Eye movement desensitisation and reprocessing (EMDR) therapy in prison and forensic services: a qualitative study of lived experience

ABSTRACT

Background: Posttraumatic stress disorder (PTSD) is common in people with serious mental illness who come into contact with the criminal justice system. Little evidence exists on EMDR treatment in forensic mental health, with no prior qualitative research exploring lived experience perspectives.

Objective: This qualitative study recruited adult forensic mental health patients with PTSD and psychotic disorders, predominantly schizophrenia, who had received EMDR as part of a clinical trial, either in prison or in hospital. We sought to understand their experiences of EMDR therapy while receiving forensic care.

Method: Ten in-depth, semi-structured qualitative interviews were undertaken and analysed using thematic analysis. We used an inductive, realist approach, reporting the experiences, meanings, and reality of the participants.

Results: Five overarching themes were identified. First, severe trauma was ubiquitous and participants felt Seriously Messed Up by their traumatic experiences, with debilitating and enduring PTSD symptoms contributing to offending and psychosis (‘giving the voices something to feed on’). Second, EMDR was regarded with Early Scepticism. Third, the therapy itself was initially emotionally taxing and Not Easy but participants generally felt safe and persevered. Fourth, they were often surprised and delighted by results (And it Worked!), describing significant symptom reduction and personal transformation. Lastly, EMDR Fits the Forensic Setting, bringing empowerment in a place perceived as disempowering. People reported changes that increased their hope in a violence-free future.

Conclusions: The limited research on EMDR in forensic mental health is unfortunate given how common PTSD is in mentally unwell offenders and its potential to impede recovery and contribute to further offending. This first qualitative study found participants experienced positive transformative change, extending beyond symptom reduction. Themes support previously published quantitative outcomes showing EMDR to be safe and effective in this cohort. EMDR was well suited to a forensic setting and was seen as an empowering therapy.

Trial registration: Australian New Zealand Clinical Trials Registry identifier: ACTRN12618000683235.

Study registration: The study was registered on the Australia and New Zealand Clinical Trials Network, registration number ACTRN12618000683235 (registered prospectively, 24 April 2018), https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id = 374682

HIGHLIGHTS

• This study canvases the lived experiences of forensic patients receiving EMDR for PTSD – people whose views are seldom captured. They described being profoundly impacted by trauma, developing debilitating and enduring PTSD symptoms which variably contribute to offending and psychosis.

• Participants did not have favourable first impressions when they first heard about EMDR, thinking it ‘quackery’. However, they were surprised and delighted by results, with the majority describing marked symptom reduction and personal transformation. Having targeted some of the underlying drivers of maladaptive behaviour, people reported hope for a better future.

• EMDR was well suited to a forensic setting and was seen as an empowering therapy.

Antecedentes: El trastorno de estrés postraumático (TEPT) es frecuente en personas con enfermedades mentales graves que entran en contacto con el sistema de justicia penal. Existe poca evidencia sobre el tratamiento EMDR en la salud mental forense, sin ninguna investigación cualitativa previa que explore la perspectiva de la experiencia vivida.

Objetivo: Este estudio cualitativo reclutó pacientes adultos de salud mental forense con TEPT y trastornos psicóticos, predominantemente esquizofrenia, que habían recibido EMDR como parte de un ensayo clínico en prisión o en el hospital. Se buscó comprender sus experiencias con la terapia EMDR mientras recibían atención forense.

Método: Se realizaron diez entrevistas cualitativas en profundidad y semiestructuradas, que se analizaron mediante análisis temático. Se utilizó un enfoque inductivo y realista, dando cuenta de las experiencias, los significados y la realidad de los participantes.

Resultados: Se identificaron cinco temas generales. En primer lugar, el trauma grave era omnipresente y los participantes se sentían gravemente perjudicados por sus experiencias traumáticas, con síntomas de TEPT incapacitantes y duraderos que contribuían a la delincuencia y la psicosis (“dar a las voces algo de lo que alimentarse)”. En segundo lugar, la EMDR se consideraba con un escepticismo precoz. En tercer lugar, la terapia en sí era inicialmente emocionalmente agotadora y nada fácil, pero los participantes se sentían seguros y perseveraban. En cuarto lugar, a menudo se mostraban sorprendidos y entusiasmados con los resultados (¡Y funcionó!), describiendo una reducción significativa de los síntomas y una transformación personal. Por último, EMDR se adapta al entorno forense, aportando empoderamiento en un lugar percibido como desempoderador. Las personas informaron de cambios que aumentaron su esperanza en un futuro libre de violencia.

Conclusiones: La escasa investigación sobre EMDR en salud mental forense es lamentable, dada la alta prevalencia del TEPT en delincuentes con trastornos mentales y su potencial para impedir la recuperación y contribuir a la comisión de nuevos delitos. Este primer estudio cualitativo halló que los participantes experimentaron un cambio transformador positivo, que iba más allá de la reducción de los síntomas. Los temas apoyan los resultados cuantitativos publicados anteriormente que muestran que EMDR es seguro y eficaz en esta cohorte. La EMDR se adaptó bien a un entorno forense y se consideró una terapia de empoderamiento.

背景：创伤后应激障碍 (PTSD) 在接触刑事司法系统的严重精神疾病患者中很常见。法医心理健康方面的 EMDR 治疗证据很少，之前也没有从生活体验角度进行定性研究。

目的：本定性研究招募了患有 PTSD 和精神病（主要是精神分裂症）的成年法医心理健康患者，他们作为监狱或医院临床试验的一部分接受了 EMDR。 我们试图了解他们在接受法医护理时接受 EMDR 治疗的经历。

方法：进行十次深入、半结构化的定性访谈，并使用主题分析进行分析。我们采用归纳、现实主义的方法，报告参与者的经历、意义和现实。

结果：确定了五个总体主题。首先，严重的创伤无处不在，参与者因创伤经历而感到严重混乱，令人衰弱和持久的PTSD症状导致犯罪和精神病（“给声音提供了一些东西”）。 其次，人们对 EMDR 很早就持怀疑态度。 第三，治疗本身最初在情感上是一种负担，而且并不容易，但参与者普遍感到安全并坚持不懈。第四，他们经常对结果感到惊讶和高兴（而且它有效！），描述了症状的显著减轻和个人转变。最后，EMDR 适合法医环境，为被认为剥夺权力的地方赋予权力。 人们报告的变化增加了他们对无暴力未来的希望。

结论：不幸的是，鉴于精神不适罪犯中 PTSD 的患病率很高，而且它有可能阻碍康复并导致进一步犯罪，因此对法医心理健康方面的 EMDR 研究有限。 本定性研究首次发现，参与者经历了积极的变革性变化，其范围超出了症状减轻的范围。主题支持之前发布的定量结果，表明 EMDR 在该队列中是安全有效的。 EMDR 非常适合法医环境，并被视为一种赋权疗法。

KEYWORDS:

• Schizophrenia
• psychosis
• forensic psychology
• post-traumatic stress disorder
• trauma
• prison
• mental health
• secure care
• qualitative research
• forensic psychiatry

PALABRAS CLAVE:

• Trastorno de estrés postraumático
• Psicología forense
• Esquizofrenia
• Salud mental
• Investigación cualitativa
• Psicosis
• Trauma
• Prisión
• Atención segura
• Psiquiatría forense

关键词:

• 创伤后应激障碍； 法医心理学； 精神分裂症；心理健康；定性研究；精神病；创伤；监狱；安全护理；法医精神病学

Acknowledgements

Heartfelt thanks to all participants willing to be part of this research and to staff working in the health and custodial settings who supported this study (Te Whatu Ora Health New Zealand and the Department of Corrections: Ara Poutama Aotearoa). Many thanks to Anna Ormond and the Wellington Medical and Health Sciences Library and to Jacqueline Short, Paul Oxnam, and Deidre Florance from the study Data Monitoring Committee.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Authors’ contributions

SEP was the principal investigator of this study with BR the main co-investigator. SEP and EB conceived the idea of the study and coordinated the main preparation of the study documents and the grant funding applications. BR, ER, TF, and OH contributed to ethics and funding applications, and to study design. BR undertook the literature review. BR and SEP conducted the interviews. SEP, BR and ER transcribed and coded the interviews and grouped data into preliminary candidate themes and subthemes. The final themes were agreed on by all authors. SEP drafted the first version of this manuscript. All authors provided editorial input and read and approved the final manuscript.

Data availability statement

The transcripts are not publicly available but are available from the corresponding author [SEP] on reasonable request and with ethics approval. The data are not publicly available due to sensitivity issues relating to the high profile of the forensic participants and because they contain information that could compromise participant privacy.

Additional information

Funding

This cost of recruiting and analysing data for participants in the custodial setting was funded by an EMDR Foundation Research Grant (https://emdrresearchfoundation.org/research-grants/research-award-recipients/#1516817093999-01faf8db-0e7d). The other study costs were funded by a University of Otago Research Grant. The researchers work for the University of Otago, but neither grant funding body had any direct role in the design of the study nor did they have any role during its execution, data collection, analysis and interpretation of data, writing the manuscript or in the decision to submit results.