E.M.D.R.

1. ADVANCES IN TRAUMA CARE: UNDERSTANDING EMDR AND ITS RELEVANCE FOR HUMANITARIAN SETTINGS AND FOR THE WHO GLOBAL MENTAL HEALTH-ACTION PLAN ISABEL FERNANDEZ PSYCHOTRAUMATOLOGY RESEARCH CENTER – MILAN (ITALY) EMDR EUROPE VICE PRESIDENT

2. E.M.D.R. Eye Movement Desensitization and Reprocessing is a form of psychotherapy designed to (1) reduce trauma-related stress, anxiety, and depression symptoms associated with posttraumatic stress disorder (PTSD); and (2) improve overall mental health functioning. EMDR has structured protocols designed to achieve the best possible treatment effects.

3. EMDR therapy is recognized as an evidence-based practice because it has been scientifically evaluated, demonstrated to be effective, and often cited as an effective treatment in national and international treatment guidelines for organizations such as: the U.S. Department of Veteran Affairs, the U.S. Department of Defense, the United Kingdom Department of Health, and the International Society of Traumatic Stress Studies. In 2010, EMDR was reviewed and included in the Substance Abuse and Mental Health Services Administration’s National Registry of Evidence-based Programs and Practices (USA).

4. Trauma and traumatic memories • “Trauma” is seen as any life experience that has a negative on going impact on the life of the person • In the long run what causes disturbance is not the traumatic experience but its memory (van der Kolk, 2000) • Unprocessed memories of disturbing life events are the foundation of pathologies

5. Trauma and mental health • In the Adverse Childhood Experiences (ACE) study by Kaiser Permanente and the Centers for Disease Control 17,337 adults: • 11% reported having been emotionally • abused as a child, • 30.1% reported physical abuse, • 19.9% sexual abuse; • 23.5% exposed to family alcohol abuse, • 18.8% to mental illness, • 12.5% witnessed their mothers being battered • 4.9% reported family drug abuse.

6. …The study unequivocally confirmed earlier investigations that found a highly significant relationship between adverse childhood experiences and depression, suicide attempts, alcoholism, drug abuse, sexual promiscuity, domestic violence, cigarette smoking, obesity, physical inactivity, and sexually transmitted diseases. In addition, the more adverse childhood experiences reported, the more likely a person was to develop heart disease, cancer, stroke, diabetes, skeletal fractures, and liver disease. Felitti VJ, Anda RF, Nordernberg D, et al. Relationship of childhood abuse to many of the leading causes of death in adults: the adverse childhood experiences (ACE) study. Am J Prev Med. 1998; 14(4): 245-258.

7. The long-term costs of traumatic stress: intertwined physical and psychological consequences A.C. MCFARLANE OFFICIAL JOURNAL OF THE WORLD PSYCHIATRIC ASSOCIATION (WPA) Volume 9, Number 1 February 2010

8. WHO Guidelines Review Committee has formally approved the use of EMDR therapy with adults and  children for  the treatment  of   PTSD. Trauma-focused CBT and EMDR therapy are recommended for children, adolescents and adults with PTSD.  Like CBT with a trauma focus, EMDR therapy aims to reduce subjective distress and strengthen adaptive cognitions related to the traumatic event. Unlike CBT with a trauma focus, EMDR does not involve (a) detailed descriptions of the event, (b) direct challenging of beliefs, (c) extended exposure, or (d) homework.  World Health Organization (in press). Guidelines for the management of conditions that are specifically related to stress. Geneva, WHO.

9. Brief eclectic psychotherapy v. EMDR therapy for PTSD: randomized controlled trial • Mirjam J. Nijdam, Berthold P. R. Gersons, Johannes B. Reitsma, Ad de Jongh and Miranda Olff BJP 2012, 200:224-231. • Results: Both treatments were equally effective in reducing PTSD symptom severity, … • EMDR led to a significantly sharper decline in PTSD symptoms than brief eclectic psychotherapy, with similar drop-out rates • Conclusions: Although both treatments are effective, EMDR results in a faster recovery compared with the more gradual improvement with brief eclectic psychotherapy.

10. EMDR’s efficacy beyond Post-traumatic stress disorder • Phobias(de Jongh, Ten Broeke & Renssen, 1999; de Jongh, et al., 2002), • Panic disorder (Goldstein et al., 2000; Fernandez & Faretta, 2007), • Generalized anxiety disorder (Gauvreau & Bouchard, 2008), • Conduct problems and self-esteem (Soberman, Greenwald & Rule, 2002), • Complicated mourning (Solomon & Rando, 2007), • Body dysmorphic disorder (Brown, McGoldrick & Buchanan, 1997), • Olfactory reference syndrome (McGoldrick, et al., 2008), • Sexual disfunction (Wernik, 1993), • Pedophilia(Ricci et al., 2006) • Performance anxiety (Barker & Barker, 2007), • Chronic pain (Grant & Threlfo, 2002), • Migraine headaches (Marcus, 2008), • Phantom limb pain (Schneider et al., 2008; de Roos, Veenstraet al., 2010).

11. EMDR: New fields and populations • “Hard Core” mental illness: Sz., Depression • Psychological First Aid (Acute interventions) • Autism • Retardation • Mutism • Medically Unexplained Physical Symptoms • Cancer • Psychosis

12. Working with EMDR in Mass disasters • Psychological interventions are performed in greatly unstable settings, while facing acute stress responses and emotional pain. • Also, these acute responses produce a longterm effect on physical and mental health (NIMH,NICE, EFPA).

13. Every country has to develop approved psychological interventions, which must be implemented on a wider scale (Council of Europe, Major Hazards in Europe Document, 2007) • Vienna Manifesto for Psycho-social Acute Care (2000) • World Health Organization (2011): Psychological First Aid

14. Psychosocialsupport and service for victims of disaster, Council of Europe • The Council of Europe hasestablishedthatcitizens must have free basicassistance in case of disaster, and itsimplementation must be incorporatedwithin the legislation and be part of the emergencyplanprogrammes

15. After 12 months, 10% wherediagnosed a PTSD%, yet 16% hadMajor Depression, 11% a General AnxietyDisorder, 9% Agoraphobia, 6% panicattacks, 6% specificphobias, 4% an Obsessive- Compulsive Disorder. (Bryant, 2011)

16. Others developsymptomsmuchlater. Thiscould be given by the process of sensitizationcaused by traumaticmemories, enablingthresholdsymptoms to occur more significantly over time(McFarlane, 2009).

17. Prevention, EMDR and the role of psychosocialsupport are the moststudied and publishedtopics in the literature of disasters.

18. Treatingchildrensurvivors ofnatural and manmadedisasters withEMDR in the acute phase (plane crash overtheirschool, earthquakes, schoolbus accidents, motor traficaccident, flood) 725 CHILDREN AND ADOLESCENTS

19. INTERVENTIONS WITH EMDR • Begins in acute phase (before 3 months) • Treatment provided to all victims (not only those with PSTD) – Individual and/or group EMDR sessions - Delayed group when possible • Consecutive days/No homework • Pre and post treatment measures (one week before and one week after treatment, so results could be more related to EMDR treatment) – Follow-up at 6 months and one year – Parents included in treatment when possible

20. DESCRIPTION • These projects have been carried out as a cooperation between Mental Health Public Services and the Italian EMDR Association. EMDR treatment was agreed upon and supported by the National health service, the authorities, the school personnel and by the parents of the children treated. • EMDR practitioners went to the disasters sites on a pro-bono basis • EMDR was part of an extensive and comprehensive program of psychosocial support with the local population. • EMDR sessions and treatment logistically based in school.

21. FIELD STUDIES ON CHILDREN VICTIMS OF MASS DISASTERS • an earthquake in 2002 (27 children died in a school building) • a plane crash in a school building in 2002 • a bus accident during a school trip in 2007 (2 children died, many seriously wounded) • a car accident downtown in 2007 (1 girl died and some seriously injured) • A flood in 2008 • Aquila’s earthquake 2009 • School bus accident 2010

23. PRE AND POST-EMDR TREATMENT

24. EMDR efficacy in the field of mass disastersas early interventionwith children EMDR is effective for acute PTSD and useful in achieving immediate relief and long-term recovery, in children who are primary victims of disasters. EMDR is effective for chronic PTSD EMDR is effective for subclinical PTSD

25. Grief and trauma not only in the individuals and their families but also in the group and community

26. Both children and parents and the community involved in disasters share all post-traumatic reactions, mourning processes, loss of homes, sense of guilt and conflicts that usually arises among survivors

27. FINAL REMARKS Children more thanadults can havechronic PTSD, long-lastingreactions, which do notresolve on spontaneousrecovery (theytend to raiseinstead). Thereisneedtoraiseawarenessof the possibile psychologicalconsequences, sincethesetraumaticexperiences can create vulnerability, notonlyPTSD. Child’ssymptoms in theseinterventionshavebeenacknowledged, validated, normalized and treated

28. EMDR facilitates narrative….Children often have fewer opportunities to discuss and process their trauma. Adults usually avoid talking about the trauma to “protect” them, so it becomes difficult for young children to verbally describe internal states and memories. Besides the trauma processing, EMDR treatment enables children to go through the mourning process in a natural way, to enhances the child’s resources, reduces stress reactions and normalizes behaviors.

29. Earthquake in Emilia May 20th – 29th 2012 • The earthquakeeffectshavehadnationalimplications. Itcaused long-lasting feelings of fear and impotence. People hadalsofeared for a long time, that the eventmighthappenagain, disrupting a sense of safety in the individual and in the entirecomunity. • Astherehadbeentwo major earthquakes, the traumaticeffectshad a stronger impact and affectedmanyareas of the comunity.

30. The goal of ourinterventionwas to re-establish a psychological balance, reduce traumatic stress responses and enablepeople to return to theirhomes, to theirjobs and to functionagain in society.

31. EMDR Association Intervention - From June 2nd to August 30th - 100 EMDR clinicians - Administered 61% of total interventions in Emilia Interventions were implemented in collaboration with and supported by the NHS of the city of Modena

32. 2089 peoplecontacted the psychologicalsupport centers in the affected area • 1136 peoplehavebeentreated with EMDR individually or in groups • Most of the interventionswerecompleted in the acute phase, othershavebeenreferred to the localservices

33. Pre and Post-treatment • Administration of IES (Impact of Event Scale)

34. EMDR benefits in the event of disaster • Brief intervention, immediate effects of treatment • Psychophysiologicaldearousalresponse, decrease in vividness of imagery • Can be administered on consecutive dayswithouthomework • Itprevents the accumulation of traumaticmemories • It can enhanceresiliency, whichis an importantfactorwhenfacingchronicsituations

35. Emdrenables: • The monitoring of symptoms and responses • To provide immediate emotionalsupport • The managing of emotions, evaluating and strengtheningresources • Itsadministrationat an individual and grouplevel • People are able to describe the event (cognitive structuring) and talk about their feelings and emotions (in a safe setting)

36. The sample: 40 people, 10 yearsafter the earthquake 22 women and 18 men Averageage = 36,20; DS =16,23; Range=15-72 Present PTSD Diagnosis (DSM-IV-TR criteria) -Present 19 -Absent 21 (12 underthreshold) Past PTSD Diagnosis (after the 2002 earthquake) -Present 29 -Absent 11 (11 underthreshold)

39. FINAL COMMENTS The intervention and the EMDR processing of traumaticmemoriesrelated to theseexperiences,notonlyminimizesriskfactors, butalsoservesas a protectivefactor for possiblefurtheroccuring life events

40. FUTURE DEVELOPMENTS A systematic and structured help treatment is available and should be provided to the population exposed to mass disaster EMDR treatment (typically 4/6 sessions) is easily administered, it focuses on the memory of the traumatic event and results are visible after one week.

41. Intervening on the psychologicalaspects in the aftermath of a natural or manmadedisasteris an issue for public and mass health. EMDR IS PROVING TO BE AN EFFECTIVE CONTRIBUTION IN THIS FIELD