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the emdr integrative group treatment protocol application with child victims of a mass disaster ignacio jarero lucina artigas amamecrisis mexico city mexico maria montero y lopez lena unam mexico city ...

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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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...The emdr integrative group treatment protocol application with child victims of a mass disaster ignacio jarero lucina artigas amamecrisis mexico city maria montero y lopez lena unam igtp has been used in different parts world since both adults and children after natural or man made disasters this combines eight standard phases therapy model thus providing more extensive reach than individual study was bereaved human provoked mexican state coahuila results showed signi cant decrease scores on s reaction to traumatic events scale that main tained at month follow up although controlled research is needed establish ef cacy intervention preliminary suggest may be an effective means large groups people impacted by critical incidents e g terrorism keywords latin america posttraumatic stress t m february there whose mission prevent alleviate explosion pasta de concho mine suffering psychological trauma ngo atrapping miners nueva rosita region experience working situ survivors became internatio...

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