ARTICOLO 25°
Introduction: The evolution of EMDR applied to humanitarian programmes: state of the art
and future challenges
Early interventions with EMDR in the middle of crisis created by different kind of mass disasters
have proved to be easy to be implemented. It is important to be well coordinated and integrated with
institutions and local services, this is the best way to proceed since EMDR interventions become
part of the sanitary assistance to populations that have been hit by a disaster. A team of EMDR
clinicians can work in the disaster sites in consecutive days, in different settings and conditions.
Nonetheless, the processing of the traumatic experience can occur without obstacles, even under
unstable conditions, which are very common in these circumstances. Using recent events protocols
like R-TEP for processing the experience, has been essential for these kind of interventions. After
processing the recent traumatic experience, present triggers and future templates are the other steps
that can be successfully done even if the disaster aftermath is not completely over. EMDR
interventions are high standards psychological and psychosocial aid in all phases in the aftermath,
in the first phase, after some weeks and months and even after some years, if the population had not
been reached before. A crisis intervention with EMDR in schools can be structured and organized
with all agencies (school personnel, parents, Education Deparment, etc.). The collaboration of
different organizations and parties establishing clear roles, starting with adults (processing of their
own experience, psychoeducation, information on how to handle children and adolescents in the
aftermath of a disaster, explaining EMDR intervention and getting the informed consent) is
important in order to treat the whole community. In some European countries the request for EMDR
intervention after a community, a school or a mass disaster is starting to be very significant. This
goes with the WHO guidelines (2013), with the spread of the knowledge of EMDR therapy. A
reason for this growing request is the fact that EMDR is starting to be well known among
psychologists and clinicians in general and when a disaster hits a group, a community, a school,
these professionals get in touch with EMDR Associations, EMDR teams or EMDR clinicians,
asking them to intervene. This phenomenon proves that EMDR efficacy is spreading and specially
when an overwhelming event occurs, different agencies and institutions seek directly an EMDR
intervention for psychological support. This request occurs sometimes right after the event, in the
same day or the day after. This allows to implement and organize EMDR intervention in order to
start in the very early part of the stress reactions. It is useful also to start planning for the middle and
long term intervention from the very beginning. EMDR work is also easy to be implemented with
the whole community and with the different populations exposed to the event (parents and relatives,
neighbours, school personnel, authorities, majors, etc.) and the community in general. To make this
possible is essential to be coordinated with the National health service, with the town hall, hospitals
and schools, in order to organize meetings, to inform, to outreach the population and tell them that
anyone who needs psychological help can get it. In the other hand institutions can outreach most of
the population involved and organize groups and meetings prior to EMDR interventions. A constant
exchange of information and planning by all parties is needed while working in the field, in order
to adapt EMDR work to the different needs that can arise in such unstable settings. After WHO
guidelines and considering all the experiences that the EMDR community in the different continents
and regions have been developing, in the next future can be very likely that EMDR interventions in
the different phases of a disaster will become an usual way of dealing with the different populations
that have undergone a devastating experience like a disaster.
EMDR in emergency contexts
EMDR and natural disasters: the process of recovery
Major catastrophes and the media coverage of these have surely contributed in expanding the field,
compelling
experts
from
different
professional
areas
(medical
doctors,
psychologists,
psychotherapists, neurophysiologists, first aid personnel, etc.) to set up new research instruments
and intervention, in order to reduce the individual and community emotional impact caused by these
emergencies.
When a disaster threatens lives, many survivors will develop acute stress responses, as well as
depressive symptoms linked to loss. These persons will search for help within the community,
families and other support systems. We must fully acknowledge survivors’ right to expect the best
immediate help to reduce their pain.
One must also recognize the great advantage of an early intervention, in preventing the onset of
future debilitating psychopathologies, such as the Posttraumatic Stress Disorder. The principal
focus of emergency interventions after a traumatizing event for individuals, families and groups,
are: a) supplying consolation and concern, in order to reduce hyper vigilance states (create a
friendly environment) and b) provide secure information to all those involved. This will help people
to start taking the first steps toward alleviating symptoms and taking control of their lives as soon as
possible. The emotional responses that cause PTSD are crosswise similar within the different
scenarios as seen in the European Union. Empirical evidence strongly demonstrates that these
responses as universal, as they have been seen in every country and culture. There is a growing
consensus, that the best ways to help survivors, is to transmit this psychological first aid expertise to
whoever wants to offer his/her help to survivors. Naturally, culture plays a main role in determining
the way these responses are manifested.
Most people develop a PTDS within the first month after having been exposed to a traumatic event.
About 15% can develop a later onset. Usually the seriousness of the initial symptoms indicates if
the survivor will develop a PTSD. Fortunately, the acute distress diminishes rapidly among most of
the afflicted people.
Breslau et al. (1991) estimated that 13% of men and 30% of women develop PTSD after a traumatic
event. Reliable sources have estimated, that 20 to 30 % of children, who survive a car accident,
develop a PTSD, and the remaining percentage will manifest isolate, less severe stress related
symptoms. In a study by Morgan et al. (2003), 33 years after a disaster in which many children
were killed, 20% of survivors still suffered from a PTSD.
Children are more vulnerable toward traumatic situations, compared to adults. If that is the case for
individual trauma, it is also true for collective trauma, where level of complexity and criticality
increase exponentially. One of the major challenges during the last decades has been to help these
little victims to overcome the emotional impact following catastrophes.
In Fletcher’s meta review (1996), which included 2500 children who had been exposed to traumatic
events, the following was found: the mean percentage of children with a PTSD was 36%, with a
major incidence in smaller children. In a study of 371 Thai children (Thienkrua et al., 2006) after
the Tsunami, 13% were estimated to have developed a PTSD and 11% suffered from depression.
These figures proved that although 9 months had passed from the catastrophic event, they had not
remitted spontaneously, as predicted by the DSM-IV- TR.
This study also shows, that no changes in the level of the disorder occur among these children,
between the 16th and 40th month after the event. In other words, we claim, that in many –far too
many - cases, childhood trauma sequelae do not remit spontaneously. Time not always heals the
deep wounds of these little victims. International guidelines underline the importance of early and
specialized intervention within emergency contexts and in subsequent stages to ensure the best help
to reduce distress and prevent future psychological and/or psychosomatic disorders in little victims.
The National Institute of Mental Health of the United States Government states that parents’
responses toward a violent event or disaster influence directly the recovery capacities from trauma
of their children. Collective disasters characterized by the quality of unexpectedness,
unpredictability and in some ways absurdity, represent an enormous challenge for parents and risk
to jeopardize the family’s unity. It is impossible to be prepared mentally and materially afore in
managing a trauma: parents feel they are without any control, being victims themselves of the same
situation. Children are able to perceive their parents’ sense of inadequacy and inability, even if just
temporary, of protecting them and this can cause a radical change within the relations of the family.
Trauma influences the communication within the family, since its members mutually send each
other signals of emotional sufferance and powerlessness. Parents can feel powerless when their
child shows symptoms and sufferance because of the trauma. Their main task is to protect their
child from danger, and from any threat or stress. Having a child who is a victim of a trauma is
therefore painful for the adults and makes it harder to deal with one’s own emotions.
The Eye Movement Desensitization and Reprocessing (EMDR) is the choice therapy in curing
consequences due to trauma. In the past 10 years, many are the reasons that have urged the Italian
EMDR Association to intervene in the aftermath of various emergencies that have hit the country.
As all members are psychologists and psychotherapists, the main conviction was due to the
awareness of the importance of fostering mental health and that emergency victims must have the
right to benefit from the best specialized help available to alleviate their distress. The international
scientific community, as we have seen, confirms that EMDR is the best choice in therapy, in case of
trauma. The main targets of the interventions described in this chapter are children. Children are the
main category at risk in the event of major emergencies, as well as people with disabilities and
elderly. But not only that. The main motivation which propelled us to use EMDR with children in
the aftermath of a disaster, is EMDR’s rapid efficacy in treating children with PTSD symptom.
When possible, the intervention focus was extended to their parents and other significant attachment
figures, such as teachers, educators, school personnel. In many cases, collaborating with official
agencies (local, school and health administrators, police forces, etc.) proved to be helpful in order to
avoid the spreading of panic among the population. EMDR interventions were also applied to
representatives of institution agencies to reduce their emotional responses, helping them to become
more efficient in supporting themselves and their community.
Molise earthquake
This earthquake which occurred in Italy on October 31st, 2002, hit various regions and mostly the
Molise. It was a devastating event and will always be sadly remembered for the collapse of an
elementary school in which children were found dead under the debris. The Italian EMDR
Association intervened with a team of volunteers who arrived at San Giuliano in Molise on 3
occasions, as well as monitored the children who had survived under the ruins one year after.
All EMDR treatment cycles had been agreed and coordinated by the National Health System (ASL
4 Basso Molise) as part of the P.O.S.P.E. emergency project (Piano Operativo di Supporto
Psicologico in Emergenza), addressing the earthquake - affected population. The EMDR Italian
Association worked closely with the local health administration. This precious collaboration yielded
and optimized the association’s intervention efficacy, ensuring more general psychological support
to the children, not just when dealing directly with the aftermath’s consequences.
The tragedy of such an event caused children to be exposed to an extreme situation which, not only
had threatened their lives (children who had survived were convinced that they were not going to be
saved from under the ruins), but had killed some of their schoolmates. Indeed, the subsequent
posttraumatic consequences were not “just” associated to the stress of having experienced a real
threat to one’s life, but also the grief of losing one’s friends, cousins and/or siblings, as well as a
prolonged exposure to corpses under the debris (form 1 to 10 hours). The sad report consisted of 32
children who had survived and 27 dead (all of age 6). In addition to these highly traumatizing
factors, many of these little survivors had lost their homes, their everyday life and their friends. The
combination of these factors had increased the chances to develop a Posttraumatic Stress Disorder
(PTSD). As recommended by the National Institute for Clinical Excellence Guidelines (2005), all
those individuals who are at high risk of developing a PTDS following a collective disaster, should
be screened within one month after the catastrophic event, which in this occasion had confirmed to
be the best evidence-based practice model, in combination with the EMDR treatment.
As already mentioned, the intervention set up by Italian EMDR Association was part of a complex
and multifaceted program, agreed upon and supported by the P.O.S.P.E., by the authorities, by the
school staff and parents of treated children. The teaching staff and other members of the school staff
proved to be cooperative and supportive in every phase of our intervention. The entire staff had
received the opportunity for psychological support: individual consultation, group debriefing,
psycho-educational meetings on stress responses in children, how to handle the class and some
critical aspects that had emerged during everyday life in the aftermath, as well as EMDR sessions
targeting more personal experiences. The program also provided parents with training programs for
understanding their own and their child’s posttraumatic stress responses. They were trained on how
to support their children at their best in such a delicate moment of their lives. During these
encounters, we collected the first useful information before starting to work with the children.
Parents were given a questionnaire to assess child symptoms. They were informed about the type of
intervention the child would received, as well as information concerning EMDR and collected the
signed informed consent and authorization to proceed.
The psychotherapeutic sessions were offered in 3 different moments: at one and three months and a
year after the earthquake. The average for each child of EMDR sessions was 6,5. The EMDR
intervention focused on the most disturbing moments of the earthquake, on the current responses
which kept causing distress and fear for the future. All phases belonging to the EMDR therapeutic
treatment had been carried out: history taking, preparation and the “Safe Place”, description of the
treatment, target identification (that is, most disturbing memories of the earthquake), desensitization
of the perceived level of distress, reassessment, current anxiety stimuli or avoidance behavior, and
future scenarios eliciting anticipatory anxiety.
EMDR treatment cycles were carried out on the basis of the standard protocol as presented by
Shapiro (1989) and Greenwald (1996). Every child took part at one EMDR session for a time
ranging from 20 to 90 minutes. One week before and after EMDR intervention, children were given
a questionnaire to monitor the trend of their psychological distress and the results achieved after the
sessions.
Between the second (January 2003) and third (Febraury 2003) EMDR treatment cycle, children’s
PTSD symptoms dropped from 63.6% to 45,5%. This was a first relief, since it proved that the
children were beginning to feel better. A further improvement in their symptoms was registered
during February 2003 (45.5%) and November 2003 (28,6%), despite no further treatment had been
submitted in-between the two periods. These results are consistent with the EMDR guidelines,
which suggest that the effects of eliciting the reprocessing of trauma, continue after the sessions.
One year after the event (December 2003), a last assessment showed another significant symptom
reduction (9,1%) after a last cycle of EMDR sessions.
In 2012, ten years after the eathquake, a group of adults that had not had any psychological support
at the time of the disaster was contacted and treated by a team of clinicians of the Italian EMDR
Association together with a group of researchers from Tor Vergata University and from the
National Research Center. Neurobiological changes occurring during EMDR sessions in 20 subjects
was investigated. The aim was to assess in real-time upon exposure to traumatic memory the
cortical activation differences between this group of psychologically traumatized clients was
compared to healthy controls. Electroencephalography (EEG) was used to monitor neuronal
activation throughout the bilateral stimulation phase of Eye Movement Desensitization and
Reprocessing (EMDR) sessions. The EEG signals of twenty subjects still suffering psychological
trauma ten years after the earthquake, as well as those of 20 controls were compared between the
first EMDR session (T0) and the last one performed after processing the index trauma (T1). EEG
showed asignificantly higher activity in orbito-frontal and anterior frontal cortex at T0 shifting at T1
towards posterior associative regions (fusiform and lingual cortex). This finding was indirectly
confirmed by the comparisons with controls. EEG monitoring enabled for the first time to disclose
during the reliving of the traumatic event the neurobiological activities of people with chronic
symptomatology after a mass disaster. EMDR treatment proved to be effective with this population,
subjects were not meeting a full blown or subclinical PTSD diagnosis after an average of 6
sessions. Independent assessors and the researchers from the different teams were the ones doing
the T0 and the T1 assessments.
Capoterra (Sardinia) flood
Early in the morning on October 22, 2008 a heavy rainstorm hit Sardinia on the mounts of
Capoterra, causing the flooding of 5 milion cubic meters of water and heavy mass of debris: mud,
rubble and tree trunks, destroyed streets and bridges that connected the area to nearby locations.
The effects of this storm were comparable to the devastations inflicted by the Caribbean hurricanes.
The entire population (adults, children and elderly) were affected by this event. Some people lost
their lives while swept away by the floods, many homes were flooded and some public facilities
were damaged as well. Above all, some schools were invaded by the water and debris, others
miraculously escaped the tragedy.
The program destined to the schools of Capoterra was carried out to completion, as well as
providing the population with psychological assistance through EMDR psychotherapy, on behalf of
the National Health System (ASL 8 Cagliari).
Figures before intervention showed that among 251 children, 51% had an acute PTSD one month
after the flooding. Subjects with PTSD had one EMDR treatment cycle. Reassessment one week
later showed that 94% had remitted. The percentage which had not responded to EDMR treatment
ranged around 6%. It would be important to explore those contributing factors, probably awarded
by the gravity of their loss, parents’ emotional responses, difficulties and emotional trauma prior to
the flooding.
After phase I of the intervention program (30-40 days after the impact), we moved on to extending
assistance (from 30-45 days to 3 months after impact). Subsequently, we proceeded to a medium
and long term intervention, and follow-up. By examining assessments of those children who had
not received any intervention 5 months after the flooding, we noted that posttraumatic responses
persisted. This proves once again, that a high percentage of PTSD cases within developmental
subjects do not recover spontaneously with time, as opposed to adults. Symptomatic children and
adolescents treated with EDMR respond well and present resolution from the posttraumatic
symptoms after treatment.
L’Aquila eathquake
All Italians followed the many phases of the earthquake which hit the region of Abruzzo in April,
2009. However, no media coverage reported the stress responses in children during the following
months. Psychologists who had treated children in some schools had registered devastating
responses. 77% of these children had significant clinical responses 6 months after the disaster. 59%
presented a frank PTSD and 18% symptoms below threshold. At the end of an EMDR treatment
applied on a group of children, only 5% still suffered from typical posttraumatic symptoms. This
result was very encouraging, since it meant that 72% of the children had been relieved from the
emotional and psychological consequences of this catastrophe. After one year, a team of
psychologists wen to the same elementary school and were able to physically and clinically verify
how these children were doing after one year of no further specialized treatment. They observed and
assessed 113 children of an elementary school in the suburbs of Aquila, finding that 66,9 % still
presented relevant posttraumatic symptoms: 20% presented a frank PTSD and 46,9% symptoms
below threshold.
Once again, the results clearly proved, that in far too many cases, children do not recover
spontaneously from the wounds of such disasters. It is therefore necessary to offer a specialized
intervention program, that does not underestimate their responses and does not take for granted that
time will cure all. The best possible way to help these little victims is to intervene in the immediate
aftermath with a proven efficacy treatment method, such as EMDR.
Emilia earthquake
On the 20th and 29th of May 2012, the region of Emilia (Northern Italy) was hit by two major
earthquakes of a magnitude 5.9 on the Richter scale. This natural disaster affected 36% of the
region, an area with approximately 227.000 inhabitants. Immediately after the first event, the
Clinical Psychology Department at the National Health Service (Ausl Modena) set up a
psychological intervention service aimed at bringing relief to the population, the workers and the
emergency service personnel. Experts in psychological first aid working in the AUSL Modena were
selected to lead the services situated in the most severely affected areas: Mirandola and Finale
Emilia. They formed, along with their colleagues, the psychological first aid team. People who
called to ask for psychological support were received in the different settings, that were located in
schools temporarily used as clinics because the main hospitals were severely damaged. Relevant
data were kept as carefully as possible, considering the lack of consent documents, medical records,
tests, lockers and other important tools. The intervention was done in the first 3 months, that is in
the acute phase of post-traumatic stress reactions (APA, 2000), starting from June 1st until August
29th. People who complained of continual fear of further shocks, anxiety, agitation and intrusive
thoughts and flashbacks of the earthquake were referred to EMDR therapists.
Among them 923 adults underwent EMDR treatment, utilizing the Recent Traumatic Episode
Protocol (R-TEP) for early intervention (Shapiro & Laub, 2008; Shapiro 2012). We excluded from
this study 250 patients who did not fill in the second assessment form during the last treatment
session, and were untraceable as a result of leaving temporarily the seismic area for the summer
period. The final sample (with pre and post measures) consisted of 673 persons. The Italian EMDR
Association gathered 108 therapists, from all over Italy, who worked pro bono in day shifts. To
respond to the numerous requests for treatment, the participants decided to provide all patients with
1 to a maximum of 4 sessions utilizing the Recent Traumatic Episode Protocol (R-TEP, Shapiro,
Laub, 2008) for Early EMDR intervention. Often people were treated by different therapists. In the
event that a EMDR therapist needed to share important clinical information about a patient, he
talked with a psychologist of the emergency team who passed the information to the subsequent
EMDR-therapist or wrote it on the patients' charts.
Besides patients referred to EMDR by professionals and institutions, many people who had come
by word of mouth came to the psychological intervention team asking to be treated for their
symptoms. As a result of this widespread information, all the subjects were highly motivated to
undergo this psychological intervention. EMDR therapists decided to treat each person considering
their subjective feeling of disturbance and in need of help. Given the particular crisis context it was
not appropriate to randomly assign the population to different groups.
Along with reducing PTSD symptoms in clinical and subclinical population, it proofs useful also
with people that describe only psychological distress and cannot be classified either as PTSD or
subthreshold PTSD. In our sample, in fact, only 10.6% of the treated population worsened their
symptoms, indicating that EMDR treatment is of great benefit for suffering people.
Analyzing the questions addressed by Shapiro (2012), particularly whether to intervene in natural
disaster, our findings show that EMDR has proven to be a useful intervention in the acute phase of
trauma.
Through its wide net of professionals, the National Health Service had to reach the highest number
of people in need of treatment. We considered it a clinical and ethical intervention to treat
everybody showing positive self-report scales or only subjective perceptions of distress. This
organization has allowed a lot of people to seek for help, even people who experienced guilt and
shame, limiting the risk of developing greater symptoms in the future. EMDR is effective even
when offered in the immediate aftermath of the disaster. EMDR limits the use of avoidance as a
main coping strategy and stimulate more adaptive answers; it may be applicable in precarious
context because it does not need rigid setting, it does not require homeworks and may be done by
different therapists with the same client in consecutive days.
A major earthquake not only involves single individuals, but also the whole community. The
presence of numerous psychologists who set up a Psychological Support Programme in the Mental
Health service may be considered as a first intervention to normalize fears, psychological distress,
and to treat clinical symptoms in the population hit by the earthquake. In this way, the presence of
dedicated professionals has contributed to repair social nets and the restoration of a sense of being
part of the community. In turn, the community has supported psychologists in providing to
everybody in need their expertise thanks to the active and effective collaborations with private
citizens, workers and first responders.
Man made disasters (incidental and not), young and adult victims
Domestic violence and infanticides in Italy
Italian tabloid columns frequently report crimes committed within the domestic environment or
against children, a phenomenon which appears to be evolving into a social alarm. For instance, in
the last weeks, in Lombardy, Italy, we have witnessed crime emergencies that have shocked entire
communities. In Cesano Maderno (in the Province of Monza and Brianza), a double infanticide was
committed (children aged 2 and 9) by their father, and in the same area, a 14 year old boy
committed suicide. In Lecco, a mother killed all three of her children and in San Giuliano Milanese,
a teacher was accused of abusing his little pupils.
All of these events have bereaved not just the people directly involved, but entire communities. In
order to face these tragedies, the affected local town administrations took action and requested help
by experts. Psychologists of the Italian EMDR Association, specialized in emergency interventions,
were summoned to support psychologically teachers, students, parents, first responders and the
community.
The association took immediate action and offered interventions for all of these traumatic events
which had caused a major psychosocial impact, not just on the families. EMDR group sessions were
offered to all the victims, who had been differently exposed to the traumatic event. In particular,
psychologists intervened in 11 classes of 3 different schools offering EMDR group sessions in the
classrooms. Psychoeducational briefings were provided to parents and students, in order to explain
which responses to stress are to be considered normal, when facing critical events. All of these
interventions were conducted on site by highly professional and dedicated volunteers and licensed
by the EMDR Italia Association.
Airplane crash of the Pirelli Building
One late afternoon on April 18th, 2002, the city of Milan was hit by a shocking event: a small
airplane crashed into the Palazzo Pirelli, headquarter of Lombardy’s regional administration offices.
Headmistress, teachers, parents and children at a nearby school recognized they needed professional
psychological help. The school headmistress forwarded the request to the National Health Services
(ASL), whose headquarters organized an intervention in collaboration with the Italian EMDR
Association. 236 children, all students of this elementary school, aged between 6 and 11,
participated at the intervention project. They received a varied version of the EMDR protocol group
treatment, with the aim of reducing the trauma impact within a children’s group context.
Sleep disorders such as nightmares and difficulties in falling asleep, intrusive images, irritability,
loss of concentration, easy crying, restlessness, avoidance behaviors and frightening fantasies were
the first symptoms manifested by the children, as reported by the teachers and school staff. Phase 1
consisted of two debriefing encounters (Mitchell et al., 1983) with the teachers. On this occasion,
after having pursued the main goal of stabilizing, ensuring containment and reassuring teachers, we
obtained indications concerning responses and fears of the children. Psychoeducational material
was distributed containing all information and guidelines useful in post emergency situations for
teachers and parents: what to do, what to observe in children, rules to follow when returning back to
school, etc.
After one month of that “Incredible Accident”, as the kids named it, the emotional impact had come
a long way and symptoms of increased anger and irritability, startle responses (e.g. if a dictionary
would fall on the floor, everyone would jumped up), as well avoidance behaviors, such as refusing
to go back to school, were found. Many began to think, that they would never get on an airplane in
their lives and that they would not have been able to go on holiday anymore, not even with their
parents. Against this background, we began providing every class with psychological support
intervention.
Each meeting began with a presentation of EMDR, using simple words suitable to their age,
regarding EMDR and how their emotional responses were absolutely normal. In other words, they
were explained, that the distressing responses they had experienced during the first month were
normal, transient and that we would have helped them to feel better.
The next step was creating and strengthening the “safe place” within EMDR groups: students were
asked to draw a place where they felt safe, a memory of a place linked to their wellbeing and were
they felt relaxed. Afterwards, each one of them was asked to concentrate on his or her safe place
they had just drawn and then we proceeded with EMDR bilateral stimulation. The stimulation that
was done in the group was the butterfly hug. This name is due to the fact that it resembles the flutter
of butterfly wings; the children wrap their arms around themselves, so that each hand touches the
opposite upper arm or shoulder. Then they are instructed to move their hands like the wings of a
butterfly, i.e. to tap their arms/shoulders in an alternating rhythm. Toward the end of this brief
relaxing exercise, the children were more calm, smiling and relaxed.
The step following the Safe Place was focusing on the trauma with the EMDR group therapy
method. The students were asked to concentrate on the “Incredible Accident” and draw what they
remembered, or whatever came to their mind when recalling the event. Their drawings were all very
similar and the majority chose to draw the skyscraper with the smoke, sheets of paper fluttering all
over and the airplane.
At the end of the butterfly hug, children were asked how they felt. The answers ranged from “I am
fine now”, to“ I am worried/ I am scared”, and to “ I am ok, but I am not ok”. EMDR was offered
individually to those children who still felt distressed. As soon as the children stated that they did
not feel any discomfort while recalling the “Incredible Accident”, they were newly invited to draw
whatever came to their mind. The new drawings represented the healthy and positive change that
had occurred through the EMDR reprocessing. Some had drawn things that had nothing to do with
the Incredible Accident, others had once again drawn the skyscraper, but under a new perspective,
such as a building with band aids on it, or with a sheet that workers had put on it to cover the
cracks, explaining that “ it’s sick, so they put a sort of a blanket on it, so they can protect it”. In
each class, the entire intervention had involved all students not more than 20 minutes, with various
repetitions.
As soon as no child reported emotional subjective distress concerning the memory, they were asked
to draw a “happy moment” chosen by them (winning at a football game, trips to the sea, birthday
parties, time spent with grandparents, afternoons at the park, receiving gifts, ect.). At the end of this
last intervention phase, every child was asked to choose a positive thought and match it to his or her
drawing of “I am safe”, or “I am happy”. The final part of the EMDR intervention, which consisted
of the installation of positive resources. Children were helped to develop their own resilience (see
chapter 6), and evolve through the traumatic experience.
Everyone was satisfied at the end of the first phase of this complex intervention program, as well as
those parents who were then able to go on summer holiday, since their children were not afraid to
get on an airplane anymore. In fact, teachers and parents did not report any further posttraumatic
stress responses.
Follow-up assessment showed that results were maintained at the beginning of the new school year
confirming a true and long- lasting improvement. The teachers referred that there had not been any
dysfunctional behaviors anymore, nor any posttraumatic stress responses linked to the Pirelli event.
The teaching staff claimed that the EMDR treatment had determined the obtainment of these
positive results.
Stroppiana, Viggiù and Settimo Torinese school bus accidents
It was a late afternoon in May, 2007. 41 children, accompanied by their 3 school teachers of
Stroppiana (VC), were returning from a school trip from Turin on a bus. Suddenly the vehicle,
which was driving at high speed, flipped over a little slope on a joint highway which connects the
A4 highway (Turin-Milan) to the A26 highway (Gravellona-Alessandria), not far from Vercelli.
Sadly, a 7 year old boy died on the spot. But that was not all. One of his schoolmates, taken to
hospital in severe conditions, died the next day in hospital in Turin. His brother who was 10, woke
up from a coma a few days later. Most of the children who were on the bus were injured, some had
to be hospitalized. One of the teachers was in serious conditions. Psychological care staff from the
child neuropsychiatry department of Vercelli’s hospital initially screened everyone, to estimate the
psychological distress and try to reduce anxiety activation. A first psychological support
intervention was offered, aiming at providing safety and comfort, alleviating the pain and begin to
promote resilience (chapter 6). Subsequently, after having found among the children the presence of
acute stress responses, the psychological team of the National Health Service (ASL 11) of Vercelli
contacted the Italian EMDR Association, in order to establish a focused intervention.
3 weeks after the accident, a meeting was organized between the EMDR association task force and
the staff of the neuropsychiatric department. On this occasion guidelines for intervention on
children and parents were set. The entire community showed deep solidarity to the victims of this
tragic accident. Precious help from the Asigliano Vercellese comprehensive school’s headmistress
and from Stroppiana’s town administration, made it possible to organize a quick and efficient
psychological support intervention. The children, teachers and parents would have been treated
inside the Stroppiana’s elementary school.
The parents were invited through a letter sent by the National Health Service and by the school
administration. They were asked if they wanted to take part at a psychoeducational meeting, in
which the EMDR intervention plan would be explained and informed consent for the therapy would
be collected, as well as dispel any doubts.
Out of 39 families whose child had survived the trip, 30 accepted the EMDR treatment for their
child. A first group of children participated at one EMDR cycle, one month after the event. A
second group (comparison group) requested to participate 3 months after the event (many families
had been on vacation in June).
Each child received a cycle of 3 to 8 EMDR sessions, in average 6 sessions. The traumatic
memories were linked to the worst moments of the accident, the moment they found out about their
friends’ death, to current situations that caused anxiety and fears for the future. They were newly
assessed during EDMR treatment follow-ups after one month, 6 months and 1 year, in order to
monitor trends in posttraumatic symptoms. The intervention was carried out in two different
moments, according to the natural distribution of the children: one group was treated on month after
the event and the other group three months later. This allowed examining the symptoms during the
acute phase (within 3 months of the event) and chronic stage (after 3 months). Alongside with the
interventions for the children, their significant adult figures received support with the purpose to
both alleviate their pain, as well as develop a social safety net for the children who survived the
accident. Given the high level of traumatization which the parents had been exposed to while
waiting to find out about their children, and since the teachers had experienced in person the
accident, they too were given the opportunity to avail themselves of a cycle of EMDR sessions. 25
adults, including parents, teachers and the school administrators, were assessed and received
treatment.
Each group of children received an average of 6 EMDR sessions of 60 minutes, on consecutive
days. Psychotherapists of the Italian EMDR Association, as well as experts in developmental
psichotraumatology, applied the EMDR standard protocol. After the preparation phase and the Safe
Place exercise, the EMDR sessions focused on the disturbing memories linked to the accident. Once
the disturbing memories linked to the critical moment had been reprocessed, further sessions on
current avoidances and fears were faced in order to subsequently focus on future scenarios that
caused anticipatory anxiety.
Children on their initial evaluation test for posttraumatic stress level, before undertaking EMDR
sessions focused on trauma, presented significant level of distress: about 77 % had developed overt
posttraumatic symptoms, of which 43% were sufficient for a PTSD diagnosis and 34% below
threshold. The remaining presented only few isolated symptoms.
Another important data concerned the incidence of posttraumatic symptoms within the second
group, treated 3 months after the accident. As we can observe in Table 1 below, those children who
had not benefitted right away from psychotherapeutic cycle, presented a higher percentage of PTSD
symptoms (44%), as opposed to the first group, who had been treated just a month after the accident
(37%). Consequently, the acute posttraumatic symptoms were not reduced at 3 months after the
accident, as predicted by the DSM IV-TR, but rather increase if not professionally treated within an
appropriate time span.
As far as the adults are concerned, 25 agreed to undergo treatment, but only 15 had been fully
assessed: 10 subjects had missing data in one or a few test results. Overall, 78% of those who had
been initially assessed (25 adults) were diagnosed with a PTSD or presented PTSD symptoms
below threshold. The remaining 22% were split between those who had developed just a few
symptoms and those who had no symptoms at all. One very important data concerned the wellbeing
that arose among the children after receiving trauma focused EMDR treatment. In other words:
significant measures of symptom remission were collected. Considering that all children who
underwent a treatment cycle, had been reassessed at three months and one year after the event, the
PTSD percentage had dropped significantly. After the EMDR treatment cycle, no child presented
sufficient criteria for a PTSD diagnosis. As far as the adults were concerned, when comparing
assessment prior to the EMDR sessions and reassessment at the end of treatment, improvements
were immediately evident, supported also by statistical data. One week after the cycle, no one
presented a frank PTSD. During the same evaluation, 13% of the sample still showed some PTSD
symptoms, while 81% did not. During the two subsequent follow-ups, 3 months and one year after
treatment, results were maintained. Adults as well, like the children, went back to enjoy falling
asleep, smiling, feeling relaxed and the possibility to travel on a bus, as well as on other means of
transportation. The initial high level of distress among the parents and teachers reinforces the need
to project and carry out psychotherapeutic interventions addressing both traumatized children, as
well as their attachment figures.
One afternoon, in January 20th, 2008 is a day that will not be easily forgotten by the people living in
Baraggia di Viggiù: around 5.30 pm, a car driven by a 52 year old man, apparently for no reason at
all, runs onto a sidewalk of a busy street of the town, hitting a group of people who had just been
returning from the town’s feast. Due to the impact, a 14 year old girl dies and another 12 people are
injured (severe head injury). The intervention startup was planned at different times and with
different approaches, depending on the targeted group (classification recommended by Taylor e
Frazer, 1981). Intervention addressed the primary victims: survivors, the injured, as well as
witnesses. Also, operators, volunteers and rescuers had benefitted from the psychological support
(civil defense, local police, firemen, carabinieri), kids and friends of the injured present at the
moment of the accident, and relatives of the injured, as well as teachers of all the schools in Viggiù
and in nearby towns, and all the inhabitants of Viggiù who were or were not present at that moment
of the accident.
Given the seriousness of the accident and the stressful responses, as emerged by the first
assessments of victims during medication at the hospital, it had been necessary to intervene
promptly, defining an intervention project which would follow the classic guidelines as
recommended by the Emergency Psychology in the event of critical interventions. Psychological
first aid was offered immediatly, as well as individual/family support to those who had been
traumatized, fostering resilience and trying to promote cohesion among the population. Little group
debriefing meetings had been organized, meant to normalize the emotional responses caused by the
event, to favor resilience, alleviate stress and promote coping strategies individually and in groups.
Finally, psychoeducational group meetings helped to provide information regarding what these
people had to face. In these meetings, topics related to what the normal posttraumatic stress
responses were and the ability to activate coping strategies, as an individual and as a group.
A few weeks after the event, rescuers were summoned to the first group meetings (firemen, civil
defense, volunteers and first aid personnel), and one month after, friends and relatives. On these
occasions different issues were dealt with: delivering explanation of emergency psychology (what it
is and what it deals with), critical event characteristics, classification of victims, what kind of
responses might arise, how to face them and overcome trauma. Individualized meetings were
offered to the parents who had lost their daughter and for those whose son was seriously injured.
Standard EMDR protocol was applied to the victims of Viggiù, starting from installation of the
“safe place” with each one of the victims, in order to reduce the high level of arousal and help them
relax and experience some relief.
Next, EMDR therapy began, in various phases and moments: first we focused on the general
traumatic situation which enabled the adaptive information processing, stored in a dysfunctional
manner. In most subjects, 3/6 sessions were sufficient to remit from symptoms and reprocessing
the event; afterward we proceeded to examine the unresolved traumas prior to the event. Once we
had terminated working on the traumatic situation, we then continued with EMDR reprocessing on
the present and future: factors which caused current anxieties and anticipatory fears regarding the
future due to the car accident, were reprocessed. The closing of sessions consisted of installing new
positive resources, to promote resilience and posttraumatic personal growth.
Analysis done after one month from the accident and before EMDR treatment showed that 63% of
the group had developed all symptoms necessary for a PTSD diagnosis. This made it clearly more
necessary for an intervention program. The kids individually received and EMDR treatment (in
average 5/6 sessions each) and after one week a second reassessment and clinical interview was
given, as well as evaluation tests, to confront if any symptoms were still persisting. On this
occasion, a significant reduction of symptoms after therapy was registered, with disorder percentage
dropping to 19%: this is a first confirmation of EMDR’s efficacy in early intervention. During a
follow-up two weeks after treatment, percentage had dropped to 14% without having received any
further treatment. Given these figures, one can claim that EMDR treatment produces rapid effects,
does not intensify symptoms, but rather reduces them, which proves the promptness in intervening
is decisive when it comes to this type of traumatic event. Follow-up assessments after one month
showed that symptoms were remitted and that the kids were not as distressed as before treatment.
A Settimo Torinese, un autobus che trasporta tre classi di quinta elementare di una scuola di
SettimoTorinese (TO) finisce fuori strada a Lignana, nella Bassa Vercellese. Il pullman si rovescia a
causa di una forte nevicata il 5 febbraio 2010. Nell’incidente stradale rimangono feriti due dei 56
bambini a bordo e una delle 6 insegnanti.
Le tre classi all’arrivo in ospedale possono dunque contare sul team operativo che già aveva
lavorato efficacemente in occasione dell’incidente di Stroppiana: Direzione sanitaria, Pronto
soccorso, Pediatria, Anestesisti, Pneumatologia e Servizio di Psicologia. In questa fase iniziale di
intervento psicologico in emergenza, lavorano due psicologhe con formazione EMDR.
Iniziano dal Pronto soccorso, accogliendo chi è arrivato in autoambulanza. Rassicurati e informati
circa la salute dei loro compagni, vengono trattati individualmente con il protocollo EMDR
semplificato e adattato da applicare in situazione acuta di crisi. Questo consiste nel chiedere di
raccontare quanto è accaduto, mentre si fa della stimolazione bilaterale per abbassare il livello di
arousal e facilitare la narrativa dell’evento, il mettere in parole l’esperienza per favorire
l’abbassamento delle reazioni da stress. Si fanno domande per aiutare nella ricostruzione del trauma
e periodicamente si fanno notare positivamente le risorse messe in atto, sia le proprie che quelle dei
compagni. Anche ad alcuni adulti viene dato un breve supporto psicologico individuale, così come
l’autista. Il trattamento con EMDR andrà ripreso in un secondo momento per poter lavorare sul
ricordo traumatico con il protocollo standard.
Per supportare efficacemente la rielaborazione dell’esperienza traumatica, l’intervento è dunque
stato articolato in tre fasi. Il lavoro iniziale in Fase Acuta, attuato entro un mese, ha previsto una
riunione con gli insegnanti, una con i genitori e infine l’intervento di EMDR di gruppo nelle classi.
Successivamente, nella Fase di Post-Emergenza, dopo un mese dall’incidente, si è passati alle
valutazioni della sintomatologia da stress post-traumatico e alle sedute individuali di EMDR per i
bambini e gli insegnanti che ne hanno avuto necessità. Al termine di queste due fasi di lavoro, è
stata fatta una riunione con i genitori dei bambini coinvolti per dare informazioni su come era
andato l’intervento di supporto psicologico. Infine, nell’ultima fase, la Fase Formativa, in un
incontro rivolto a tutti i docenti della scuola, si sono affrontati i temi della Psicologia
dell’Emergenza e di Traumi nei bambini, con indicazioni specifiche e linee guida per insegnanti.
Il primo intervento EMDR di gruppo è stato attuato con il gruppo sperimentale in Fase Acuta a un
mese dall’incidente (rispettivamente nelle classi di 5ª A e 5ª C), il secondo intervento con il gruppo
di confronto è avvenuto in fase di post-emergenza. Li hanno svolti 4 psicoterapeuti indipendenti
dalle valutazioni pre e post-trattamento, esperte in psicotraumatologia dell’età evolutiva, e che
hanno applicato il protocollo EMDR standard, seguendo i criteri di “fidelity” indicati dalla ricerca
scientifica su questo metodo.
In questo studio sul campo effettuato ad un mese dall’incidente che ha colpito le 3 classi di 5° della
scuola elementare di Settimo Torinese, abbiamo potuto intervenire su 2 delle classi con un
trattamento EMDR di gruppo. Dopo settimane più tardi abbiamo valutato i livelli di PTSD e di
PTSD sottosoglia dei 2 gruppi trattati e del 3° gruppo non trattato e abbiamo verificato che i 2
gruppi trattati avevano una percentuale più bassa di PTSD e di PTSD sottosoglia di quello non
trattato. Il 3° gruppo è stato trattato 2 settimane più tardi.
Abbiamo potuto costatare anche in questo disastro collettivo che ha colpito un gruppo di bambini
che se non si interviene con un trattamento mirato ed efficace sul trauma come l’EMDR i sintomi di
disturbo post-traumatico aumentano, e soprattutto non vanno in remissione spontanea. Questo può
portare quindi ad una cronicizzazione e potrebbe fungere da fattore di rischio per disturbi emotivi
successivi.
CONCLUDING REMARKS
These projects show important results in terms of support of the effectiveness of EMDR treatment with
children, as well as with adults in the aftermath of a mass disaster.
An important aspect of these interventions is the participation of a large percentage of the population
involved in the events. If we compare results with those published in the literature, we can consider a very
high representativeness of the population hit by disasters and a high compliance.
The field studies described here seem representative due to the high participation of the subjects to the
interventions. We found that full blown and subclinical PTSD rate are usually higher than found in that
studies. For instance, in one of the studies 43% of these children developed post-traumatic stress disorder
and 34% were in the sub-clinical category.
We consistently observed that acute post-traumatic stress symptoms do not subside 3 months from the
event as postulated in the DSM IV-TR, but, lacking specialized treatment, they further increased in children.
The results obtained after treatment have been important to highlight the effectiveness of the EMDR
approach, both immediately and long-term in the acute symptomatology of post-traumatic stress disorders
and confirm some findings published in the literature especially with respect to the application with
children. Reactions may persist for several months without spontaneous remission in survivors in
developmental age.
Symptom development is different between adults and children. Children seem to have experienced high
stress reactions as confirmed by the results of most of our field studies.
Adults stress reactions were also significant: the amount of PTSD diagnoses at pre-treatment led us to
consider the need to intervene with EMDR treatment with parents and adults in general as well.
Usually in EMDR interventions, parents were immediately trustful and allowed their children to receive
psychological interventions provided by the team of the neuropsychiatry and EMDR clinicians.
Psychological teams of EMDR clinicians were fundamental in managing the emergency situation developed
in the immediate aftermath of the events, they meet with survivors and provide support to deal
emotionally with such a critical event, even some hours after the events occur. They also provided some
psychological first aid in order to promote coping skills and resilience.
Most projects were supported and enhanced by town halls and their majors, by the School principals and
personnel, by the National Mental health public services.
In fact, thanks to the good cooperation often was possible to work with the children in a setting familiar to
them such as their school. The availability of this setting has certainly facilitated the acceptance of such a
large number of children and fostered the emotional reactions' normalization process.
Finally, both the epidemiological data on the incidence of PTSD in the developmental age stemming from
our study and the results obtained with a cycle of 6 EMDR sessions on average with the victims, support the
claim of the importance of a specialized intervention in the acute as well in the chronic phases of postdisasters. EMDR has proved an effective treatment tool with children, and provided interesting findings
likely to expand research on these epidemiological and clinical issues.
The data drawn from surveys with parents and adults on the effectiveness of the EMDR treatment
programmes conducted with them support the strong need for a specific intervention also for the
caregivers of children victims of trauma and for survivors.
Traumatized children in Greenland
Fireworks factory explosion in the Netherlands