous EMDR studies
have yielded positive results in this population.
Finally, it is quite remarkable that the included studies
were all published between 1994 and 1999. In our search,
no research articles on the use of EMDR in the military
population that met our criteria were found published after
the year 2000. One could wonder what the reason for this
finding is. Is it because EMDR is already accepted as a proper
treatment? Is it because there was no more funding? It is to the
possible detriment of this veteran population that research on
this subject has been particularly lacking in the past decade,
while the effectiveness of EMDR according to evidencebased standards is not yet proven.
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