EMDR early intervention is important to so many people in the world who are facing traumas such as fires, earthquakes, political and personal violence, and personal loss. Dr. Amanda Roberts article below from the EMDR Early Intervention (EEI) issue of the Go With That magazine (Vol 23, Issue 3 from September 2018) may be helpful to those treating people with these difficulties and to further efforts to prevent long-term trauma that occurs as a result of these disasters. This article provides a current summary of the interventions in the field.
In addition, the EMDR Research Foundation EEI Toolkit is an excellent resource for clinicians!
Click here to access EMDR Research Foundation EEI Toolkit
The first Global Summit in EMDR Early Intervention was held in Natick, Massachusetts, outside of Boston from April 19-24, 2018. It was jointly organized by Mark Nickerson, LICSW Past President of the board of EMDRIA and Rolf Carriere, a developmental economist at the Geneva-based organization known as the Global Initiative for Stress and Trauma Treatment, GIST-T.
Approximately 350 EMDR clinicians attended this conference event either in person or virtually. Several other prominent non-mental health professionals interested in the global implications of effectively delivered EMDR trauma treatment also attended. The conference goal was the facilitation and cross-fertilization of ideas and mutual collaboration prior, during and hopefully following the event itself. Additionally, there was focus on the opportunities and challenges for scaling up through the use of allied non-mental health professionals in the delivery of EMDR Early Interventions in low resourced countries, in the developing world, where mental health infrastructures are scare and EMDR capacity virtually non-existent.
WHY EMDR EARLY INTERVENTION IS SO IMPORTANT
EMDR Early Intervention can be viewed as having two arms: treatment and prevention. PTSD is part of a complex psychobiological process that leads to the emergence of the disorder in the weeks, months, or years after the event(s). Exposure to traumatic stress leads to a general disruption of an individual’s underlying homeostasis. The delayed effects of traumatic stress and their cumulative impact on psychological and physical health (including hypertension, obesity and cardio-vascular problems, fibromyalgia, irritable bowel, chronic fatigue, and various pain syndromes) has been well established by the groundbreaking Adverse Childhood Experiences study (Felitti, 1998).
Following a traumatic event, predicting who will develop symptoms is difficult and uncertain. PTSD is often preceded by sub-clinical symptoms that place individuals at risk for delayed onset PTSD in the months and even years following exposure. A phenomenon called kindling, where patterns of negative information are more easily activated, produces an accumulation of stressors causing sensitization. This can lead to progressively greater responses over time from repeated exposures. Even in the absence of clinically significant symptoms, the risk of onset of PTSD remains with time (McFarlane 2008, 2009, 2010, 2015). If accumulated traumatic exposures sensitize later disorders, and dysfunctionally stored memories underlie many disorders, as hypothesized by the adaptive information processing theory (F. Shapiro, 2001), then there is a promising and compelling reason to intervene early (E. Shapiro, 2018). It has been proposed that people exposed to significant adverse events should be offered “AIP checkups” as a strategy to prevent this kind of accumulation (E. Shapiro, 2018). This draws attention to a promising role for EMDR Early Intervention for both prevention and the promotion of resilience. It is as though we are applying a metaphoric “stitch in time” (E. Shapiro, 2018).
EMDR EARLY INTERVENTION
EMDR intervention was birthed shortly following the Loma Prieta earthquake in the San Francisco Bay Area in 1989. While working with these victims, Francine Shapiro discovered that earthquake survivors were not responding as expected to the standard basic EMDR protocol. People being treated were having difficulty accessing a representative image or memory of the event(s), their SUD ratings were not reducing and they were not obtaining the anticipated relief.
Observations by Francine Shapiro led to the hypothesis that, due to the fragmented nature of the traumatic material, narratives were not yet fully consolidated into long-term memory networks and were there-fore not amenable to the benefits of the usual EMDR basic processing. Realizing that a new approach was necessary, she devised the Recent Events Protocol, which conceptualizes the traumatic event as a fragmented experience, as yet not fully assimilated, so that no single image can rep-resent the entire event. It is therefore necessary to process a number of targets, which are aspects or parts of the event in order to facilitate full integration and consolidation (F. Shapiro, 1995, 2001)
At that time and up until quite recently, it was believed that recent traumatic memories remained unconsolidated for approximately three months after adverse experiences. However, although this is still now generally assumed to be the case by those in clinical practice, this is not grounded by empirical evidence and there is an emerging debate on this issue. A central tension and evolving debate within the field of EMDR Early Intervention is whether to relegate and confine its use to the first three months after critical events or to extend its use beyond that time frame. Conventional practice dictates the former while empirical evidence supports the latter. Perhaps it is neither one nor the other but both; that clinical decisions should be guided by patients’ and their contextual needs and not theoretical orthodoxy.
WHAT EVERY EMDR THERAPIST NEEDS TO KNOW ABOUT EMDR EARLY INTERVENTION AND BE ABLE TO EXECUTE PROFICIENTLY
In EMDR Early Intervention, protocols should be applied with solid case conceptualization, assessment of patient readiness, and fidelity to the method, while also employing some measure of flexibility and adaptability to the patients’ unique needs. Additionally, as in all things EMDR, clinicians should have access to expert consultation/supervision when necessary. This clinical knowledge must be buttressed by a solid knowledge of the evolving empirical research, a thorough discussion of which is beyond the scope of this article.
WHAT ARE THE DIFFERENT PROTOCOLS AND METHODS
The major early intervention protocols have been recently named by Ignacio (Nacho) Jarero “The Fantastic Four” so named after the Marvel Comic superhero quartet. The analogy is fitting as each protocol has its own unique personality and abilities, standing alone are vulnerable, but together are un-defeatable (Jarero 2018).
The protocols are: the EMDR R-TEP, the EMDR G-TEP, the EMDR-PRECI for individuals, and the EMDR-IGTP for groups. These early EMDR protocols are accumulating solid empirical evidence and are recognized members of the family of EMDR protocols (Roberts, 2018).
RECENT TRAUMATIC EPISODE PROTOCOL, R-TEP
After the development of the Recent Events Protocol, the specialty area of EMDR Early Intervention remained in relative obscurity. In 2008, Elan Shapiro and Brurit Laub devised the EMDR Recent Traumatic Episode Protocol (R-TEP). This protocol is used glob-ally in disaster areas for traumatic events with ongoing stressors where the difficulties are as yet unresolved. The protocol can be used extensively in outpatient mental health practices for a variety of mental health issues and even with dissociative patients who require restricted processing. The EMDR R-TEP utilizes a flexible and sophisticated approach to processing that can be uniquely tailored to the patient’s needs.
A major conceptual contribution from EMDR R-TEP is that of the trauma episode. This is defined as the onset traumatic event along with all of the ongoing consequences and their sequelae up until the present and possibly including future concerns. It recognizes that very often the fallout and aftermath from the original event(s) are an integral and essential part of processing trauma. Often traumatic stress is ongoing and so this protocol is especially suited to these clinical scenarios.
EMDR R-TEP uses two main strategies. The first of these is the EMDR approach which is generally the default strategy. In line with the current trauma episode treatment contract, the clinician only allows the patient to articulate associative material pertinent to the episode itself. This focuses processing and keeps the patient safe and contained while discouraging potential emotional overload. The second of these is the EMDR strategy, which is used to process cognitive, visual, auditory, sensory or olfactory intrusions that play such a central role in the production and maintenance of posttraumatic stress disorder. EMD will often permanently dissolve unbid-den and intractable frequently recurring disturbing images, sensations or thoughts within minutes. In this procedure the clinician only allows the associative material directly related to the intrusion itself.
THE EMDR PROTOCOL FOR RECENT CRITICAL INCIDENTS AND ONGOING TRAUMATIC STRESS (EMDR-PRECI)
This protocol was developed and has been used extensively in the field by Ignacio Jarero and Lucina Artigas during their work in Latin America, the Caribbean, Europe and South East Asia. A modification of Francine Shapiro (2001) Recent Event Protocol, it is specifically tailored to accommodate an extended time frame where there is no post-trauma safety period for traumatic memory consolidation with a continuum of ongoing traumatic external stressors. There is good evidence that it reduces symptoms even in the face of ongoing threat or danger. This is highly suggestive that the procedure is also promoting resilience, one of the gold standard features of EMDR Therapy as a modality in contrast to other therapies that focus on merely symptom reduction. To encompass the whole ongoing traumatic stress spectrum, in this protocol the patient is instructed to run a mental movie from just before the event until today, or even to look into the future in order to identify the worst part or fragment. This has similarities to the EMDR R-TEP but differs in that a request for the worst aspect is made. Clinical observations during EMDR-PRECI reveal that well attuned speed and length of eye movement sets, tailored to the patient’s unique necessities, facilitates the rapid resumption of maladaptively stored information. This protocol specifically suggests the use of the Butterfly Hug for patients with a narrow window of tolerance.
Lucina Artigas is recognized for the development of the ubiquitously used butterfly hug, a self-administered form of bilateral stimulation for trauma processing, achieved by crossing the arms over the chest and delivering alternate tapping with the hands the butterfly hug maintains a patient within their respective window of tolerance. It is hypothesized that self-administration of bilateral stimulation facilitates an inherent self-regulation, and clinical practice indicates that patients rarely, if ever, dissociate with this procedure. (Artigas & Jarero, 2009, 2014)
THE EMDR GROUP PROTOCOLS
The initial 11 years of EMDR therapy, “the first wave”, focused on individual EMDR interventions used in private practices and agencies. EMDR group therapies were then provided primarily in disaster settings with the use of the EMDR Integrative Group Treatment Protocol (IGTP). EMDR-IGTP is the first EMDR group protocol and was introduced in 1998 (Jarero, 2006).
EMDR Integrative Group Treatment Protocol, IGTP: This protocol has been used extensively in disaster zones following natural or man-made disasters. This protocol has been used with children during ongoing war trauma, war refugee children, adults during ongoing geopolitical crisis, children victims of severe inter-personal violence, cancer-related PTSD patients, and children, adolescents and adults with acute and ongoing traumatic stress (Jarero et al, 1998, 1999, 2010, 2016). It is an eight-phased protocol administered in an art therapy format with six sets of associative chains focused on the trauma(s), a future vision and body scan, using the butterfly hug for bilateral stimulation. It has various adaptations designed to suit different ages and cultural circumstances (Jarero & Artigas, 2014).
THE GROUP TRAUMATIC EPISODE PROTOCOL (G-TEP)
This protocol is an application of the EMDR R-TEP for groups. A central feature of the protocol is a highly structured six step worksheet with embedded resourcing, stabilization, containment and grounding. A visual spatial representation of the trauma episode is created, differentiating the past onset trauma event from the present and enveloping it with present, past and future resources. Expression can be made with drawings, written words or symbols. The EMDR G-TEP utilizes a modified EMD type strategy. EMD is the original procedure pioneered by Francine Shapiro which is primarily a desensitization procedure. The pro-cessing is considered to be restricted, with a narrow focus on the disturbing target (Shapiro, 1989). There were certain necessary tradeoffs that were made in phase III assessment and phase IV installation in order to accommodate a group format. The EMDR G-TEP retains the EMDR R-TEP’s metaphorical “google search” for the identification of points of disturbance.
Despite it being a relatively brief treatment, access to EMDR treatment may be limited when large numbers are in need, as existing mental health resources often have great difficulty in meeting requests for services. EMDR group therapies may be recognized as the “second wave” for EMDR therapy, in which the access to effective EMDR treatment can be scaled up. This was an important and enduring theme throughout the Global Summit. Providing group therapies in various clinical settings will make economically viable psychosocial interventions more widely accessible every-where. It has the added benefit of de-stigmatizing mental health services to people from cultural groups for whom there are negative perceptions of psychotherapeutic services. EMDR group protocols are also highly relevant in the treatment of families, couples and even some individuals. The EMDR-IGTP can be used with larger groups and with younger children. An additional distinctive advantage is that problem homogeneity between participants is not a requirement in either of the group protocols. (Roberts, 2018).
EMDR IGTP and EMDR GTEP carry the additional advantage of dis-allowing any verbal articulation of traumatic material, thus posing several potent clinical advantages: the ability to treat large numbers of patients simultaneously, preservation of privacy by the discouragement of trauma narrative disclosure, and protection from vicarious traumatization and unanticipated ancillary triggering. The group protocols also provide the advantage of economies of scale. These group protocols are suitable and adaptable to diverse clinical settings and populations, including but not limited to: children and adolescent populations, addictions, residential facilities, the military, first responders, chronic pain, hospital settings, university settings, corporations, the medically ill, correctional facilities, sports teams, school settings, Trauma Recovery Networks, natural and man-made disaster zones, inpatient psychiatric units, peace mediators, hostage survivors, homicide and suicide survivors, general outpatient mental health facilities, and private practice settings. EMDR IGTP and EMDR G-TEP with their art therapy formats can also be used effectively with asylum seekers, gender-based violence, (GBV) and torture survivors where disclosure poses the peril of vicarious traumatization to the therapist(s) and shame-based exposure for the patient(s). They can also be used with the developmentally disabled, aphasic, some traumatic brain injuries, under-educated/illiterate populations, alexithymia or with those who have language barriers such as immigrants and refugees.
In short, these protocols when used competently and diligently have enormous versatility and robust clinical impact.
THE EMERGENCY RESPONSE PROCEDURE (ERP) / IMMEDIATE STABILIZATION PROCEDURE (ISP)
Gary Quinn, MD from Israel developed ERP and ISP in 2004. Although not considered to be a full protocol, the procedure is widely recognized as a powerful and efficacious stabilization procedure. There is some preliminary clinical practice evidence that it also facilitates some initial adaptive information processing treatment effects. The procedure involves safety oriented bilateral stimulation administered by the clinician through hand tapping delivered along with positive cognitions or ego strengthening statements. It is currently being also used by paraprofessionals and first responders in the Middle East and is widely used in emergency/disaster settings and in outpatient psychotherapy practice sessions to reestablish self-regulation in dysregulated patients.
OUTSTANDING QUESTIONS FOR EI EMDR THERAPY
As noted above, traditionally early intervention EMDR therapy has been viewed as occurring within three months of the trauma. There is re-cent evidence to suggest the utility of these interventions, and how early intervention is conceived may be changing.
Ignacio Jarero and Lucina Artigas published a seminal article entitled the AIP model-based Acute Trauma and Ongoing Traumatic Stress Theoretical Conceptualization (Iberoamerican Journal of Psychotraumatology and Dissociation, Vol 10. Number 1, 2018). The article speaks persuasively to a working hypothesis which seeks to expand the clinical and research horizons of EMDR Early Interventions. It posits that the definition of EMDR Early Intervention should be expanded beyond the generally accepted three months. It argues that these protocols are ideally suited for acute trauma and clinical scenarios with on-going external traumatic stressors, where the memory networks are in a constant state of re-stimulation and chronic excitation. In many clinical situations there can be no post trauma safety period, because the trauma continuously expands with each subsequent stressful event. This reinforces the important utility of these protocols for use in multiple clinical scenarios beyond early intervention confined to the first three months.
Research evidence on the efficacy of the EMDR-RTEP, EMDR-PRECI, EMDR G-TEP and the IGTP is accumulating. A search of the Fran-cine Shapiro library, PubMed, Google scholar, ResearchGate or a simple web-based search will yield many references and articles on each of these protocols. EMDRIA will be de-veloping and providing further resource mate-rial and bibliographies on these interventions in the future. The Global Summit white paper provides a bibliography of references on EMDR Early Intervention research.
Artigas, L., & Jarero, I. (2007, March). The butterfly hug. Mexico City, Mexico: Asociacion. Mexicana para Ayuda Mental en Crisis.
Artigas, L., & Jarero, I. (2014). The butterfly hug. In M. Luber (Ed.), Eye movement desensitization and reprocessing (EMDR) scripted protocols: Special populations (pp. 5-7). New York, NY: Springer Publishing Company.
Blenkinsop, C., Carriere, R., Farrell, D., Luber, M., Maxfield, L., Nickerson, M., . . . & Thomas, R. (2018, April 9). Eye movement desensitization and reprocessing early intervention (EMDR EI). Global Summit White Paper. Retrieved from: http://emdrearlyintervention.com/emdr-ei-white-paper/
Felitti, V. J., Anda, R. F., Nordenberg, D., Williamson, D. F., Spitz, A. M., Edwards, V., . . . & Marks, J. S. (1998). Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: The adverse childhood experiences (ACE) study. American Journal of Preventative Medicine, 14(4), 245-248. Open access: https://doi.org/10.1016/S0749-3797(98)00017-8
Jarero, I., & Artigas, L. (2010). EMDR integrative group treatment protocol: Application with adults during ongoing geopolitical crisis. Journal of EMDR Practice and Research, 4(4), 148–155. Open access: https://doi.org/10.1891/1933-322.214.171.124
Jarero, I., & Artigas, L. (2018). AIP model-based acute trauma and ongoing traumatic stress theoretical conceptualization. Iberoamerican Journal of Psychotraumatology and Dissociation, 10(1). ISSN: 2007-8544. Retrieved from: https://www.revibapst.com/volumen-10-numero-1-2018-2019
Jarero, I., Artigas, L., & Hartung, J. (2006). EMDR integrative group treatment protocol: A post-disaster trauma intervention for children and adults. Traumatology, 12(2), 121-129. https://doi.org/10.1177/1534765606294561
Jarero, I., Artigas, L., Mauer, M., López Cano, T.,& Alcalá, N. (1999, November). Children’s posttraumatic stress after natural disasters: integrative treatment protocol. Poster presented at the annual meeting of the International Society for Traumatic Stress Studies: Miami, FL
Jarero, I., Artigas, L., Montero, M., & Lopez, L. (2008). The EMDR integrative group treatment protocol: Application with child victims of a mass disaster. Journal of EMDR Practice and Research, 2(2), 97-105. Open access: https://doi.org/10.1891/1933-3126.96.36.199
Jarero, I., Artigas, L., Uribe, S., & Garcia, L. E. (2016). The EMDR integrative group treatment protocol for patients with cancer. Journal of EMDR Practice and Research, 10(3), 199-207. Open access: http://dx.doi.org/10.1891/1933-3188.8.131.52
Roberts, A. K. (2018). The effects of the EMDR group traumatic episode protocol with cancer survivors. Journal of EMDR Practice and Research, 12(3), 105-117. http://dx.doi.org/10.1891/1933-3184.108.40.206
Shapiro, E. (2014). The recent episode protocol (R-TEP): An integrative protocol for early EMDR intervention (EEI). In M. Luber (Ed.), Implementing EMDR early mental health interventions for man-made and natural disasters: Models, scripted protocols and summary sheets (pp. 193-207). New York, NY: Springer Publishing.
Shapiro, E., Laub, B., & Rosenblat, O. (2018). EMDR early intervention following intense rocket attacks on a town: A randomized clinical trial. Clinical Neuropsychiatry, 15(3), 194-205. Open access: https://www.clinicalneuropsychiatry.org/clinical-neuropsychiatry-volume-15-issue-3-june-2018/
Shapiro, E., & Moench, J. (2015). EMDR G-TEP fidelity scale for the group traumatic episode protocol.
Shapiro, F. (1989). Eye movement desensitization: A new treatment for post-traumatic stress disorder. Journal of Behavior Therapy and Experimental Psychiatry, 20(3), 211-217. https://doi.org/10.1016/0005-7916(89)90025-6
Shapiro, F. (2018). Chapter 9: Standardized protocols and procedures for special situations. In Eye movement desensitization and reprocessing hterapy: Basic principles, protocols, and procedures (3rd ed, pp.220-227). New York: Guilford Press.
Thomas, R., (2014, 2018). EMDR Early Intervention and Crisis Response: Researcher’s Toolkit. Retrieved from https://emdrresearchfoundation.org/resources/toolkit/