Healing Combat Trauma in Sri Lanka via EMDR
Posted on May 10th, 2011

Dr. Ruwan .M Jayatunge M.D. Trained in EMDR

The Sri Lankan society is hugely affected by combat related stress as a result of the 30 year armed conflict. Combatants as well as a large number of civilians including members of the LTTE have undergone a tremendous amount of war related stress for the last 3 decades. There had been large military operations where the combatants were directly exposed to hostile battle conditions. Following these traumatic combat events a considerable number of soldiers became psychologically wounded. Deplorably Psychological wounds of the Eelam war were not addressed appropriately. As a result of the   armed conflict in Sri Lanka a callous wave of PTSD, Depression, Somatization, and Adjustment Disorders etc has been generated. Many cases are not yet diagnosed entirely and following the late reactions of combat trauma the numbers would be high. To heal the war trauma in Sri Lanka an effective psychotherapeutic method was needed. In 2005 the EMDR HAP trained Sri Lankan mental health clinicians to use EMDR to deal with   psychological trauma.  EMDR was effectively used to treat Sri Lankan combatants. Many of the EMDR sessions were conducted under the supervision of the EMDR HAP facilitators. Following these treatment the Sri Lankan combatants with PTSD and Depression showed positive therapeutic outcome. Their psychological distress reduced significantly. This article reveals the efficacy of EMDR in the treatment of four combatants with PTSD and two with Depressive Disorder. After 5 to 8 sessions of EMDR most of the veterans became free of their disturbing symptoms and today living productive lives.

Key Words:  EMDR, Combat Trauma, Veterans, Sri Lanka, Eelam war.

The Democratic Socialist Republic of Sri Lanka is an island in the Indian Ocean about 28  Kilometers (18 mi.) off the southeastern coast of India with a population of about 19 million. Sri Lanka was devastated by an internal prolonged conflict which claimed over 95,000 lives. Many mental health clinicians claim that this conflict has a drastic impact on the psychosocial wellbeing   the combatants who were directly exposed to hostile war conditions.  The war trauma experienced by the Sri Lankan combatants was not shown adequately. Often they were demonized and shown as the perpetrators of violence by a partial media.  A balanced picture should be portrayed to understand the war trauma in Sri Lanka.  Following the 30 year armed conflict in Sri Lanka combat veterans have undergone war trauma beyond the usual human experience.  Unlike the servicemen of WW1, WW2 or the Vietnam War, Sri Lankan combatants were exposed to combat trauma for long years. Many soldiers have served 10-15 years in the operational areas and witnessed the gruesome realties of the Eelam war.

 There are no empirical data that directly address the prevalence of PTSD among the Sri Lankan combatants. But the 3 year study (from 2002 to 2005) done by the author with the Consultant Psychiatrist of the Sri Lanka Army Dr. Neil J Fernando reveals that combat related PTSD is emerging in Sri Lanka. In one separate study which was done with 824 Sri Lankan combatants who were referred to the Military Hospital Colombo for various psychiatric, stress and anxiety related conditions and disciplinary infractions  full blown symptoms of PTSD was found in 56 combatants  ( To diagnose PTSD , DSM-IV Criteria has been used). This may be the tip of the ice burg that is still able to be seen.  There are many undiagnosed cases of combat related PTSD among the combatants who took part in the Eelam war.

 Risk Factors

The American Psychiatric Association (2000) discusses risk factors that affect the likelihood of developing PTSD. Among the risk factors the severity, duration, and proximity of an individual’s exposure to the traumatic event are the most important factors affecting the likelihood of developing this disorder. There are some evidences that indicate social supports, family history, childhood experiences, personality variables, and preexisting mental disorders may influence the development of Posttraumatic Stress Disorder.

There were several risk factors that affected the Sri Lankan combatants negatively and it played a crucial role in developing PTSD among the Sri Lankan combatants. Regrettably combat stress management was disregarded and not considered as a priority. During the 30 year Sri Lankan conflict the military had no fully fledged combat psychotherapy facilities to deal with combat related stress issues. During the war there were no full time military Psychiatrists / Military Psychologists to treat the soldiers. Psychological first aid and similar psychological support services were not conducted soon after the traumatic combat events. Combat related stress reactions went undiagnosed and untreated for a number of years.  Many former Sri Lankan combatants are still suffering from combat related PTSD now popularly known as Palali Syndrome. Many of these combatants have various trauma related issues such as alcohol and drug abuse, domestic violence, community violence, child abuse, self-harm, suicide attempts and many of them are troubled by the foreshortened future.

The Uncontrolled EMDR Study with the Sri Lankan Veterans

In one of our uncontrolled studies we have treated 18 Sri Lankan Soldiers suffered from PTSD with EMDR. Their therapeutic outcome was exceptional. This study was started in 2005 and 18 combatants with PTSD were selected. Prior to the study their consent has been obtained and they were explained about the EMDR procedure. Some of the EMDR sessions were supervised by Dr. Nancy Elizabeth Errebo PsyD of the EMDR HAP.  All of the combatants underwent 5-8 sessions of EMDR. Most of them showed spectacular results with EMDR. After EMDR sessions they were subjected to follow up which continued for 12 -24 months.

In this sample all the combatants have undergone various combat related traumatic events and had key symptoms of PTSD.  Some were treated with SSRI, Exposure Therapy, Client Centered methods and Rational Emotive therapy. Majority of them had undergone traditional healing methods too. Regardless of these treatment modes they still experienced intrusions, nightmares, hyper vigilance, emotional numbing etc and had various psychosocial problems that affected their personal and occupational lives.

For this uncontrolled study we had total of 18 combatants with PTSD. Twelve of them showed a dramatic improvement after 5-6 sessions of EMDR each session was conducted approximately once or twice a week. Despite the clinical interventions two soldiers did not show any improvement at all.  The rest of the soldiers had   doubtful results; probably they may have concealed their clinical improvement in order to gain sympathy or to avoid being discharged from the ward.

Case Reports

Lance Corporal S

Lance Corporal S (44Y) has served in the operational areas for five years. In 2000 March he met with a land mine explosion in Mannar (Northern Part of Sri Lanka). Although he survived the blast with minor physical injuries he witnessed the death of other soldiers who traveled with him. Many of them were his friends who had served with him for a number of years. He saw their bodies coved with blood and how they were lying on the road. Lance Corporal S was shattered by this incident and went in to anxiety and depression mixed reaction. Gradually he experienced survival guilt, night terror, exaggerated startling reactions, numbing of general responsiveness and marked avoidance. In 2002 he was diagnosed with PTSD by the visiting Psychiatrist of the Sri Lanka Army. He was on SSRI and relaxation therapies and these treatments gave some favorable results. His PTSD symptoms were under controlled until the Tsunami disaster in 2004 December. He was exposed to Tsunami events in Matara (Southern part of Sri Lanka) and had a major relapse. His PTSD symptoms aggravated and he was admitted to the hospital.  He was treated with SSRI s and then discharged. But his PTSD symptoms remained for a long time. In 2005 he was re admitted to the hospital with marked anxiety, nightmares, intrusions and flashbacks.  At the hospital he was offered the option of undergoing EMDR. With his consent he was treated with EMDR.  The first session of EMDR with L/Cpl S was observed by Dr. Nancy Elizabeth Errebo of the EMDR HAP.

Lance Corporal S willingly and positively responded to EMDR. During the first session he experienced a psycho-physiological reaction and eye movements were switched to hand taps. But in the subsequent sessions he faced eye movements without a difficulty. He underwent 6 sessions of EMDR (one session per week). With EMDR his nightmares became minimal and later disappeared so as his intrusions and flashbacks. His negative feelings changed in to more positive. The follow-up after six months revealed that L/Cpl S was free of combat related and Tsunami related nigh terror, intrusive memories, flashbacks and depressive feelings. He was sent back to his unit and started working without firearms.

Lance Corporal K

Lance Corporal K was another soldier who underwent EMDR with an enthusiasm. He joined the Army in 1989 and served in the operational areas for many years. When the LTTE attacked the Kiran Camp his unit went on a rescuer mission.  There he saw a large numbers of dead bodies (SLA Soldiers and the LTTE) mutilated and decomposed. During the rescue mission the enemy attacked them with heavy weapons. Lance Corporal K became distressed and had frightening feelings.  He went in to an acute stress reaction.  But he was not treated by any means and ordered to take part in the mission.

when the  rescue mission was over they came home.  Lance Corporal K was overwhelmed and the events at the Kiran Camp started troubling him. He could not sleep and for the slightest sound he would give a startled reaction. He had flashbacks with fear feelings. He relived the traumatic battle events with avoidance. He felt that his life had no aim and meaning. He had suicidal thoughts. Finally he was referred to the Military Hospital Colombo and diagnosed as having PTSD.

Lance Corporal K faced EMDR with a mild hesitation. He was used to talk therapy and eye movements were somewhat a new experience for him.  But gradually he was able to adapt to EMDR. His image was a thunder and the negative cognition was “I wish I was dead with my fellow soldiers” and the SUD was 9. (Subjective Units of Disturbance Scale SUDS; adapted from Wolpe as described in Shapiro, 1989a.  This measure is taken at several intervals during the treatment of each upsetting memory, as treatment is generally continued until the SUDS reaches 0. Non-reactivity to the traumatic memory is considered an indicator of recovery (Horowitz  1986).

After the first session of  EMDR   he was able to sleep without any night terror and then he was more positive about EMDR. Subsequent sessions marked a significant therapeutic success in him. When Lance Corporal K came for a follow up on the 28th of November 2005, except startling reaction  most of the PTSD symptoms had been reduced.  His final follow up that was done in August 2006 revealed that Lance Corporal K was psychosocially more stable and do not experience any intrusions or nightmares. Above all he was free of suicidal thoughts.

 Corporal W

Corporal W (37Y) has served 15 years in the operational areas. In 1992 he was exposed to a blast event in  Welioya .  Although the blast did not harm him physically his psyche was shattered.  He concealed his fear and distressing feelings from fellow soldiers and the unit leaders.  Although Corporal W started experiencing hypearousal reactions and became distressed he took part in military missions.

After these events at the Comma Point -Mulative he was ordered to bury dead soldiers who killed in action. The bodies were half swollen and putrefied. Some of the dead bodies were eaten by the Monitor Lizards (Varanus exanthematicus). It was a dreaded picture to Corporal W because some of the dead soldiers were known to him. Since it was an order he fulfilled the duty with utter repulsion. Following these events he felt despair. Gradually his nights became disturbed; he was depressed and had no aim in life. He stopped associating with people and became more withdrawn. His mind was full of past combat events and sometimes he had a sense of re-experiencing the traumatic battle events especially the events that occurred at the Comma Point. While experiencing PTSD symptoms Corporal W became extremely hostile. Once he physically punished his teenage daughter and she was hospitalized for several days.  He became disgusted with life and numerous times he tried to commit suicide.

Corporal W was admitted to the Military Hospital Colombo with agitated behavior and suicidal ideation. After his agitation was subsided and safe place exercises were practiced he consented to undergo EMDR.  Corporal W was treated with EMDR and SSRI s. His image was an unarmed man surrounded by the enemy and SUD was 8. He underwent six sessions of EMDR as an inpatient. In each session he showed a dramatic improvement. Finally he was free of most of the PTSD symptoms. His suicidal ideation diminished. The follow up (after 24 months) revealed that Corporal W is now retired from the military and leading productive life.

Captain KHZ86

Captain KHZ86   was a brave officer who had participated in a number of military operations. In 1992 he went on a rescue mission and directly engaged the enemy. In this confrontation in front of his eyes he lost 23 of his men whom he treated as his own children. He trained them and looked after them and went to the battle ground with them. But they were perished leaving a deep despair in his heart. Captain KHZ86 could not forget these terrible events for many years.  He felt that he was personally responsible for their deaths. In order to avoid guilt, intrusions and night disturbances he started indulging in alcohol. He became numbed and withdrawn. He silently suffered a number of years until he decided to come for psychological therapies.

Captain KHZ86   volunteered for EMDR and underwent the full therapeutic protocol. With the reprocessing therapy his disturbed feelings and intrusive memories disappeared.  He was able to come to terms with trauma.  The survival guilt that drastically affected him a number of years diminished gradually. After many years he was able to sleep without horrible nightmares and look forward to the future.

Treating Depression with EMDR

The component of depression was evident to Dr. Mendez Da Costa who introduced the term Irritable heart during the US Civil War and Lt Col (Dr) Fredric Mott who coined the term Shell Shock during the World War One. Sometimes depression is apparent among the servicemen who were exposed to traumatic combat events. In addition to depressive symptoms they can have anxiety related features with survival guilt.  Depression has been diagnosed in a number of Sri Lankan combatants.  A depressed soldier experiences deep unshakable sadness and diminished interest in most of the personal as well as military activities.  Depression can dramatically impair a soldier’s ability to function in field situations. They may experience such extreme emotional pain that they consider or attempt suicide

Case Study: Signalman P

Some of the Sri Lankan combatants who were treated with EMDR showed favorable results. Signalman P was one of them. Signalman P met with a claymore mine explosion in Jaffna in December 2005. He sustained minor injuries to the left hand as a result of this explosion. But 13 of other soldiers died in this incident. Signalman P witnessed the hurtful deaths of two privates and a sergeant. He became severely depressed. Following is a therapeutic conversation and complete EMDR (first ) session with Signalman P.

Therapist- “You feel depress about the recent event that took place in Jaffna. Perhaps we could talk about this event in order to get an emotional release.”

Signalman P- “That was a horrible event indeed. We went to our area camp by a truck. Along with me a group of soldiers were traveling. I was in the front and holding my weapon. Suddenly I heard a large noise. The soldiers in front of me fell down. Then I realized that it was an enemy attack. Despite the ceasefire agreement they attacked us with claymore mines and then with small arms.”

Therapist “”…” How do you visualize this incident?

Sig:P- “Terrible. When the enemy attacked our driver became wounded. But he was able to keep the vehicle stable and we kept on going further. There was a large tire inside the truck then I took cover. While I was lying down two wounded soldiers asked for water from me. But there was no water. We had to travel few more kilometers to the nearest camp. Another wounded sergeant crawled near me and said something. His mouth was full of blood. Within a minute he became motionless. His eyes were opened and he was dead. When the truck entered the nearest camp I rushed to help the wounded men. Most of them were dead including the two soldiers who asked for water. I felt really sorry for them. I could not help them even to give a cup of water.”

 Therapist- When disturbing events like these occur, it can get locked in the nervous system. The sad feelings that you experience even after months after the event is due to this mechanism. We have an effective method which is called EMDR that helps to resolve your melancholic feelings. (The therapist explains the EMDR procedure)

Therapist- “What part represents the worst part of the incident?

Sig P- “The two soldiers approaching me and asking for water”

Therapist- What words go best with that picture that expresses your negative belief about yourself now?

Sig P- “I could not help them”

Therapist- When you bring that picture what would you like to believe about yourself now?

Sig P- “I was wounded and helpless. Therefore I could not help them”

VOC =3

Emotion “”…” Sadness

SUD= 10

Sensation “”…” in the chest

Therapist- “Bring up that picture and the sad feeling which is filled inside your heart and follow my fingers and tell me what you are getting”

Sig P- ” I see our soldiers are shouting and try to escape the bullets”

Therapist “”…” “Go with it and follow my fingers”

Sig P- “They are bleeding”

Therapist “”…” “Go with it and follow my fingers”

Sig P- ” I feel really sorry about the sergeant and two soldiers”

Therapist “”…” “Go with it and follow my fingers”

Sig P- “I could not help them”

 Therapist “”…” “Go with it and follow my fingers”

Sig P- “If I had water I could have given to them”

Therapist “”…” “Go with it and follow my fingers”

(After another 10 – 15 hand movements Sig P experiences a psychophysiological reaction. His tension in the head is reducing and his overwhelmed emotions are settling)

Sig P- “I feel little easy, my head tension is reducing”

Therapist “”…” “Go with it and follow my fingers”

Sig P-  ” I feel like somebody took a heavy weight that was on my shoulder”

Therapist “”…” “Go with it and follow my fingers”

Sig P- “I feel little easy”

Therapist “”…” “Go with it and follow my fingers”

Sig P- “I think I should face the life now”

Therapist “”…” “Go with it and follow my fingers”

Sig P- “Now I know I have nothing to do with this terrible event”

Therapist “”…” “Go with it and follow my fingers”

Sig P- “Their deaths were    inevitable, either I could give water or not”
Therapist “”…” “Go with it and follow my fingers”

Sig P- “I feel easy”

Final SUD 2

Final VOC 7

Clear Body scan

Signalman P undergoes another 4 sessions of EMDR within a period of 6 weeks. In each session his tension, melancholic feelings and survival guilt dropped gradually.

Follow up “”…” after 5 weeks of the last EMDR session “”…” Signalman P has no depressive feelings but he recalls the incident as an unfortunate event of the war. No survival guilt or unpleasant intrusions recorded.

Follow up after 10 weeks -“”…” Signalman P is free of depressive symptoms. He was able to rationalize the event and does not blame himself for the death of the soldiers.

Follow up after 25 weeks “”…”Uneventful

Follow up after 40 weeks “”…”Uneventful

Follow-up after one year – Signalman P is free of depressive feelings and trauma related symptoms. He is now serving in his unit effectively.

Case Study Lieutenant JXC

Lieutenant JXC had served 7 years in the operational areas. There he underwent a numerous combat related traumatic events. In one of the confrontations with the enemy at Kokuthuduwai in Mullaitivu he killed 7 enemy carders who came to overrun his camp. Subsequently these killings had caused severe guilty feelings in him. He was repenting over the mines that he had planted in the war zone. According to Lieutenant JXC he and his group laid a large number of antipersonnel mines in the outer perimeter of their camp in order to prevent enemy advances. He had severe guilty feelings over this action.   He had often said “My actions have created   cripples” He could not get away with this thought.   He was experiencing sad feelings, suffered from generalized somatic pain, loss of libido, insomnia, and change of appetite.

Lieutenant JXC was diagnosed with depressive disorder in 2004. He was treated with SSRI (Fluoxetine) for over 9 months. Despite the anti-depressants his cheerless symptoms troubled him immensely. He found no interest in his military and private life. Often he became hostile to family members and neglected his military duties. With the consent of the Consultant Psychiatrist   EMDR was administered as a supportive therapy.  Lieutenant JXC underwent 8 sessions of   EMDR and with the reprocessing therapy   his depressive feelings and irrational and erroneous cognitions diminished. Gradually he became symptoms free. Lieutenant JXC was able to come to a positive cognition and changed his life philosophy after the EMDR intervention.  The follow up (first follow up after 6 months and second follow up after 1 year) revealed that Lieutenant JXC is free of depressive symptoms. Today he is working for a multinational company as a senior executive  officer and living a productive life.

Combat trauma is a very complex multi-dimensional phenomenon. It disrupts the soldier’s military performance as well as his psychosocial functioning. Prolonged exposure to combat trauma can cause various anxiety related conditions. Soon after a traumatic combat action soldiers should be provided with psychological first aid and counsel them in an ethically and culturally appropriate manner.

Psychological Trauma has no demographical barriers. Human reaction to mental pain is universal. The contemporary society is filled with its complexness that many cannot avoid natural or manmade trauma. The Sri Lankan society was affected by natural and man-made calamities. To heal the trauma an effective and viable mode of psychotherapy is essential. The EMDR has proven effective, easy to practice, low cost and above all it has no cultural obstacles. EMDR appears to be a treatment that could effectively address the combat trauma in Sri Lanka.

The six case reports (four veterans with PTSD and two with Depressive Disorder) that have been described in this article highlight the positive therapeutic outcome following EMDR. After 5 to 8 sessions of EMDR their distressing symptoms were eradicated and the veterans were free from their intrusions, nightmares and depressive feelings. Now they lead productive lives. For example Lance Corporal S is free of his PTSD symptoms. Captain KHZ86   got an honorable discharge and now married and working in a large company. Signalman P is still serving in the Army and depression combined posttraumatic symptoms do not trouble him.  He performs normal duties. Lieutenant JXC is working in a multinational company, holding a top post. Also he has become a motivational speaker and conducts lectures.  Most of these combatants would have had unhappy endings if not for the EMDR. Therefore the efficacy of EMDR and its clinical significance gives new hope for the  Sri Lankan combatants.


1)      American Psychiatric Association (2000). Diagnostic and Statistical Manual of Mental Disorders. Fourth edition. Text Revision. Washington, DC:
2)      Boscarino JA. Diseases among men 20 years after exposure to severe stress: Implications for clinical research and medical care. Journal of Psychosomatic Medicine. 1997;59:605″”…”614.

 3)      Jayatunge R (2004) PTSD Sri Lankan Experience. ANL Publishers Colombo

4)       Shapiro F. (1995) Eye Movement Desensitization and Reprocessing: Basic

         Principles, protocols and Procedure. New York: The Gilford Press

One Response to “Healing Combat Trauma in Sri Lanka via EMDR”

  1. Fran Diaz Says:

    Our heartfelt thanks to Dr Ruwan Jayatunge for the valuable work he has done to heal our soldiers, and his continued efforts to heal the psyche of the Nation.

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