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The EMDR Integrative Group Treatment Protocol:
Application With Child Victims of a Mass Disaster
Ignacio Jarero
Lucina Artigas
AMAMECRISIS, México City, México
María Montero y López Lena
UNAM, México City, México
The EMDR Integrative Group Treatment protocol (EMDR-IGTP) has been used in different parts of the
world since 1998 with both adults and children after natural or man-made disasters. This protocol
combines the eight standard EMDR treatment phases with a group therapy model, thus providing more
extensive reach than the individual application of EMDR. In this study the EMDR-IGTP was used with
16 bereaved children after a human provoked disaster in the Mexican State of Coahuila in 2006. Results
showed a signifi cant decrease in scores on the Child’s Reaction to Traumatic Events Scale that was
main tained at 3-month follow-up. Although controlled research is needed to establish the effi cacy of
this intervention, preliminary results suggest that EMDR-IGTP may be an effective means of providing
treatment to large groups of people impacted by large-scale critical incidents (e.g., human-provoked
disasters, terrorism, natural disasters).
Keywords: EMDR; group treatment; Latin America; human-provoked disaster; posttraumatic stress; children
t 2:35 a.m. on February 19, 2006, there was whose mission is to prevent or alleviate the human
an explosion in the Pasta de Concho mine, suffering provoked by psychological trauma. This NGO
Atrapping 65 miners. The Nueva Rosita region has more experience working in situ with survivors of
became the international media center of attention natural or human-provoked disasters than any other
when rescue efforts were broadcast worldwide from agency in Latin America.
this carbon mine in the Mexican State of Coahuila. AMAMECRISIS provided the following services:
Unfortunately after several days all hope was lost,
the rescue failed, and the miners were offi cially de- • In May, psychoeducation for 50 social workers who
clared dead. Media attention then shifted to related gave support to the families of the dead miners.
political issues, because the disaster had been caused The social workers were taught strategies to cope
by negligence in mine security. Although the explo- with compassion fatigue.
sion remained in the political spotlight for weeks, the • In May, meeting with the local mental health pro-
families of the dead miners—their parents, wives, and fessionals who were working with the children on
children—and the members of the rescue team—re- a daily basis in the schools to plan this fi eld research
ceived no mental health support to alleviate their study.
deep grief, anguish, and distress. • In June, training eight mental health professionals
In May, when political conditions had become fa- in the Nueva Rosita region. The therapists received
vorable, a member of the Asociacion Mexicana para full scholarships for EMDR basic training and two
Ayuda Mental en Crisis (AMAMECRISIS) fl ew to the advanced trainings with EMDRIA credits: EMDR
region to plan the provision of services. AMAMECRISIS integrative group treatment protocol and resources
is a nonprofi t nongovernmental organization (NGO) for more debilitated clients.
Journal of EMDR Practice and Research, Volume 2, Number 2, 2008 97
© 2008 Springer Publishing Company DOI: 10.1891/1933-3196.2.2.97
• In June, implementing this fi eld research study with extensive need for mental health services after Hur-
provision of the EMDR Integrative Group Treat- ricane Pauline ravaged the western coast of Mexico in
ment protocol to 16 bereaved children. Treatment 1997. The team arrived expecting to provide one-on-
was provided by the eight local therapists in col- one EMDR to just a few individuals but were greeted
laboration with the AMAMECRISIS team. by more than 200 distressed children and adults who
• In September, follow-up with children, parents, had lost families and homes. The challenge was how
and teachers. to treat so many people simultaneously with a pow-
The Treatment of Trauma erful trauma therapy (EMDR) that was originally in-
tended for use with only one patient at a time ( Jarero,
Eye movement desensitization and reprocessing Artigas, & Hartung, 2006). The result was the EMDR-
(EMDR; Shapiro, 2001) is a psychotherapeutic ap- IGTP, a protocol that combines the eight standard
proach proven to be effi cacious in the treatment of EMDR treatment phases with a group therapy model
posttraumatic stress disorder (PTSD; American Psychi- (Artigas, Jarero, Mauer, López Cano, & Alcalá, 2000;
atric Association, 2004; Bisson & Andrew, 2007; Bleich, Jarero, Artigas, López Cano, Mauer, & Alcalá, 1999).
Kotler, Kutz, & Shalev, 2002; Chemtob, Tolin, van der It is hypothesized that the resulting format offers more
Kolk, & Pitman, 2000). Published studies have inves- extensive reach than individual EMDR applications
tigated the effects of EMDR following man-made and and that the treatment may produce a more effective
natural disasters (Grainger, Levin, Allen-Byrd, Doctor, outcome than that expected from traditional group
& Lee, 1997). EMDR has been reported effective in therapy.
treating children following a hurricane in Hawaii We recommend that the EMDR-IGTP be part
(Chemtob, Nakashima, Hamada, & Carlson, 2002), of comprehensive programs for trauma treatment
with victims of the 9/11 terrorist attacks in New York with victims of disasters. Because of its utility, it has
City (Silver, Rogers, Knipe, & Colelli, 2005), and with been used in multiple settings around the world. For
victims of earthquakes in Turkey (Korkmazlar-Oral & example, Fernandez, Gallinari, and Lorenzetti (2004)
Pamuk, 2002). reported that the group intervention appeared to
A separate body of literature also describes the ef- successfully alleviate symptoms for all but 2 of the
fectiveness of non-EMDR group therapy approaches 236 students who witnessed an airplane crash in Italy.
for disaster intervention. Following the 1988 earth- Adúriz and colleagues (in press) used the EMDR-IGTP
quake in Turkey, Goenjian et al. (2005) provided four with 220 child victims of a fl ood in Santa Fe, Argen-
30-minute cognitive behavioral (CBT) group sessions tina, in 2003 and reported signifi cant improvement
and an average of two individual sessions to children that was maintained at 3-month follow-up. Similarly,
in a school-based intervention. They found that the results with 44 children following the Piedras Negras
grief-focused treatment was effective in reducing fl ood in Mexico in 2004 ( Jarero et al., 2006) showed the
PTSD symptoms and halting the progression of de- effi cacy of the approach. Scores on the Subjective Units
pression. In another study in Athens, Giannopoulou, of Disturbance Scale (SUDS) and the Child’s Reaction
Dikaiakou, and Yule (2006) provided a 7-week group to Traumatic Events Scale (CRTES) showed large
CBT treatment to children traumatized by an earth- changes from pretreatment to posttreatment and at
follow-up (see Table 1).
quake. Results showed improvement in symptoms
of PTSD and depression that continued at follow-up. Anecdotal reports in other situations are consistent
These studies suggest that the postdisaster imple- with these results. Gelbach and Davis (2007) stated that
mentation of mental health intervention programs to the EMDR Humanitarian Assistance Program (HAP)
children can reduce trauma-related psychopathology. regularly teaches this approach to local clinicians.
However, all of these treatments required the chil- It . . . seems to be equally effective cross-culturally,
dren’s attendance over a period of several weeks, a and it has the advantage of reaching more people
requirement that may be hard to implement in some more quickly, involving larger segments of the
disaster or refugee settings. community. Paraprofessionals can be taught to
The EMDR Integrative Group lead the groups under supervision of a clinician,
Treatment Protocol which allows wide application in societies that
have a few clinicians. For instance, in Guajarat,
The EMDR Integrative Group Treatment protocol India, after a major earthquake, newly trained
(EMDR-IGTP) was developed by members of AM- clinicians conducted group sessions that reached
AMECRISIS when they were overwhelmed by the thousands of symptomatic children. In Chennai,
98 Journal of EMDR Practice and Research, Volume 2, Number 2, 2008
Jarero et al.
TABLE 1. Results From the EMDR-IGTP Studies in Mexico and Argentina
SUD Scores CRTES Scores
Number of Immediate 1-Month 3-Month
Study Participants Pretreatment Posttreatment Pretreatment Follow-Up Follow-Up
Piedras Negras,
Mexico 44 9.2 1.3 32.8 8.3
Santa Fe,
Argentina 220 7.3 2.2 26.4 10.8
Source. Adúriz et al., in press; Jarero et al., 2006
India, after the tsunami, HAP-trained clinicians Team members have to be aware of the needs of the
treated 5,000 children in these groups in 1 year. clients within their extended family, community, and
(p. 399) culture.
EMDR-IGTP has also been used in its original for- Phase 2—Preparation
mat or with adaptations to meet the circumstances to Phase 2 of the protocol begins with an exercise in-
assist victims of fl ooding in Acapulco, México, 1997, tended to familiarize the children with the space and
Posoltega, Nicaragua, 1998, Caracas, Venezuela, 1999, objects included in the intervention, to establish rap-
Santa Fé, Argentina, 2003, and Piedras Negras, México, port and trust, and to facilitate group formation. Toys
2004; earthquake survivors in Pereira and Armenia in such as a doll dolphin can be used to familiarize the
Colombia, 1999, Adapazari, Turkey, 1999, and San children with the expression of emotions (e.g., they
Salvador, El Salvador, 2001; child refugees of the Alba- imitate the expressions of the dolphin). Once appro-
nia and Kosovo War, in Germany, 1999; and survivors priate rapport is established, the children are guided
of the tsunami (Adúriz et al., in press; Artigas et al., through a safe/secure place exercise, which provides
2000; Gelbach & Davis, 2007; Jarero et al., 2006; Jarero them with a coping skill. The children are repeatedly
et al., 1999; Korkmazlar-Oral & Pamuk, 2002; Wilson, validated regarding their feelings and other posttrau-
Tinker, Hofmann, Becker, & Marshall, 2000). matic symptoms.
Description of the Procedure Phase 3—Assessment
EMDR-IGTP is administered by an EMDR clinician
who leads the team and who is assisted by other Instead of being asked to visualize the target incident,
clinicians or paraprofessionals previously trained in as in traditional EMDR, the children are instructed to
this protocol. The assisting clinicians or paraprofes- think about the aspects of the event that made them
sionals are called the “Emotional Protection Team” now feel most frightened, angry, or sad, and then to
(EPT). Teachers can also be of great assistance, help- draw that image on the paper provided (see Figure 1,
ing the children write their names, ages, and SUD drawing A). They are then shown a diagram that
numbers. depicts faces representing different levels of nega-
The protocol application takes 50 to 60 minutes. tive emotion (from 0 to 10, where 0 shows no distur-
A ratio of 8–10 children for each mental health profes- bance and 10 shows severe disturbance) and asked to
sional is recommended. A team of fi ve clinicians (one select the face that best represents their emotion and
leading the protocol and four doing the Emotional to write the corresponding number on their picture,
Protection Team work) can treat 40–50 children, a thus providing the team with ratings of subjective dis-
total of 160–200 children in 4 hours of work. turbance (SUD).
Phase 1—Client History Phase 4—Desensitization
During Phase 1 of the protocol, team members edu- The children are asked to look at their picture (e.g.,
cate teachers, mothers, and relatives about the course Figure 1, drawing A) and to provide their own alter-
of trauma and enlist these individuals to identify chil- nating bilateral stimulation with the Butterfl y Hug
dren who have been affected by the traumatic event. (Artigas et al., 2000) by crossing their arms and tapping
Journal of EMDR Practice and Research, Volume 2, Number 2, 2008 99
The EMDR Integrative Group Treatment Protocol
FIGURE 1. Example of a child’s drawings before and during EMDR-IGTP treatment.
Note. The numbers represent the child’s self-reported SUD scores.
A) Drawing A: The fi gures trapped inside the mine (his father one of them) are saying: “Ha,” “Help,”
“Help us” (SUDS = 5).
B) Drawing B: “Me” and “Picture of my Dad” (SUDS = 10).
C) Drawing C: “My mother,” “me,” “Bertha,” “Martha” (his sisters) (SUDS = 0).
D) Drawing D: “My Dad” (SUDS = 0).
themselves on the chest in a bilateral alternating fash- processing. Consequently, the group protocol utilizes
ion. The children are then instructed to draw another the future vision to identify adaptive or nonadaptive
picture of their own choice, related to the event, and cognitions (e.g., I want to die and be with my dad in
rate it according to its level of distress. Processing heaven) that are helpful in evaluating the child at the
continues with the child looking at the second picture end of the protocol. The children draw a picture that
and using the Butterfl y Hug. The process is repeated represents their future vision of themselves, along
twice more so that there are four pictures (Figure 1). with a word or a phrase that describes that picture
The level of distress associated with the incident is (see Figure 2). The drawing and the phrase are then
then assessed by asking the child to focus on the draw- paired with the Butterfl y Hug.
ing that is most disturbing and to identify the current Phase 6—Body Scan and Phase 7—Closure
SUD level. This number is then written on the back of
the paper (see Figure 2, upper left corner). In Phase 6, the children are instructed to close their
Phase 5—Future Vision (Replacing eyes, scan their body, and do the Butterfl y Hug.
Installation) Finally, in Phase 7, the children are instructed to re-
turn to their safe/secure place.
Phase 5 of the standard EMDR protocol cannot be Phase 8—Re-Evaluation
conducted in large groups since each participant may
have a different SUD level. Also, some children can- Phase 8 takes place immediately after the group inter-
not progress any further in the group protocol to vention: The team leader and the Emotional Protec-
reach an ecological level of disturbance. This may be tion Team members have a debriefi ng about which
because they have blocking beliefs, previous prob- identifi ed children may need individual attention and
lems or trauma, and/or require additional time for which may need thorough evaluation to identify the
100 Journal of EMDR Practice and Research, Volume 2, Number 2, 2008
Jarero et al.
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