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Building Resilience and Dismantling Fear: EMDR Group
Protocol With Children in an Area of Ongoing Trauma
Mona Zaghrout-Hodali
Ferdoos Alissa
East Jerusalem YMCA, Beit Sahour, Palestine
Philip W. Dodgson
Sussex Partnership NHS Trust, Brighton and Hove, and
Canterbury Christ Church University, Canterbury, UK
A number of studies indicate that EMDR (eye movement desensitization and reprocessing) may be effi ca-
cious in treatment of children and young people with symptoms of posttraumatic stress. However, reports
are limited in the use of the EMDR psychotherapy approach in situations of ongoing violence and trauma.
This case study describes work with seven children in an area of ongoing violence who were subject to
repeat traumas during the course of an EMDR psychotherapy intervention, using a group protocol. Results
indicate that the EMDR approach can be effective in a group setting, and in an acute situation, both in
reducing symptoms of posttraumatic and peritraumatic stress and in “inoculation” or building resilience
in a setting of ongoing confl ict and trauma. Given the need for such applications, further research is
recommended regarding EMDR’s ability to increase personal resources in such settings.
Keywords: EMDR; confl ict; trauma; treatment; resilience; group therapy
ye movement desensitization and reprocessing that showed a positive effect, namely stress manage-
(EMDR; Shapiro, 1995, 2001) is a well- established ment and group cognitive behavioral therapy (CBT).
Eand well-researched psychotherapy approach
that has been recognized in national and international EMDR With Children
guidelines as an effective treatment for posttraumatic
stress disorder (PTSD) in adults (e.g., American Psychi- Research on EMDR with children is promising but
atric Association, 2004; Chemtob, Tolin, van der Kolk, less well established. The research fi ndings provide
& Pitman, 2000; CREST, 2003; National Institute for preliminary evidence that EMDR may be effi cacious
Clinical Excellence, 2005; U.S. Department of Veterans in the treatment of children and young people with
Affairs and Department of Defense, 2004). symptoms of posttraumatic stress (Adler-Tapia & Set-
There is a substantial body of research evidence tle, in press).
that underpins these recommendations and, review- There is also evidence that EMDR may have an
ing the literature on the effi cacy of EMDR, Maxfi eld effect on future behavior. Jaberghaderi, Greenwald,
(2007) and Spector (2007), for example, concluded that Rubin, Zand, and Dolatabadi (2004), for example, in
EMDR is both effective and effi cient in the treatment a randomized controlled trial compared EMDR with
of PTSD in adults. A recent meta-analysis (Bisson et CBT in the treatment of 14 Iranian girls between ages
al., 2007) also concluded that EMDR and trauma- 12–13 years who had been sexually abused. Their fi nd-
focused cognitive behavioral therapy were effective in ings suggest that both CBT and EMDR can be effective,
the treatment of PTSD, and there was some evidence and EMDR more effi cient—requiring fewer sessions—
to suggest that they were superior to other therapies in enabling recovery from the psychological effects
106 Journal of EMDR Practice and Research, Volume 2, Number 2, 2008
© 2008 Springer Publishing Company DOI: 10.1891/1933-3196.2.2.106
of sexual abuse, as indicated by self-report, parent- indirect evidence, as noted above, of the effectiveness
report, and teacher-report scales. The study also found of EMDR in enabling children to develop resilience, or
signifi cant improvement in behavior as measured by “inoculation” to trauma, in situations such as war or
the Rutter Teacher Scale (Rutter, 1967), which in- ongoing confl ict.
cludes the rating of problematic behaviors such as
hyperactivity, antisocial behaviors, and relational Resilience and Adaptive Information
problems. Processing
Chemtob, Nakashima, and Carlson (2002) also Although resilience is a growing area of interest in
noted some behavioral change following EMDR in the fi eld of trauma (Harvey, 2007), there is very little
children with PTSD 3.5 years after Hurricane Iniki, in research on resilience as an outcome of psychological
the United States. In a randomized controlled trial of therapy. In a study of adults with PTSD, Davidson et
children with a diagnosis of PTSD at a 1-year follow- al. (2005) found that a combination of psychotropic
up of a previous counseling intervention, Chemtob medication and CBT was associated with improve-
et al. (2002) found that, after EMDR, children showed ment in resilience as measured by a self-report scale.
a substantial decrease on the Child Reaction Index The greatest changes were associated with confi dence,
(Pynoos, Frederick, & Nader, 1987), a semistructured control, coping, adaptability, and knowing where to
interview for assessing posttrauma symptoms, and on turn for help.
self-report measures of anxiety and depression. They A literature review found no studies examining re-
also made fewer health visits to the school nurse and silience as an outcome of therapy in children. The role
had improved scores on a negative self-esteem sub- of psychological therapy in relation to resilience needs
scale, both of which might be associated with a de- to be explored more fully (Alayarian, 2007; Kaminsky,
creased sense of vulnerability and the development of McCabe, Langlieb, & Everly, 2007), as does the possi-
personal resources, including resilience. ble impact of EMDR on the development of resilience
There is limited evidence of the effectiveness of in traumatized people.
early psychological intervention with children fol-
lowing trauma. Stallard et al. (2006), for example, in The Concept of Resilience
a randomized controlled trial examining the effects of
early psychological debriefi ng on children involved in Fraser (cited in McAdam-Crisp, 2006, p. 461) described
a road traffi c accident, found that early psychological resilience as “an individual’s ability to ‘bounce back’ or
intervention together with structured assessment did return to a normal state following adversity.” Harvey
not result in any additional gains on self-report mea- (in press) referred to resilience being evident “when
sures of psychological distress when compared with an event has little or no deleterious impact” (p. 7). Re-
structured assessment alone. silience has been conceptualized as a personality trait
Following the attacks on the World Trade Center on and has typically been linked with vulnerability and
September 11, 2001, Silver, Rogers, Knipe, and Colleli examined in terms of risk factors associated with the
(2005) reported a study of a time-limited psychological etiology of posttraumatic stress, including acute stress
relief program using EMDR as an early intervention disorder and PTSD (McFarlane & Yehuda, 1996). For
with children, adolescents, and adults whose age example, resilience was determined to be a factor pre-
range was 6–65 years. They found EMDR to be a dicting psychological adjustment in Palestinian chil-
useful treatment both in the immediate aftermath of dren after political violence (Punamäki, Qouta, & El
disaster as well as later but also noted that the longer Sarraj, 2001).
that treatment was delayed, the more severe was the
level of disturbance experienced by the clients. Resilience and the Adaptive Information
Similarly, Jarero, Artigas, and Hartung (2006) re- Processing Model
ported promising results for an EMDR group treat-
ment protocol used in an early response to children If resilience is an adaptive response to situations of
between the ages of 8–15 years who had lost their trauma, Shapiro’s (2001) Adaptive Information Pro-
homes, and in some cases loved ones, in the 2004 cessing (AIP) model may help understand possible
fl ood in Piedras Negras, Mexico. This study is referred mechanisms for developing resilience. This model
to in more detail below. posits that memory networks are the basis of per-
There is, however, no evidence of the effectiveness ception, attitudes, and behavior, and that disturbing
of EMDR in children with acute stress disorder in events are the primary basis for pathology. According
situations of ongoing confl ict or war, and there is only to the model, information (memory of experiences)
Journal of EMDR Practice and Research, Volume 2, Number 2, 2008 107
EMDR and Resilience in Children in Ongoing Trauma
is usually processed by the neurobiological system to The EMDR-IGPT was based on the EMDR stan-
an adaptive resolution. The information becomes in- dard eight-phase protocol but used the “Butterfl y
tegrated with other memories and is accessible as a Hug” as bilateral stimulation in place of the more
memory of a past event. usual eye movements. The Butterfl y Hug was de-
However, some traumatic experiences become veloped by Artigas, Jarero, Mauer, López Cano, and
stored in memory in a way that blocks the process- Alcalá (2000) for use with children but has been ex-
ing to adaptive resolution and are experienced in the tended to work with adults. In the Butterfl y Hug, the
present with the thoughts, images, cognitions, emo- person is asked to cross his/her arms across the chest
tions, and sensations that were experienced in the and tap alternately with each hand on the contralat-
past and associated with the disturbing event. Pro- eral shoulder, upper arm, or chest area.
cessing the memory of disturbing events is a function An adaptation of the Butterfl y Hug protocol
of EMDR that allows appropriate connections to be was used in a group setting with Kosovar-Albanian
made to adaptive networks. With the integration of refugee children in Germany (Wilson, Tinker, Hof-
the memory of the disturbing event(s) into the full mann, Becker, & Kleiner, 2000) and with children who
range of memory, there are associated shifts in symp- witnessed the Milan air crash in Italy (Fernandez,
toms, personal characteristics, and the sense of self Gallinari, & Lorenzetti, 2004).
(Shapiro, 2001, 2006). Largely, this development of the EMDR approach
If this is so, then effective treatment with EMDR in groups has been a response to the practicalities of
should give the individual access to a wider range of providing a therapeutic service in settings in which
memory, experience, and personal resources, and, the numbers of people needing treatment have made
therefore, the potential for resilience in situations of individual work impracticable. A common factor has
repeated trauma, where previously the person may been that the traumatic incident or incidents have af-
have been vulnerable to psychological diffi culties. fected communities or groups of people and families
The model leads to the hypothesis that EMDR who have experienced a similar or shared traumatic
could help a person change patterns of response and event or events, such as a natural or human-made di-
enable a person to develop resilience in an ongoing saster, war, or confl ict.
situation such as war or armed violence, perhaps by This was the case in the present study. The com-
integrating experiences into semantic, accessible munity experienced ongoing confl ict but the children
memory, thereby making it possible to make a con- in the clinical study were from a group of families
sidered response and informed choices. sharing adjacent accommodation in a refugee camp,
and the children were affected together by the same
EMDR Psychotherapy Approach in Groups incidents. The children were seen as a group, there-
While EMDR is primarily an individual psychotherapy fore, not because they were large in number, but be-
approach, it has also been used in groups. Jarero, Arti- cause they had been involved in the same incident. It
gas, López Cano, Mauer, and Alcalá (1999) developed was thought that being together as a group would en-
an EMDR-integrated group treatment protocol (EMDR- courage them to work with diffi cult material and that
IGTP) for children following the Hurricane Pauline di- sharing the same therapeutic approach and the same
saster on the west coast of Mexico in 1997 and later experiences could be helpful. It was also thought that
developed it for use with children and young adults. being together would increase their sense of support
The EMDR-IGPT was effective in alleviating symptoms and safety.
of posttraumatic stress, as measured by the Child’s Present Study
Reaction to Traumatic Events Scale ( Jones, Fletcher, &
Ribbe, 2002) and a modifi ed Subjective Units of Distur- The present report describes clinical work with seven
bance Scale (SUDS; Wolpe, 1958), which is used as part Palestinian children between the ages of 8 and 12 from
of the standard EMDR protocol ( Jarero, Artigas, & the Aida Refugee Camp, which is located at the north-
Montero, this issue ; Jarero et al., 2006). ern entrance to the city of Bethlehem and close to the
Jarero and colleagues (2006) found that the hybrid wall that separates Bethlehem from Jerusalem. Their
of EMDR and group work “took treatment effi cacy living accommodation was opposite the “separation”
and effi ciency well beyond that expected from [the] wall guarded by military personnel from a watchtower
traditional group process” ( p. 121), and it was possible and was built within a few meters of their home.
to reach a larger number of people than it would have The children, three girls and four boys, ranged in
been with 1:1 therapy. age from 8–12 years and were referred by their parents
108 Journal of EMDR Practice and Research, Volume 2, Number 2, 2008
Zaghrout-Hodali et al.
for psychological therapy 5 days after a shooting. The Preparation and Assessment
parents said that while playing on a balcony of their During the preparation phase, children were given an
building the children were exposed to shooting by explanation of what was going to happen and then
military forces who were in the watchtower. Four of asked to “Think about a safe place or pleasant place or
the children were harmed by shrapnel. Another child, a pleasant or safe moment.”
not included in this study, was shot in his belly and In this setting of ongoing confl ict, a lot of time
taken to a hospital. He received individual EMDR needed to be given to enabling the children to iden-
later after being discharged from the hospital. tify a safe, special, or pleasant place. Some participants
Five days after the incident, the seven children needed to think of a pleasant dream or a moment
were referred for psychological help with the follow- from a picture on television or in a magazine where
ing symptoms: physical illness and high temperature; they would feel safe or happy, as they were unable to
hyperactivity; nightmares; sleeping diffi culties, includ- identify anywhere in reality.
ing an inability to sleep and a fear of sleeping in their After imagining a safe, special, or pleasant place,
bedrooms; anxiety and worry; unwillingness to stay in the children were asked to “draw a picture of the
a single place; severe grief reactions; inability to deal pleasant place. Look at the drawing, to let your-
with discipline; diffi culties in concentration. Because self feel the same sense of relaxation or of feeling
this was an acute response to a traumatic situation, in- pleasant.”
dicators of severity of symptoms and outcome of treat- The children, having been shown how to do the
ment were limited to clinical observation and report, a Butterfl y Hug, were asked to “do the Butterfl y Hug
visual analog version of the SUD Scale (Wolpe, 1958), and notice what kind of feelings you have.”
and the self-reports of the parents and children. The children were then asked to rate how they
The seven children were seen as a group for four felt using a pictorial form of the adapted semantic
sessions plus one follow-up session by two therapists differential SUD Scale in which “no disturbance or
using the group treatment protocol described below. neutral” was represented by a happy “smiley face”
The treatment was set in the context of an ongoing and “the highest disturbance you can imagine” was
psychosocial program for children and families. These represented by a sad “smiley face.” The children were
families were already known to the service, and the asked to “point at how you feel at this moment, and
histories were given by the parents and children. make a mark on the scale.”
Group Treatment Protocol
The EMDR group approach used here was based on Reprocessing
the “Butterfl y Hug” protocol used by Wilson et al. The children were asked how they felt now. When
(2000). Unlike the eight phases of the standard EMDR they felt “OK” and ready to do something else, they
protocol (History, Preparation, Assessment, Desen- were asked to think about the incident and the worst
sitization, Installation, Body Scan, Closure, and Re- part of the memory: “Think of the incident that
Evaluation), the approach described here does not happened; go back to what happened [when you were
include explicit elicitation of negative and positive playing on the balcony]. Draw the worst part of that
cognitions and does not include a Validity of Cogni- incident.”
tion rating scale or a body scan. Using the visual analog of the SUD Scale, the chil-
The phases of the group protocol described here dren were asked to “show how disturbed you are now
comprise: History; Preparation and Assessment; Re- when you look at the picture and think of the inci-
processing (including Desensitization and Installation dent. And mark the scale.”
and/or Closure); Re-Evaluation. These are described Having done so, the children were asked to “do the
in more detail below. In this program, the reprocess- Butterfl y Hug. Let whatever happens, happen. If the
ing sessions were preceded and followed by time in picture changes, draw it. Whatever it is changed to,
a play area in which the children had ready access to draw it.” There were no “messages” that the picture
toys and other materials. Each session was one-and-a- should be better—“whatever it changes to, draw it.”
half to two hours, of which the reprocessing was half Having drawn the picture, the child was asked to
an hour to an hour. “look at the [new] picture and rate how disturbed you
History feel now.” Then to “do the Butterfl y Hug until the
picture in your mind changes.” The process was re-
History was taken from the children and their parents. peated usually about four times, sometimes fi ve.
Journal of EMDR Practice and Research, Volume 2, Number 2, 2008 109
EMDR and Resilience in Children in Ongoing Trauma
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