Scaling Up What Works: Using EMDR to Help Confront the World’s Burden of Traumatic Stress

Group early intervention eye movement desensitization and reprocessing therapy as a video-conference psychotherapy with frontline/emergency workers in response to the COVID-19 pandemic in the treatment of post-traumatic stress disorder and moral injury—An RCT study

Objective

Frontline mental health, emergency, law enforcement, and social workers have faced unprecedented psychological distress in responding to the COVID-19 pandemic. The purpose of the RCT (Randomized Controls Trial) study was to investigate the effectiveness of a Group EMDR (Eye Movement Desensitization and Reprocessing) therapy (Group Traumatic Episode Protocol—GTEP) in the treatment of Post-Traumatic Stress Disorder (PTSD) and Moral Injury. The treatment focus is an early intervention, group trauma treatment, delivered remotely as video-conference psychotherapy (VCP). This early intervention used an intensive treatment delivery of 4x2h sessions over 1-week. Additionally, the group EMDR intervention utilized therapist rotation in treatment delivery.

Methods

The study’s design comprised a delayed (1-month) treatment intervention (control) versus an active group. Measurements included the International Trauma Questionnaire (ITQ), Generalized Anxiety Disorder Assessment (GAD-7), Patient Health Questionnaire (PHQ-9), Moral Injury Events Scale (MIES), and a Quality-of-Life psychometric (EQ-5D), tested at T0, T1: pre—treatment, T2: post-treatment, T3: 1-month follow-up (FU), T4: 3-month FU, and T5: 6-month FU. The Adverse Childhood Experiences – International version (ACEs), Benevolent Childhood Experience (BCEs) was ascertained at pre-treatment only. N = 85 completed the study.

Results

Results highlight a significant treatment effect within both active and control groups. Post Hoc comparisons of the ITQ demonstrated a significant difference between T1 pre (mean 36.8, SD 14.8) and T2 post (21.2, 15.1) (t11.58) = 15.68, p < 0.001). Further changes were also seen related to co-morbid factors. Post Hoc comparisons of the GAD-7 demonstrated significant difference between T1 pre (11.2, 4.91) and T2 post (6.49, 4.73) (t = 6.22) = 4.41, p < 0.001; with significant difference also with the PHQ-9 between T1 pre (11.7, 5.68) and T2 post (6.64, 5.79) (t = 6.30) = 3.95, p < 0.001, d = 0.71. The treatment effect occurred irrespective of either ACEs/BCEs during childhood. However, regarding Moral Injury, the MIES demonstrated no treatment effect between T1 pre and T5 6-month FU. The study’s findings discuss the impact of Group EMDR therapy delivered remotely as video-conference psychotherapy (VCP) and the benefits of including a therapist/rotation model as a means of treatment delivery. However, despite promising results suggesting a large treatment effect in the treatment of trauma and adverse memories, including co-morbid symptoms, research results yielded no treatment effect in frontline/emergency workers in addressing moral injury related to the COVID-19 pandemic.

Conclusion

The NICE (2018) guidance on PTSD highlighted the paucity of EMDR therapy research used as an early intervention. The primary rationale for this study was to address this critical issue. In summary, treatment results for group EMDR, delivered virtually, intensively, using therapist rotation are tentatively promising, however, the moral dimensions of trauma need consideration for future research, intervention development, and potential for further scalability. The data contributes to the emerging literature on early trauma interventions.

Clinical Trial Registration:Clinicaltrials.gov, ISRCTN16933691.

Future Research: Global Implications

Therapists trained to provide eye movement desensitization and reprocessing (EMDR) therapy have a global responsibility. This article summarizes the multiple impacts of high stress events, and their long-term effects on individuals, families, communities, and nations. While it is well documented that EMDR treatment will remediate the individual symptoms of posttraumatic stress, research is still needed to determine how far-reaching such outcomes are. Future studies should determine whether treatment reverses the neurobiological changes, cognitive deficits, and affective dysregulation, which are associated with exposure to traumatic events. Research should also investigate whether successful treatment decreases high-risk and/or perpetrator behavior, and whether these effects are translated into behavioral and attitudinal changes sufficient to bring an end to intergenerational trauma and ethnopolitical conflicts. It seems self-evident that the ideal way to address pressing societal needs, on both local and global levels, is by the integration of science and practice. The article also discusses the development of nonprofit EMDR humanitarian assistance programs, and their essential work in the alleviation of suffering around the world. In addition to recommending the examination of EMDR's efficacy in treating traumatization from direct, natural, structural, and cultural causes, this article advocates that research resources be dedicated for testing interventions in the areas of the world with the greatest needs. The alleviation of suffering is the duty of our profession.

Evaluating the EMDR Group Traumatic Episode Protocol With Refugees: A Field Study

In 2015, more than 1.5 million refugees arrived in Germany, many severely traumatized. Eye movement desensitization and reprocessing (EMDR) therapy has been proven to be an effective treatment for acute and chronic traumatic stress symptoms. A modification for provision in group settings was developed by E. Shapiro: the EMDR Group Traumatic Episode Protocol (G-TEP). In this field study, we investigated the effectiveness of 2 sessions of EMDR G-TEP in treating traumatized refugees. After receiving a psychoeducation session, 18 Arabic-speaking refugees from Syria and Iraq who had come to Germany during the previous 5 months were assigned to treatment and/or waitlist. The Impact of Event Scale-Revised (IES-R) and Beck Depression Inventory (BDI) were administered at pre- and posttreatment. Analysis was conducted using the Mann–Whitney U test and planned Kolmogorov–Smirnov tests. Results showed significant differences between the treatment and the waitlist groups, indicating a significant decline in IES-R scores (p < .05). Although differences in BDI scores did not reach significance (p = .06), a large decline in BDI scores was seen in the treatment group. These results provide preliminary evidence that it might be effective to treat groups of traumatized refugees with EMDR G-TEP.

EMDR, Community Psychology, and Innovative Applications of a Trauma Recovery Network as a Tool for Social Change

This article discusses the need for and ways to implement novel applications of early eye movement desensitization and reprocessing (EMDR) interventions (EEIs) at the community level for marginalized groups. Trauma Recovery Networks (locally based groups of licensed EMDR clinicians volunteering to provide pro bono disaster services, also known as TRNs) are an underused and insufficiently tapped tool when it comes to addressing the sequelae of disasters in our communities. We propose expanding our concept of and work with disasters beyond the traditional, legally recognized definition of Disaster (big D) to include ongoing stressful and traumatic community events or “little d” disasters. By serving those affected by little d disasters, the field of disaster response can be broadened in powerful ways. Marginalized communities typically suffer more and receive fewer services in the wake of traditional Disasters, threatening their civil rights and increasing the allostatic load on their collective health. Attending to the ongoing little d disasters, in these communities can be an important tool for social change, and various proposals for local TRNs are discussed.

EMDR Therapy Program for Advanced Psychosocial Interventions Provided by Paraprofessionals

The aim of this preliminary study was to evaluate the effectiveness of specially trained and supervised paraprofessionals in administering the eye movement desensitization and reprocessing Integrative Group Treatment Protocol (EMDR-IGTP) to reduce work-related posttraumatic stress disorder (PTSD) symptoms. The 2 paraprofessionals in this study were specially selected and trained in the application of the EMDR-IGTP and then provided treatment in an uncontrolled clinical trial to 37 clients from 3 non-governmental organizations in Bolivia. The participants were adult staff members (protective services workers, caregivers, psychologist, lawyers, and social workers) who provided care to children and adolescents with severe interpersonal trauma. Four EMDR-IGTP sessions within a parallel 2-week period were administered for each randomly assigned group. The Posttraumatic Stress Disorder Checklist for DSM-5 (PCL-5) was administered at pretreatment and 30 and 90 days’ posttreatment. A repeated measures analysis of variance (ANOVA) determined that PCL-5 score means differed statistically significantly between time points F(2, 72) = 574.53, p < .001, ηP2 = .94. The study presents preliminary evidence scaling up EMDR therapy in a low- and middle-income country, making it possible to reach larger numbers of people in a shorter time, thereby offering an operational advantage. The study has limitations specially related to the size of the sample, the use of only one measure, and the lack of comparison with a control group or treatment. Further studies are required to present large samples with more measures and comparison of results with another therapy or control group.

Perceptions and Use of EMDR Therapy in Rape Crisis Centers

Sexual violence is pervasive and generates significant trauma symptoms that can last a lifetime for survivors. Rape crisis centers provide critically important services for survivors of child sexual abuse and adult sexual assault, including individual and group counseling. Eye movement desensitization and reprocessing (EMDR) has been found to be an effective treatment for a wide array of trauma symptoms in both children and adults. This study sought to determine the extent to which rape crisis centers use EMDR therapy, practitioners’ perceptions of EMDR, and the provider characteristics that might support or hinder implementation of EMDR in this setting. A statewide web-based survey generated responses from 76 counselors working within 47 rape crisis centers. Results indicate that there is a low-use rate of EMDR (8%) in this setting, perceptions of EMDR were predominately marked by uncertainty, reflecting a lack of familiarity, but there is strong interest in receiving training. The desire for training is complicated by the range of education levels of counseling staff in rape crisis centers with only 54% holding advanced degrees. There is an opportunity and need to build capacity for the implementation of EMDR in this vital service sector, but there are also significant challenges that will need to be addressed.

Humanitarian Programs and Interventions in Turkey

In this article, the concept of humanitarian aid, the basic needs in crisis situations, the definition of eye movement desensitization and reprocessing (EMDR), and EMDR as a humanitarian intervention are explained. General needs and needs in Middle East are discussed. Some of the published studies about the EMDR therapy as a humanitarian intervention are summarized. Training and humanitarian programs in Turkey are documented. Two of our important humanitarian projects with EMDR including Marmara earthquake training and Intervention and Kilis Syrian refugees projects are described in detail. The aim of this article is to underline the importance of basic elements of natural and man-made disasters in terms of organization, financing, training, and intervention.

EMDR Therapy Humanitarian Assistance Programs: Treating the Psychological, Physical, and Societal Effects of Adverse Experiences Worldwide

The negative effects of trauma and other adverse life experiences have been shown to interfere with individual, family, and societal functioning. Eye movement desensitization and reprocessing (EMDR) therapy is empirically supported and recommended as a frontline treatment for psychological trauma in numerous practice guidelines. It provides both effective and efficient treatment without the need for detailed descriptions of the disturbing event or homework. This allows field teams to provide culturally sensitive therapy on consecutive days for those in remote areas and in crisis situations. Humanitarian assistance organizations have conducted projects internationally to provide EMDR therapy after both natural and manmade disasters and have helped develop sustainable mental health resources worldwide. This brief introduction provides an overview of current programs, treatment rationale, and a call for future action.

Commemorating EMDR’s 25th Anniversary byHighlighting EMDR Humanitarian Projects

This editorial introduces the special issue of the Journal of EMDR Practice and Research that commemorates the 25th anniversary of eye movement desensitization and reprocessing (EMDR) therapy by highlighting EMDR humanitarian programs around the world—in North America, Europe, Africa, the Middle East, Asia, Latin America, and the Caribbean. EMDR therapy is a valuable and appropriate intervention in humanitarian crises, given its effectiveness as a brief individual treatment, consecutive-day application, and group therapy. There are many compelling clinical vignettes in this issue, including some from a refugee camp in Syria, a hurricane in South America, and earthquakes in India and Italy. The authors in this issue bring years of experience to their articles, and their commentary on the challenges, future needs, and concerns is illuminating and thought-provoking.