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

1. Introduction

Many people who find themselves the interface of the mental health and criminal justice system have extensive trauma histories with comorbid serious mental illnesses (Driessen et al., 2006; Gray et al., 2003; Indig et al., 2016; Prins, 2014; Wolff et al., 2014). The rates of posttraumatic stress disorder (PTSD) in forensic psychiatry are high, with more than one in three forensic mental health patients meeting diagnostic criteria for PTSD (Bianchini et al., 2022; Gray et al., 2003). In New Zealand, where this study took place a lifetime PTSD diagnosis was found to be four times higher among prisoners (24%) than the 6% prevalence in the general population (Indig et al., 2016).

One effective treatment for PTSD is Eye Movement Desensitisation and Reprocessing (EMDR). EMDR is a structured psychological therapy in which the client is instructed to think about the traumatic event for brief periods while simultaneously tracking a therapist's hand as it moves back and forth across their field of vision. The resulting bilateral brain stimulation is thought to activate the brain's information processing pathways, enabling more adaptive associations to be made. Over time, this leads to processing of traumatic events into long-term memory and to the reduction of affective distress and physiological arousal (Shapiro, 2017).

In the general population, EMDR has a strong evidence base for the treatment of PTSD (Bisson et al., 2013; Forbes et al., 2007; National Institute for Health and Clinical Excellence (NICE), 2018) and evidence-based guidelines recommend its use ahead of pharmacological treatment (National Institute for Health and Clinical Excellence (NICE), 2005). It is one of two therapies (the other being trauma-focused cognitive behavioural therapy) recommended by the World Health Organization for PTSD (World Health Organization, 2013). However, there has been little research on the use of EMDR in prisons and forensic hospitals, with such evidence limited to a few favourable EMDR case reports (Clark et al., 2014; Fleurkens et al., 2018; Kayrouz & Vrklevski, 2015; Lad, 2013; Pollock, 2000; Ricci et al., 2006). Furthermore, little EMDR research has been conducted with indigenous populations, including Māori, who are overrepresented in the criminal and mental health systems due to the downstream effects of colonisation, intergenerational trauma, and institutional racism (Lacey et al., 2022; McKenzie et al., 2023) Although the tri-directional relationships between trauma, mental illness and incarceration are increasingly being recognised (Baranyi et al., 2018; Collier & Friedman, 2016; Fritzon et al., 2021; Maguire & Taylor, 2019), forensic mental health services do not usually systematically screen for PTSD, or routinely offer trauma-focussed psychological therapy, such as EMDR or TF-CBT. A meta-analysis of trauma-focused interventions for PTSD in prison identified no trials of EMDR or other NICE recommended interventions (Malik et al., 2023).

This qualitative study followed a single blind randomised controlled trial (RCT) we conducted comparing EMDR therapy to waitlist (routine care) conducted in people with psychotic illnesses in the forensic inpatient, outpatient and prison population (Every-Palmer et al., 2023). We had randomised forensic mental health service users (n = 24) to either ‘treatment-as-usual plus waitlist for EMDR’ or to ‘treatment-as-usual plus EMDR’. A psychologist assessor blinded to the treatment condition assessed outcomes at baseline, 10 weeks, and 6 months. EMDR was found to be a safe and effective treatment for PTSD in this cohort. PTSD symptoms reduced significantly with EMDR treatment compared to control and there was some evidence of reductions in depressive symptoms and overall disability, and improved self-esteem in the EMDR group. There were no significant differences in adverse events between groups although point estimates favoured EMDR (Every-Palmer et al., 2023).

While the trial used quantitative methods to test EMDR's effectiveness and safety according to predetermined standardised instruments, this qualitative study focussed on lived experiences of the recipients of EMDR. In healthcare settings, qualitative research can complement quantitative approaches by providing uniquely person-centred insights (Renjith et al., 2021). Qualitative research allows us to better understand patient experiences, including the barriers to treatment and avenues for treatment improvement.

Very few studies have explored clients’ perspectives of EMDR, even in the general setting. Whitehouse (2021) completed a systematic review and thematic synthesis of qualitative research about clients’ experiences of EMDR, identifying five eligible studies, in which all reports of therapy were positive (Whitehouse, 2021). Recently, Shipley extended this review to include data from unpublished studies, finding a total of 13 eligible studies within the published and grey literature (Shipley et al., 2022). EMDR was commonly seen as transformative, supporting the idea that most clients experienced positive changes after treatment. However, EMDR was not a universally positive experience, with some people experiencing increased anxiety and stress after sessions. Interestingly, these less glowing accounts only appeared in the grey literature, leading the authors to suggest bias might be present in the published literature. Further exploration of negative client experiences was recommended.

In another recent study, Boterhoven de Haan et al. (2021) explored client and therapists’ perspectives of both EMDR and an alternative trauma-focussed therapy (imagery rescripting therapy) in patients with PTSD from childhood trauma. They found that patients were positive about treatment, however, acknowledged the challenges of going back and re-exploring the trauma. People treated with EMDR described greater hope for the future, improved self-acceptance and being more in control of their lives after therapy. None of the studies identified by either of these two recent qualitative analyses or through our own searches included participants in any of the following groups: people with psychotic disorders such as schizophrenia; people in inpatient care; people receiving forensic mental health input; or people in prison. Given these gaps in the research and the importance of exploring the lived experiences of these populations, it is important to further our knowledge about the experiences of people with serious mental illness treated with EMDR in these settings.

In the current study, we aimed to explore the subjective experiences of participants under the care of forensic mental health services: we were interested in what peoples’ perspectives were; prior to, during and after EMDR therapy.

2. Methods

2.1. Ethical approval

The study received full ethics approval from the New Zealand Health and Disability Ethics Committee (HDEC, reference 18/CEN/48), and was subject to Māori consultation with the Ngāi Tahu Research Committee (10 April 2018). Written informed consent was obtained from all study participants.

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/. The protocol was published in Trials (Every-Palmer et al., 2019).

2.2. Study setting

Participants were all patients of a regional forensic mental health service. Forensic mental health services in New Zealand work closely with the justice system to provide secure assessment, treatment and rehabilitation services for mentally ill offenders or alleged offenders. This includes but is not limited to people who have been made forensic ‘special patients’ and ‘restricted patients’ within the legislative framework of the Mental Health (Compulsory Assessment and Treatment) Act 1992 and the Criminal Procedure (Mentally Impaired Persons) Act 2003 (Every-Palmer et al., 2022; Ministry of Health, 2022). Forensic services also provide prison in-reach treatment to people in custody with severe mental illness. The participants were all current forensic patients with psychotic illnesses and comorbid PTSD (at baseline) who had received EMDR for the treatment of PTSD as part of the aforementioned RCT (Every-Palmer et al., 2023).

2.3. Sampling frame

People were eligible for this study if they were forensic patients who had received EMDR treatment (as described below) and were: aged between 18 and 65 years; had a lifetime history of a psychotic disorder or a mood disorder with psychotic features as diagnosed according to ICD-10 or DSM-5 criteria, with this diagnosis established prior to screening for this study; met diagnostic criteria for PTSD (Clinician Administered PTSD Scale – CAPS or CAPS-5) before commencing EMDR; and were competent to provide informed consent.

2.4. Description of EMDR therapy

Prior to the interviews, participants had received EMDR therapy administered according to Shapiro's eight-phase/three-pronged protocol (Shapiro, 2017). Our EMDR trial protocol (Every-Palmer et al., 2019) limited the EMDR sessions to a maximum of nine and there was no period of stabilisation prior to the EMDR therapy commencing. Like a previous study (van den Berg et al., 2015), the trial had not aimed to provide full therapy but rather to test a dose of EMDR within an effective range in a structured way.

The EMDR therapist (a senior psychiatrist or psychologist who was a qualified EMDR practitioner) and the participant developed a standardised case conceptualisation in the first session then in the following sessions, each 60-minutes long, memories were processed with eye movements applied as the dual-attention stimulus as described in the study protocol (Every-Palmer et al., 2019). Ten percent of sessions were observed and assessed for treatment fidelity using the EMDR Fidelity Rating Scale (Korn et al., 2017). EMDR treatment had high adherence to the protocol with a mean (SD) fidelity score of 2.8 (Every-Palmer et al., 2023).

2.5. Participants

After the EMDR trial concluded, we invited people who had received EMDR treatment and were still contactable to participate in qualitative interviews (i.e. had not been discharged and lost to follow up). We invited 11 people, of whom 10 agreed to participate. We were interested in talking to participants with positive and negative experiences of EMDR and so we recruited people who dropped out early (n = 2) as well as those who had completed the course of EMDR therapy (n = 8) for qualitative interviews. Two were female and eight were male. Their median age was 37 years (range 20–59 years). Half identified as New Zealand European and half as Māori. All were under the care of one regional forensic service in New Zealand. Most (n = 6) were inpatients in a forensic hospital and two were living in the community under the care of a forensic community team after having recently been released from secure care. Two were in custodial care (sentenced prisoners with schizophrenia).

All participants had been diagnosed with psychotic illnesses prior to recruitment with diagnostic codes derived from data submitted to the National Mental Health Database (PRIMHD) according to ICD-10 criteria. The most common diagnosis was schizophrenia (n = 7, 58%), followed by bipolar affective disorder with psychotic features (n = 2, 17%), and schizoaffective disorder (n = 1, 8%). All participants were receiving antipsychotic medication (clozapine n = 3, olanzapine n = 3, risperidone n = 1, quetiapine n = 1, aripiprazole n = 1, paliperidone n = 1). The most common pre-existing comorbid diagnoses (aside from PTSD) were substance misuse disorders, personality disorder, and anxiety disorder.

Index offences involved charges of significant violence, with the most serious charge for each participant being murder (n = 4), attempted murder (n = 1), assault (n = 3), arson (n = 1) and a serious sexual offence (n = 1).

All participants had PTSD as diagnosed by the CAPS-4 or CAPS-5 taken at baseline (as one of the inclusion criteria of the study), but half (n = 5) had not previously had this diagnosis recorded by the service caring for them. All but one participant described multiple lifetime traumas. In all cases, the index trauma had occurred prior to secure care and at least two years or more before participation in this study. In terms of the index trauma, for six participants this related to events around the index offence (the reason they were in forensic care). For the four remaining patients, the nominated index trauma related to either childhood sexual abuse or being a victim of a physical assault or sexual assault.

The eight participants in the care of mental health services were under compulsory treatment orders but those in prison were not (in New Zealand, it is not possible for sentenced prisoners to remain on compulsory treatment orders in prison). Of the committed patients, five had been found not guilty by reason of insanity and made ‘special patients’ under forensic orders and three were under a civil compulsory treatment order.

2.6. Data collection

Participants were interviewed approximately 6 months following the conclusion of EMDR therapy and after data collection for the RCT had concluded. Interviews took place between August 2019 and November 2021. All interviews were conducted by researchers SEP or BR. Seven interviews took place face to face and three were conducted by phone due to COVID restrictions. No mental health (or custodial) staff were present for the interviews, which were held in a quiet private room, either within the mental health service or the prison. We used a semi-structured interview schedule, which included a mix of open and closed questions. Although there were broad topics, the interviewer adapted to explore the themes raised by the participant rather than sticking rigidly to the schedule. Probing questions and prompts were used to draw out further information from participants. The interview schedule with the topic prompts is available as a supplementary file (S1).

Interviews lasted between 20 and 90 minutes and were audio recorded and translated verbatim.

2.7. Qualitative analytical approach

Thematic analysis (Clarke & Braun, 2017) was selected as the qualitative approach for the study because of its structured and flexible framework which has been found to work well in applied healthcare research (Braun & Clarke, 2014). Thematic analysis is an established method for recognising, analysing and reporting patterns within data. It is an iterative process consisting of six steps: (1) becoming familiar with the data, (2) generating codes, (3) generating themes, (4) reviewing themes, (5) defining and naming themes, and (6) locating exemplars (Braun & Clarke, 2006). We used an inductive, realist approach to data analysis, in which we reported the experiences, meanings, and the reality of the participants (Patton, 1990). The inductive approach involves coding the data without forcing it into a pre-existing coding frame or the researcher's analytic preconceptions.

The transcripts were independently coded using open coding by BR and SEP, and then grouped into candidate themes and subthemes by SEP, BR and ER. These candidate themes and subthemes were reviewed by revisiting the data, refining their names and discussions with the wider team. Consensus was reached through a continuous iterative process of discussion and review. Key themes and subthemes and their interpretation were agreed on by the team and are presented in the findings.

In terms of positionality and background, the researchers were two women, four men, all of New Zealand European/European ethnicity, and all clinicians experienced in the management of psychosis. Of the researchers who conducted the interviewing, line-by-line coding, and early candidate theme development, SEP is an academic forensic psychiatrist with expertise in qualitative methods and BR and ER are psychiatry registrars/residents. Our positionality towards EMDR was one of informed interest, but none were practitioners or recipients of EMDR therapy. We were not part of the treating team for any participants, and apart from one instance, we had not met them prior to setting up the interviews. The wider team included an EMDR expert psychiatrist/psychotherapist (TF), an academic clinical psychologist (EB) and a forensic psychiatrist (OH).

3. Results

There were five super-ordinate themes with thirteen subthemes. These are summarised below in Table 1.

Table 1. Summary of overarching themes and subthemes.

Overarching theme	Subtheme
‘Seriously messed up’ by trauma	Debilitating PTSD symptoms Giving the voices something to feed on Not coping Other treatments had not helped
Early scepticism	Probably quackery Nothing else worked, why this?
Not easy	First the worst Emotionally draining Worth persevering
And it worked!	PTSD symptom reduction Coping better with life
Fits the forensic setting	Empowering in a disempowering place Hope for a violence-free future

3.1. Theme 1: ‘seriously messed up’ by trauma

Our participants, as anticipated, had been deeply impacted by trauma. They described significant exposure to trauma, often being affected by childhood trauma, trauma as an adult, and offence-related trauma. Several participants talked about experiencing multiple traumas that compounded over time. While the index traumas preceded forensic admission in all cases, aspects of care were sometimes identified as re-traumatising.

 … it's hard being in hospital in a forensic unit for years. And, um, so that was just being re-traumatised again and again … (3)

Participants had experienced debilitating and enduring PTSD symptoms including arousal, reactivity, as well as cognitive and mood symptoms that had persisted for years.

I just would have these flashback times when I would think about what had happened. It was getting through it and thinking ‘it's happened’ and I’d get really emotional (1)

waking up in the middle of the night with cold sweats. (2)

It was like a terror for me … I had distressing memories, definitely. I had flashbacks, nightmares. (6)

Yeah, really uncomfortable nightmares, they might be just about [the trauma], or some of my nightmares are really sick nightmares. Really strange things. You wake up, and … I feel embarrassed to talk about it (7)

Some participants felt their experiences of trauma had changed their personality, causing them to have negative views about the world as well as themselves.

[The trauma] took a lot of control of my life - the depression, the anxiety, the medications that I was on and off and on. It led me to be a very negative person. It led me to be an angry person … . I was angry at society, myself, the people who did those things …  (9)

Additional barriers to communication included shame and guilt – many people felt unwilling or unable to discuss their experiences with their treating teams despite some of them receiving encouragement to do so.

I’m just trying to move on with my life, if you know what I mean. And they keep fucking bringing up the baggage and making me feel like shit. (4)

Conversely, some participants felt that traumatic events that predated their index offence were overlooked or minimised by their treating teams despite being important risk factors. One described the burden of trauma he had experienced as a young adult as ‘slowly simmering away for a long time’ until it culminated in the event that led to him entering forensic care. He characterised this as ‘the exclamation mark at the end of several chapters’. He felt the contributing role of underlying trauma was not prioritised in his treatment, with the spotlight being fixed singularly on his index offence; ‘of course that was what everybody focussed on, not the why … ’ (3)

Some participants identified their trauma as either a precipitant or a perpetuating factor in their mental illness, explaining traumatic experiences contributed to their psychotic symptoms. One person described this as ‘giving the voices something to feed on (9)’

Because I wasn't able to talk to anyone about it, I suppose my psyche invented a voice for me to talk to. I think that's where the voices stemmed from. (9)

[Trauma caused me to be] angry, frustrated. Scrambled thoughts. I thought I could hear people talking to me, but they weren't even there. Stuff like that. (8)

Another subtheme was difficulty coping and the maladaptive strategies people used in attempts to manage their symptoms, with many reporting self-harm and substance misuse in attempts to ameliorate intense emotional distress.

 … I didn't cope well with it and … I made like a little shiv [home-made knife-like weapon] and I used it to cut my arms and legs …  (2)

A lot of my drug use was to suppress my trauma. So that was my tool of, I guess, dealing with the trauma. (10)

Some participants associated the trauma and their coping strategies as factors that promoted externalising antisocial behaviour including reactive violence.

My propensity towards violence had escalated due to my drug use and my trauma. (10)

A lot of [the trauma] led to why I am in prison now. (9)

Others talked about internalising their distress, leading to low self-worth, thoughts of self-harm, suicidal ideation and in two cases, suicide attempts.

I had thoughts of self-harming, ending my life at some point, it was really hard for me. (2)

I have attempted suicide eight times in the past.(9)

Overall, participants were clear that their traumatic experiences had significant and pervasive effects on themselves, their relationships, and their behaviour and that these sequelae had persisted over several years. Interestingly, many mentioned they had difficulties sharing these insights with their treating clinicians, or in some cases, that they had not felt these observations were welcomed. This may explain why only five had recorded diagnoses of PTSD in their medical records prior to being assessed for this research.

Participants reported that other treatments had not helped. Some participants had previously tried different types of therapy, most commonly pharmacological therapy and various forms of psychological therapy. In terms of PTSD specific medication, one participant mentioned prazosin, an alpha blocker, but others were more vague, unable to remember specifics and talking about ‘the pills’ or anti-anxiety medication.

Those who talked about medication thought it had some benefits but were concerned about adverse effects.

[Medication helped to some degree] but so much less positive with medication because of all the side effects and suffering. It's just hard to accept the help from something that [was] actually hurting my physical health. (1)

And also, the pills, they interfere with your frontal lobe, and that's the bit that makes you human. (3)

In terms of psychological therapies, people talked about receiving cognitive behaviour therapy (CBT), or dialectical behaviour therapy (DBT) and non-specific counselling with mixed results.

I have done some CBT, but I’m not sure how well this works … I [also] did some graded relaxation work, but it's not for me, I get more agitated. (6)

I had tried different types of counselling. I had tried different types of therapy … Nothing worked and this was over a 20-year span [of trying]. (9)

People said their PTSD symptoms had affected the way they interacted with others including their engagement in therapy.

There was a lot of distrust out there for me. I didn't trust a lot of people. It took me a long time to trust a person and even then, I kept them at an arm's distance. (9)

It affected my relationships. I was always wary of new relationships. I would self-sabotage before they had the opportunity to sabotage it for me, so to speak. (10)

3.2. Theme 2: early scepticism

Despite having insight into the negative effects PTSD had on their lives at the outset of their treatment, participants described initial scepticism that EMDR would or could help them. Their initial impressions of the therapy were not favourable. Almost all participants recalled a variation on the belief that EMDR was probably quackery, recounting first impressions using unflattering epithets such as peculiar, weird, rubbish, nonsense or a gimmick.

I was pretty sure it was rubbish … It kind of reminded me of something off Star Wars. You know, trying to do something with your mind. (1)

I thought it's probably quackery. And so, I didn't have any faith when I first heard about EMDR a couple of years ago. (3)

Fear was another recurring theme. The word ‘scary’ was frequently encountered in the transcripts to describe how participants dreaded the idea they would be compelled to talk about the topics they most wanted to avoid.

I thought it was going to be a whole two hours of sitting there, talking about the past, and having to go really deep into it. (8)

Nothing else worked. Why this? Some participants were sceptical that EMDR could work for them. Some also believed that the central problem lay with them, rather than the therapy per se – that their symptoms were intractable and hence beyond help.

I was doubtful about how much the [EMDR] therapy was going to help me, so I had that in the back of my mind. Because I had been through so many other processes in the past to deal with what had happened to me. (9)

Participants regularly referred to having been uncertain, apprehensive or puzzled by the process, either prior to undertaking the therapy or during their first session. Given that most participants found the prospect of EMDR scary and/or had little faith that it would be effective, it seemed surprising that they consented to therapy. When talking about this, they said they had been encouraged by others, or were experiencing a mixture of curiosity, desperation, or hope.

Nothing in life that's not scary is worth trying. (1)

These responses were all variations on the theme of wanting to try something to reduce their suffering, apart from one participant who said he had agreed because he wanted to assist the research team.

I was sort of curious to where it would lead, but … I didn't really think was for me, it was more for you. (4)

3.3. Theme 3: EMDR is not easy

People described the therapy as difficult, with the first being the worst session. The phrase ‘hard work’ recurred in multiple accounts. Challenges predominantly revolved around the emotionally draining nature of exposure to unpleasant memories and emotions that participants had been hitherto avoiding.

The nature of the trauma that I’ve experienced and that, of course it was gonna be a bit of an ordeal really to go back and try and reprocess some of this stuff. (3)

At first, I got a bit worse, but as I went through it more, it got easier to sleep, I was having less stress. (2)

The first sessions made me feel worse. [The therapist] said in the first few days, your memories will come to the fore, but then settle down. I noticed memories more prominently after sessions for the first two to three days, but after a few days, the memories were not as severe. (6)

At times the experience was so intense it was almost intolerable.

When the memory came flooding back really, really fast, I could barely cope with it. Sometimes I had to actually leave for a couple of minutes and come back. (2)

You’ve gotta rethink and rethink and rethink of the experience that he tells you about. I could only do short bursts of it, probably 10 or 15 minutes. (7)

Participants described EMDR as emotionally draining and they sometimes felt exhausted after a session.

It does make you tired because your eyes are going so crisscross. He did say I could feel tired for a couple of days, and he wasn't wrong. (10)

After the sessions, I was particularly drained, almost emotionally fatigued. And sometimes when I got home, all I wanted to do was just sit down and have a cup of tea and a lie down kind of stuff, you know? (3)

The therapist made them feel safe and allowed them to have control to go at their own pace, to take breaks, and to only share what they felt they were able to.

 … if I started struggling with it, he would stop, and I would just close my eyes and he would start tapping on my knees in a sequence. The same thing as the finger movement but it was …  I didn't see it; I could feel it. And it felt good and helped when I got really anxious about it. (2)

I’ve been in counselling and that and they are asking you questions about your trauma, and you can't say ‘oh I don't want to talk about it’ because it goes on your files as a bad report. With [EMDR], it you don't want to talk about it, you don't have to talk about it. (10)

They said that it was worth persevering because they quickly started noticing the benefits.

I think in the beginning I did not like talking about it, what happened to me. Because it always triggers feelings, emotions. But I persevered through it. (9)

Some of the aspects of EMDR that people particularly liked were that it was targeted, specific and time-limited. The early realisation of benefits inspired participants to continue with therapy, even though the first sessions might have been difficult.

Emotionally I found it quite hard … quite scary. [But] yeah, I felt good at the end of every session. I felt I was making tangible progress with each one. (1)

And it was [working] so fast too … I was quite blown away. (10)

The next day I noticed that I hadn't had the feelings and emotions that I usually have during the night … I rang up mum and I said, I said to her, ‘guess what, I’m in a bloody good mood today!’ She said, ‘what have you done, are you alright, are you taking drugs? …  And I was like, ‘I don't know but I think it's got something to do with this guy waving his hand up in air. (9)

3.4. Theme 4: and it worked!

Despite their reservations at the outset, most participants reported that to their surprise, EMDR was highly effective. A number expressed wonderment and delight at this, describing it as like an ‘awakening’, ‘A ha moment’ or a ‘light bulb’ going off.

It's just like a light bulb has gone off in my head and I thought – wow - holy shit! Someone has to talk about this! I have to tell someone how great that this therapy is, that it can help someone like me … it took away something that was really hard to let go of. And for that to happen in my lifetime and what I’ve been through … that's a lot! He did things that I could never understand or explain but I appreciate so much. (9)

[EMDR is a] great treatment, really helpful … it was an Ah-ha moment. That happens not that often with other treatments. (1)

And then when I felt the benefits of it, it was like an awakening. (10)

The most immediate benefit was PTSD symptom reduction: intrusive memories and re-experiencing phenomena reduced.

When we first tried it [EMDR], I was quite sceptical. Cos all he started doing was asking questions and this stirred up some memories of what happened to me as a child. And I didn't quite like it. I thought here we go again; this is the same-old, same-old. And then he then did this thing with his hand, and I just followed it. I couldn't explain what was going on but when he was finished it felt like he had taken those memories from here [gesturing] in the front part of my head and locked them away in the back part of my head … I had stopped holding on to those memories and moved them to a different place in my head, to place where it was healthy enough to stay and wouldn't come back to annoy me, won't come back to traumatize me anymore. And it worked! (9)

[EMDR] gave me the tools to process rather than just shut it down and avoid it. (10)

Some participants experienced dramatic improvements in their sleep and in their mood.

 … these days I feel more comfortable in my skin and with what's happened. I’m certainly not having sort of problems in the way with my mood so much … you know getting down to the point that I’m thinking about harming myself as much. (3)

And [the day after EMDR] my mate looked at me and he said … ‘What's with the singing. Did you take your happy pill last night?’ And I said ‘nah, I am in a good mood … I had a very good sleep. (9)

Participants said that EMDR allowed them to cope better with life. Talking about being able to ‘not freak out’ and ‘just live my life’, with a common thread being a new-found ability to shift focus from the past to the present and even the future. Participants commonly described better managing distressing memories and emotions associated with the trauma and putting these in their place.

And before, I couldn't actually remember anything about it, only little fragments, but I can remember the whole thing now, and I’ve learnt to deal with it and cope with it, and it's just in the past now. (2)

I liked getting rid of the really bad thoughts. The thoughts aren't gone but I can manage them much better. They do still upset me, but its more muted. (6)

People also described feeling like their personality had ‘returned’ and they were more accepting of themselves, using phrases like ‘more relaxed’ and ‘more comfortable’.

Aspects of my sense of humour have returned. (3)

 … these days I feel more comfortable in my skin and with what's happened … on the whole I feel more relaxed, coping better, not um … I’m more accepting of myself; I’m not thinking about ending it all or anything in any sort of serious way …  (3)

Some participants had noticed improvement in their psychotic symptoms. One participant described that in the past, triggers to the trauma always seemed to exacerbate his auditory hallucinations. Having reprocessed his memories he felt there was no longer enough energy for the voices to feed on and that their intensity and frequency had abated.

But after having the therapy, I now notice because I don't have the thought patterns of the memories there, the voices don't have that power anymore, to come in and take control. I mean, I’m not saying it's perfect. I still hear the voices two or three times a week but that's better than 20 times a day, seven days a week. (9)

Others said they felt better equipped to manage their previously harmful relationship with substances.

I can deal with my trauma, I don't need drugs and alcohol, I don't need to be on prescription pills [for anxiety], I can do it myself. (10)

Some people noticed improvements in their relationships, describing no longer avoiding others in the fear that difficult questions might come up that they felt ill-equipped to handle.

Yeah, so when I started it, I barely talked to people. Now I talk to people. I can actually socialise without being anxious about ‘the thing’ or asking questions about what happened … I’ve made a lot more friends because of that treatment. I can talk to people about what I’ve done, what happened. (2)

I feel since the treatment, I’ve been engaging better with my community, I don't feel so self-conscious, I just try and be me, and not worry too much about how other people might be thinking. (3)

One participant explained how they integrated what had happened and in doing this they developed more empathy for the person they had hurt.

I’ve done something real bad, and it's not [only] affected me, it's affected the other person, and I can cope with that now, and hopefully I can get the chance to apologise for what I’ve done. (2)

The benefits of EMDR persisted over time.

Even now – months after it happened – it's still as fresh as the day that he did it. (9)

It is worth noting that while eight participants were acclamatory about EMDR, saying it had changed their life, there were two participants who did not find EMDR transformative. These were the two participants who had chosen not to complete the course of nine EMDR sessions offered during the trial. One considered it had reduced but not obviated his symptoms. He did not consider it life-changing but said it was ‘worth a try’.

Yeah, it helped, but I still think about things with the experience. I maybe didn't do it long enough … It might have changed some aspects, but I still think about [the trauma]. (7)

Another participant, who was in hospital, did not find EMDR useful and discontinued treatment after a few sessions. He said he felt he would be better off not confronting the trauma underlying his PTSD.

Ah, you know, it's better with all that stuff, you know, if I just leave it in the past and move on. (4)

3.5. Theme 5: suited to forensic settings

People thought that EMDR was well suited to forensic settings, conceptualising it as an empowering therapy in a disempowering place. Some participants reflected on the general lack of autonomy and privacy in forensic/custodial care. They felt that the highly controlled environment impinged on their previous experiences of psychological therapy due to extrinsic incentives to ‘fake good’ to therapists who might be authoring psychological reports to parole boards or special patient review panels. What was voiced externally might not be an honest reflection of was felt internally: ‘you pretty much lie your way through everything’ (10). With EMDR, the person held their own thoughts but did not have to articulate them. Some found this caused them less shame and fear of exposure, allowing them to engage in a personal journey rather than a contrived performance. This was considered more authentic and empowering.

Like I say, [EMDR] gives you the power. You don't have to expose yourself and feel it's all … for a piece of paper. Because that's my experiences of counselling. I’ve had to go through counselling just to get a good report for parole or whatever. … In my experience with everything else, counselling, or whatever else, I’ve left feeling agitated and frustrated and angry. (10)

EMDR … it helped me look at things at their root almost instead of just looking at what was above the ground. (3)

Another subtheme was around hope for a violence-free future. Participants were optimistic that they would be less likely to reoffend as they were more insightful, less hypervigilant, and felt more comfortable with themselves.

There's a lot of people in here [prison] … for the same thing that I have done, but they are in a place where they’ll do it again. They’re not in a place where I am at the moment. I suppose I can say I have seen the light and I have learnt from this. And I can move on from this. (9)

I’ve been hypervigilant. My go-to [had been] to arm myself and to protect myself at all costs. But I [now] know that - that's not how normal people think, if you know what I mean. It [EMDR] sort of made me change the way I think. (10)

Some participants regretted they had not tried EMDR earlier, suggesting their life trajectory may have followed a different course if they had been relieved of some of their PTSD symptoms earlier.

I wish this had happened a lot sooner in my walk, you know. (3)

If I had this EMDR thirty years ago I’d be in a different place from where I am at the moment. I would not be in prison. If I had just an ounce of the [EMDR] therapy, then I would not be here today …  (9)

4. Discussion

While EMDR is a well-established treatment for PTSD in the general population, and there is emerging evidence for its effectiveness for people with serious mental illness, there has been little research assessing the use of this intervention for PSTD within forensic mental health populations. This is unfortunate given the well-established potential for trauma-related symptoms to impede recovery and rehabilitation for people with serious mental illness. Moreover, the additional relationship between mental state and offending argues further for the treatment of posttraumatic stress in mentally disordered offenders. This is the first qualitative EMDR study to occur in a forensic setting – or indeed involving people with psychotic illness, psychiatric inpatients, or people in prison ­ – and as such it adds considerably to the evidence base.

Overall, five overarching themes were identified with 13 subthemes. Severe trauma was ubiquitous and participants felt they had been profoundly impacted by these experiences, developing debilitating and enduring PTSD symptoms which variably contributing to offending and psychosis. People did not have favourable first impressions of EMDR. The therapy itself was ‘not easy’ due to the emotionally taxing nature of the work but participants felt safe and that it was worth persevering. They were often surprised and delighted by results (And It Worked!), with eight out of ten participants describing marked symptom reduction and personal transformation. EMDR was well suited to a forensic setting, and it was seen as an empowering therapy enabling personal growth. Having targeted some of the underlying drivers of maladaptive behaviour, people reported hope for a better future.

4.1. Strengths and limitations

The strengths of this study include the involvement of participants whose views are seldom captured – people in long-term forensic care and in prisons. This research accompanies a randomised controlled trial, and themes from the lived experience voice can be triangulated with quantitative outcome data to build confidence in the findings.

Only one of the six researchers was an EMDR practitioner. This meant our positionality was of curiosity, but without preconceptions of how EMDR might be experienced by our participants. Participants were recruited from within a trial, with 10 out of 11 of those invited to participate agreeing to do so. This means case selection bias was less likely. We explicitly asked all participants what they did not like about EMDR, and sought to explore this in depth, in order to mitigate against the positive reporting bias that has been identified by previous EMDR researchers (Shipley et al., 2022). While there may have been some response bias (i.e. participants trying to provide the answers they believed the researchers wanted), we tried to minimise this by using interviewers independent from the treating teams, having interviewers adopt a position of open inquiry, interested in all experience of therapy, both good and bad, and conducting interviewers several months after EMDR therapy had concluded.

There are some limitations regarding ecological validity in terms of how the experimental findings might translate to real life. For example, the EMDR therapists who delivered therapy were experienced in working with people with serious mental illness (like psychosis), which may not be the case for all therapists, and may have contributed to the positive experiences reported by participants. On the other hand, the EMDR treatment protocol involved no more than nine sessions of EMDR without any prior stabilisation, which differs from the usual approach in clinical settings, in which therapy will continue for longer if indicated. Given the complexities of presentations, some participants might have benefited from a longer lead-in period and additional treatment sessions, limiting the benefits they experienced.

Lastly, although our Māori participants described positive experiences of EMDR, we did not adequately canvas the cultural aspects of the acceptability of therapy, which is a limitation given the interconnection between colonisation, mental illness, trauma and over-representation of Māori in forensic services and in New Zealand prisons (Monasterio et al., 2020). This is an important avenue for future research.

4.2. Comparison with other studies

In a 2022 systematic review of 13 eligible qualitative studies examining clients’ experiences of EMDR, two themes aligned strongly with our results: initial scepticism; and eventual transformation (Shipley et al., 2022). The subtheme ‘initial scepticism’ was prominent in five of the 13 studies reviewed by Shipley and colleagues. This related to how most clients expressed ‘some level of scepticism when … first presented [with] EMDR as a treatment option, ranging from mild hesitation to outright fear’. (Marich, 2010).

An overarching theme ‘EMDR is transformative’ was observed across 10 studies by Shipley and colleagues, with this consisting of three subthemes – ‘transformation’, ‘symptom reduction’ and ‘gaining a new perspective’ (Shipley et al., 2022). Our results were consistent with this and with other research where participants shared that ‘EMDR was one of the most effective forms of therapy they had experienced’ (Schwarz et al., 2020).

In our study, while a majority of participants reported strongly positive outcomes from EMDR, most described some negative aspects of therapy, with a key theme being it was emotionally difficult and exhausting work. One participant was ambivalent about its value, and one was negative about the overall experience; EMDR stirred up thoughts and emotions he preferred to avoid, leading him to drop out of therapy after three sessions. While Whitehouse's analysis of qualitative EMDR studies did not reveal any negative themes relating to EMDR, Shipley found a small number of studies recounted some negative experiences (Shipley et al., 2022). Interestingly, there was only one published study that reported some negative experiences (Marsden et al., 2018), the other accounts were sourced from the grey literature. This is possibly due to case selection bias (participants that are invited or who elect to participate may be more likely to have had favourable experiences) or due to confirmation bias with EMDR researchers possibly being positively inclined towards EMDR and attending more to views that align with these preconceptions.

This study clearly revealed the challenges participants faced overcoming initial scepticism and post-traumatic avoidance. It is important to understand these subjective experiences so the client can be orientated prior to therapy. In our study, having had the possible adverse effects explained before therapy was helpful, as was being reassured they could proceed at their own pace.

4.3. Novel findings for the forensic setting

The nature of trauma in the forensic context is highly relevant. Many forensic mental health patients experience offence-related trauma (Crisford et al., 2008; Spitzer et al., 2001). In our sample, a number had been acquitted by reason of insanity of psychotically-driven violent acts (while specific details cannot be provided, a hypothetical example might be killing a loved family member to ‘rescue’ them from demonic possession). Recovering from psychotic symptoms may be a comparatively straightforward part of subsequent treatment; recovering from the grief, guilt and distress around the index offence can be much more difficult. The desire to seek help for trauma-associated symptoms can be complicated by shame, fear and stigma related to social taboos around the causal events (Kessler et al., 2001). Post-traumatic avoidance can hinder recovery and compromise the management of future offending risk.

While all ten participants clearly had PTSD prior to commencing EMDR therapy (confirmed by Trauma Symptom Questionnaire [TSQ] screening scores and CAPS evaluations) and had insight into the distress this caused them, a PTSD diagnosis had not been made by the treating team in five out of ten cases. Participants discussed having avoided disclosing these symptoms and, in some instances, the symptoms being minimised by others.

A subtheme unique to our study was that EMDR was empowering in a disempowering place. Forensic participants appreciated that EMDR therapy allowed them more personal control and privacy in an environment characterised by significant limitations in these domains. Some participants reported that in the past, the pressure to demonstrate the requisite ‘success’ in therapy to enable progression had led them to lie their way through, leading to resentment and limiting therapeutic gains. However, because EMDR did not require them to articulate their inner thoughts, the pressure ‘to say the right thing’ was obviated and they felt they could engage authentically without shame or fear of negative appraisal. Difficult memories and thoughts could enter the therapeutic space but be kept private. Previously intolerable psychological work became tolerable.

People did not talk about the practical aspects of treatment apart from saying that they liked that EMDR was time-limited and focused. However, we note that EMDR may be particularly well suited to people in secure care because it can take place anywhere – including in custody. The desensitisation in EMDR is limited to imaginal activities and does not involve the real-world (in vivo) graduated exposure to trauma triggers that is often a component in trauma-focussed CBT. Furthermore, other exposure therapies may involve up to 1–2 hours of daily homework during some phases of treatment, while EMDR uses none. This is particularly important when considering that people with serious mental illness may be less likely or able to undertake homework (Nelson, 2005). Finally, EMDR does not require strong verbal skills, and can be appropriate for people with who are reluctant or unable to articulate aspects of their distress because of shame, guilt, or the fear that they might be penalised for this.

4.4. Recommendations

We recommend that EMDR should be considered for people with trauma symptomatology in forensic services. The outcome data suggests it is effective for treating PTSD and well suited for the complexities associated with forensic settings.

Our participants’ disclosure of initial scepticism and apprehension came through strongly. It is recommended that clients are well oriented and supported, particularly through their first session which many found difficult. This should include taking time explaining the model in detail. This might include providing handouts and/ or a brief video of an actor having EMDR therapy.

Educating staff about EMDR is also important. If EMDR is being offered as a new therapy in an inpatient or custodial setting, then staff unfamiliar with the research supporting its efficacy might share similar scepticism to clients. Anecdotally we observed this in our study. We hypothesised that early in this trial, staff uncertainty may have infected the participants, but as staff became accustomed to the therapy, successive participants received better support and reassurance. Further research around the barriers and facilitators to referral for EMDR for people with severe mental illness in forensic settings is recommended.

This research was confined to those with psychotic illnesses. Further study is recommended recruiting a broader forensic population and a prison study where there are very high levels of unmet need.

5. Conclusions

The impacts of trauma on people in forensic settings occur at individual, social, cultural, and economic levels. Many people in forensic services experience PTSD, but there has been little research on how to treat this within a real-world forensic context. This qualitative study finds that EMDR was considered an effective and acceptable treatment by forensic patients. Its benefits were considered to extend beyond PTSD symptoms to improve self-esteem and contribute to better lives. These findings are supported by quantitative outcome data from the randomised controlled trial limb of this research project. EMDR should be considered as a treatment for PTSD for people with serious mental illness in forensic services.

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.

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).

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.