A Real-World Evaluation of Treating Post-traumatic Stress Disorder in Military Veterans with Eye Movement Desensitization and Reprocessing Therapy: Comparing EMDR-Indoors and EMDR-Outdoors

Objective: This real-world evaluation compared eye movement desensitization and reprocessing (EMDR) therapy delivered in a conventional outpatient environment (EMDR-Indoors/EMDR-I) with EMDR delivered in an outdoor environment (EMDR-Outdoors/EMDR-O) for military veterans with military-related post-traumatic stress disorder (PTSD), inclusive of combat exposure. Method: Thirty veterans who routinely accessed Veterans NHS Wales in Hywel Dda University Health Board and had completed a course of EMDR-I or EMDR-O were included in this evaluation. Data collected regarding the veterans’ demographics, military background, mental health, patient-reported outcome measures (PTSD Checklist for DSM-5, Patient Health Questionnaire, General Anxiety Disorder, and Work and Social Adjustment Scale), and veterans’ written feedback about the service they received were subjected to mixed-methods analysis. Results: Both EMDR-I and EMDR-O led to statistically significant and clinically meaningful improvements in military-related PTSD, depression, and anxiety. Improvements in PTSD were maintained at 6 months posttreatment; however, only EMDR-O demonstrated the maintenance of subclinical levels of anxiety and depression. Furthermore, EMDR-O was more time efficient in achieving improvements. Distinctions were evident in these 2 approaches to EMDR, with veterans viewing EMDR-O as an integrative approach in which being outdoors and walking serve as accelerants in the recovery process. Conclusions: This evaluation demonstrates a proof of concept for EMDR-O, underpinned by a proposed neurobiological theory of the role of footsteps as a form of dual-attention bilateral stimulation in EMDR therapy. This evaluation tentatively supports the case for EMDR-O as a credible treatment. However, further research is required to scale EMDR-O toward a clinical trial.