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
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.
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).
“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

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.
…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.
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
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.
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.
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, Veenstra et al.,
2010).









“Hard Core” mental illness: Sz., Depression
Psychological First Aid (Acute interventions)
Autism
Retardation
Mutism
Medically Unexplained Physical Symptoms
Cancer
Psychosis
•
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).
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
The Council of Europe has established that citizens
must have free basic assistance in case of disaster,
and its implementation must be incorporated within
the legislation and be part of the emergency plan
programmes

After 12 months, 10% where diagnosed a PTSD%, yet
16% had Major Depression, 11% a General Anxiety
Disorder, 9% Agoraphobia, 6% panic attacks, 6%
specific phobias, 4% an Obsessive- Compulsive
Disorder.

(Bryant, 2011)
Others develop symptoms much later. This could be
given by the process of sensitization caused by
traumatic memories, enabling threshold symptoms to
occur more significantly over time (McFarlane, 2009).

Prevention, EMDR and the role of psychosocial
support are the most studied and published topics in
the literature of disasters.

Treating children survivors
of natural and manmade disasters
with EMDR in the acute phase
(plane crash over their school, earthquakes, school
bus accidents, motor trafic accident, flood)
725 CHILDREN AND ADOLESCENTS
 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
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 probono 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.

 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
TREND OF CLINICAL AND SUBCLINICAL POST TRAUMATIC REACTIONS
100
88%
80
60
77%
61%
63% 69%
78%
67%
64%
63%
>50%
49%
40
>17%
20
0
DSM
EARTHQUAKE
SCHOOL BUS
ACCIDENT
ROAD TRAFFIC
ACCIDENT
FLOOD
EARTHQUAKE
(6M)
EARTHQUAKE
(1Y)
ACUTE POST TRAUMATIC REACTIONS
CHRONIC POST TRAUMATIC REACTIONS
SCHOOL BUS
ACCIDENT
80
70
60
50
40
30
20
10
0
63%
64%
63%
9%
EARTHQUAKE
77%
69%
SCHOOL BUS
ACCIDENT
12,5%
4%
5%
ROAD TRAFFIC
ACCIDENT
PRE-EMDR
5%
FLOOD
POST-EMDR
EARTHQUAKE
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
Grief and trauma not only
in the individuals and
their families
but also in the
group and community
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
Children more than adults can have chronic PTSD, longlasting reactions, which do not resolve on spontaneous
recovery (they tend to raise instead). There is need to
raise awareness of the possibile psychological
consequences, since these traumatic experiences can
create vulnerability, not only PTSD.
Child’s symptoms in these interventions have been
acknowledged, validated, normalized and treated
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.
The earthquake effects have had national
implications. It caused long-lasting feelings of fear and
impotence. People had also feared for a long time,
that the event might happen again, disrupting a sense
of safety in the individual and in the entire comunity.

As there had been two major earthquakes, the
traumatic effects had a stronger impact and affected
many areas of the comunity.

The goal of our intervention was to reestablish a psychological balance, reduce
traumatic stress responses and enable
people to return to their homes, to their
jobs and to function again in society.
- 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
2089 people contacted the psychological support
centers in the affected area
 1136 people have been treated with EMDR
individually or in groups
 Most of the interventions were completed in the
acute phase, others have been referred to the local
services

Administration of IES (Impact of Event Scale)
Pre-treatment Post-treatment
intrusivity
18,67%
9,78%
avoidance
13,22%
9,41%
hyperarousal
14,9%
7,02%
Brief intervention, immediate effects of treatment
Psychophysiological dearousal response, decrease
in vividness of imagery
 Can be administered on consecutive days without
homework
 It prevents the accumulation of traumatic memories
 It can enhance resiliency, which is an important
factor when facing chronic situations


Emdr enables:
 The monitoring of symptoms and
responses
 To provide immediate emotional
support
 The managing of emotions, evaluating
and strengthening resources
 Its administration at an individual and
group level
 People are able to describe the event
(cognitive structuring) and talk about
their feelings and emotions (in a safe
setting)
The sample: 40 people, 10 years after the earthquake
22 women and 18 men
Average age = 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)
Diagnosi Asse I DSM-IV-TR
Present
Past
(Current Comorbidity)
(Past Comorbidity)
14
13
MAJOR DEPRESSION
8
10
BIPOLAR DISORDER
1
1
PANIC ATTACK DISORDER
5
5
SPECIFIC PHOBIA
2
1
SOCIAL PHOBIA
1
0
27
28
PRESENT DISORDERS - TOTAL
NO DISORDERS
40 SUBJECTS
Comparison pre-EMDR - post-EMDR
SGP – pre (n = 20)
SGP – post (n = 20)
CAPS – Re-experiencing/intrusion***
13.25 (9.34)
3.55 (4.16)
CAPS – Avoidance/numbing***
17.90 (8.49)
8.10 (1.49)
CAPS –Hyperarousal***
14.35 (5.63)
7.40 (4.80)
IES – Total***
30.70 (18.39)
18.45 (16.08)
IES – Intrusive***
16.45 (10.70)
8.55 (7.58)
IES – Avoidance*
14.25 (10.69)
9.90 (9.41)
BDI – Total**
13.45 (7.66)
7.40 (6.41)
SCL-90-R – Positive Symptom Distress Index*
1.63 (0.42)
1.26 (0.57)
All Data are mean (SD); pairwise comparison p-values: * p < 0.05, ** p<0.01, ***p < 0.001.
FINAL COMMENTS
The intervention and the EMDR
processing of traumatic memories related
to these experiences, not only minimizes
risk factors, but also serves as a
protective factor for possible further
occuring life events
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.
Intervening on the psychological
aspects in the aftermath of a natural
or manmade disaster is an issue for
public and mass health.
EMDR IS PROVING TO BE AN EFFECTIVE
CONTRIBUTION IN THIS FIELD