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NGO Forum for Health - Mental Health and Psychosocial Working Group
Global Mental Health Briefing, Friday 8 July 2011 EMDR Therapy for Trauma and Beyond:
Individual Treatment Applications and Global Humanitarian Outreach
[Notes prepared by Maria Van Heestra, WCC] Dr. Francine Shapiro:
Negative life experiences can have as much or more impact on one's life than acute violent traumatic events such as war, natural disasters, rape, kidnapping etc. If one goes back in one's memory and can still remember the incident, it means one has not yet processed it and it could be affecting one in ways you do not suspect. EMDR enables access to this memory so that it can be processed, so you can get rid of the pain and avoid resorting to destructive behaviors (e.g. drug addiction, becoming a victimizer etc.) to do so. There are also intergenerational effects of trauma: children suffering the effects of the trauma experienced by their parents. EMDR aims to tackle this also. The main problem is unprocessed emotion. For example, when we meet a new person who triggers unpleasant memories owing to the association of some characteristic with that person, this could create a problem with relating to that person through no fault of the person him/herself. The effectiveness of EMDR has been evidenced through 22 randomized controlled studies. An example of EMDR therapy on a person who had experienced the trauma of an earthquake revealed that the therapy elicited other traumatic events form the person’s past which, although unrelated, were linked in the person's mind. The foundation of EMDR therapy is the same for adults as for children. Its advantages are that it is relatively short, which also makes it less costly, and the patient need not focus exclusively on the major traumatic incident that was the reason for doing the therapy; rather the mind is allowed to wander where it wants. Furthermore, the patient is not obliged to recall all the details of the memories that come up, which makes possible to be culturally sensitive. For example for rape victims in Congo the women do not have to talk about it; the processing happens internally. Physically EMDR has been shown to increase the volume of the hippocampus. Comparison with Prozac showed it to more effective, particularly in the longer term (in the follow-up). It has been applied in cases of mothers who cannot feel love for their child, child molesters who often have themselves been molested in the past (as they feel guilt and see the children they molest as being the perpetrators), chronic pain such as in phantom limbs etc. It has been used with success in the Marmora earthquake in Turkey, in ACEH in Indonesia both for the trauma of the tsunami and the civil war that was going on at the time, earthquake in Mexico. Group training was used in Italy and Latin America. Memories and future thinking are highly inter-related. Unhealed trauma prevents us from having a positive vision of the future. EMDR Humanitarian Assistance Programmes
Carol Martin:
EMDR HAP, which was established in 1995 by EMDR educators, now has over 12,000 clinicians trained in EMDR in the USA and some 2,000 outside the USA, as well as volunteers. It is a treatment that works. Their mission is to build capacity in needy countries to do evidence-based treatments in a culturally appropriate manner. EMDR has been used successfully in Haiti and the WHO has documented the fact that untreated mental health conditions leads to low productivity. In general treatment of mental health conditions is related to level of development, with reduced mental health in lesser developed countries. Discussion
Q.: In reference to eliciting other past trauma, can one treat an adult without
reworking the past trauma?
A: It's possible to minimize the process so the patient does not get overwhelmed. One must adapt to the client. There are stabilization techniques and also a generalization process, i.e. dealing with one type of incident impacts on other similar events. It is relatively rapid, which is important in humanitarian situations where the beneficiary is often living far away. Q: What type of professionals would receive this training?
A: There are two situations: 1) in the USA it would be the licensed mental health professionals, such as psychiatrists, psychologists, social workers, and certain techniques can be taught to para-professionals. 2) In other countries it is advisable to train a variety of professionals as there may not be very many trained mental health specialists. The idea is to develop a sort of "EMDR without borders". For example EMDR-trained people in Israel may work in Palestine and visa versa, thus contributing to avoiding anger building up. Q: What type of training goes to licensed versus para-professionals?
A: Specific techniques would be done by the para-professionals such as the preparatory work rather than the therapy itself. Q: A person from Japan asked about the timing, the target group and about how the
patient-therapist rapport is addressed taking into account the culture.
A: There are EMDR trained clinicians in Japan. Timing of the treatment can be anytime from the first few weeks after the trauma to three years afterwards, although the sooner the better for the benefit of the person concerned. What is important is not to interfere with other important processes such as urgent humanitarian assistance for purposes of survival. They wait until they are requested to intervene with EMDR and do not impose themselves. As regards the cultural issues, such as patient-clinician rapport, the advantage of EMDR is that it is not necessary to delve too deeply into the trauma for the treatment to be effective therefore cultural issues are not generally a problem. Q: Where does mental health fit in the many humanitarian assistance organizations
and how are they coordinated?
A: They need to reach out to the UN to scale up our activities. Training of UN mental health professionals is now under way in Haiti for example. They are here just for this purpose, to see how they can bring EMDR to the world. Bringing mental health to the world takes funds and one of the advantages of EMDR is that it is must cheaper than other therapies. They also do care for the clinicians themselves. When a clinician experiences the effectiveness he/she will push for it locally. Q: If they wait until they are requested to intervene, how to they get to perpetrators,
such as child molesters, who are in denial?
A: It is a problem to get to the perpetrators. In the US child molesters who are arrested are forced to get therapy but are usually given CPT which does not work. Q: Why is there still so much scepticism about the technique when the evidence has
shown its success?
A: The field of mental health has gone through a sequence of new paradigms as new research comes in so it is a question of time. Q: How does HAP evaluate the effectiveness of EMDR, because it does not work in all
situations and all cultures?
A: EMDR has to be presented in a culturally appropriate manner for it to work. Q: How can EMDR help people who are exposed daily to traumatic conditions and are
unable to leave their daily traumas?
A: In Aceh, Indonesia, for example, along with the trauma of the tsunami there was a civil war going on. As is the case some people do better in general than others despite their outside environment, so anyone who is developing mental health symptoms such as depression etc. will need treatment. Those who have been traumatized as children will generally need treatment. Mental health professionals need to deal with these issues holistically, not only addressing the major disasters. Therefore ideally everyone should be enabled to process all unprocessed memories. As many humanitarian organizations only have resources for specific situations, their aim is to build capacity to have a more global action. Q: What are the risks of the group model of EMDR and have there been any negative
effects of EMDR?
Q: Given the lack of mental health staff in developing countries how successful have
they been working with para-professionals and how long is the training?
A: Training of non-professionals takes a bit longer and needs more supervision. Obviously one can only accomplish what is possible according to the resources at hand. In Liberia for example there is only one psychiatrist, and in Bangladesh there are only 50 mental health professionals in the whole country, therefore one has to assess what can realistically be done in each situation. Travelling field teams can be set up that go from place to place. Comment: it was shocking to note that important organizations continue to do work that is not evidence-based. The World Bank has only one person dealing with mental health. The Inter-Agency Standing Committee should take a leadership and standard setting role in this regard.

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