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Journal of EMDR Practice and Research, Volume 2, Number 2, 2008 97
© 2008 Springer Publishing Company DOI: 10.1891/1933-3196.2.2.97
A
t 2:35 a.m. on February 19, 2006, there was
an explosion in the Pasta de Concho mine,
trapping 65 miners. The Nueva Rosita region
became the international media center of attention
when rescue efforts were broadcast worldwide from
this carbon mine in the Mexican State of Coahuila.
Unfortunately after several days all hope was lost,
the rescue failed, and the miners were offi cially de-
clared dead. Media attention then shifted to related
political issues, because the disaster had been caused
by negligence in mine security. Although the explo-
sion remained in the political spotlight for weeks, the
families of the dead miners—their parents, wives, and
children—and the members of the rescue team—re-
ceived no mental health support to alleviate their
deep grief, anguish, and distress.
In May, when political conditions had become fa-
vorable, a member of the Asociacion Mexicana para
Ayuda Mental en Crisis (AMAMECRISIS) fl ew to the
region to plan the provision of services. AMAMECRISIS
is a nonprofi t nongovernmental organization (NGO)
whose mission is to prevent or alleviate the human
suffering provoked by psychological trauma. This NGO
has more experience working in situ with survivors of
natural or human-provoked disasters than any other
agency in Latin America.
AMAMECRISIS provided the following services:
• In May, psychoeducation for 50 social workers who
gave support to the families of the dead miners.
The social workers were taught strategies to cope
with compassion fatigue.
• In May, meeting with the local mental health pro-
fessionals who were working with the children on
a daily basis in the schools to plan this fi eld research
study.
• In June, training eight mental health professionals
in the Nueva Rosita region. The therapists received
full scholarships for EMDR basic training and two
advanced trainings with EMDRIA credits: EMDR
integrative group treatment protocol and resources
for more debilitated clients.
The EMDR Integrative Group Treatment Protocol:
Application With Child Victims of a Mass Disaster
Ignacio Jarero
Lucina Artigas
AMAMECRISIS, México City, México
María Montero y López Lena
UNAM, México City, México
The EMDR Integrative Group Treatment protocol (EMDR-IGTP) has been used in different parts of the
world since 1998 with both adults and children after natural or man-made disasters. This protocol
combines the eight standard EMDR treatment phases with a group therapy model, thus providing more
extensive reach than the individual application of EMDR. In this study the EMDR-IGTP was used with
16 bereaved children after a human provoked disaster in the Mexican State of Coahuila in 2006. Results
showed a signifi cant decrease in scores on the Child’s Reaction to Traumatic Events Scale that was
main tained at 3-month follow-up. Although controlled research is needed to establish the effi cacy of
this intervention, preliminary results suggest that EMDR-IGTP may be an effective means of providing
treatment to large groups of people impacted by large-scale critical incidents (e.g., human-provoked
disasters, terrorism, natural disasters).
Keywords: EMDR; group treatment; Latin America; human-provoked disaster; posttraumatic stress; children
98 Journal of EMDR Practice and Research, Volume 2, Number 2, 2008
Jarero et al.
• In June, implementing this fi eld research study with
provision of the EMDR Integrative Group Treat-
ment protocol to 16 bereaved children. Treatment
was provided by the eight local therapists in col-
laboration with the AMAMECRISIS team.
• In September, follow-up with children, parents,
and teachers.
The Treatment of Trauma
Eye movement desensitization and reprocessing
(EMDR; Shapiro, 2001) is a psychotherapeutic ap-
proach proven to be effi cacious in the treatment of
posttraumatic stress disorder (PTSD; American Psychi-
atric Association, 2004; Bisson & Andrew, 2007; Bleich,
Kotler, Kutz, & Shalev, 2002; Chemtob, Tolin, van der
Kolk, & Pitman, 2000). Published studies have inves-
tigated the effects of EMDR following man-made and
natural disasters (Grainger, Levin, Allen-Byrd, Doctor,
& Lee, 1997). EMDR has been reported effective in
treating children following a hurricane in Hawaii
(Chemtob, Nakashima, Hamada, & Carlson, 2002),
with victims of the 9/11 terrorist attacks in New York
City (Silver, Rogers, Knipe, & Colelli, 2005), and with
victims of earthquakes in Turkey (Korkmazlar-Oral &
Pamuk, 2002).
A separate body of literature also describes the ef-
fectiveness of non-EMDR group therapy approaches
for disaster intervention. Following the 1988 earth-
quake in Turkey, Goenjian et al. (2005) provided four
30-minute cognitive behavioral (CBT) group sessions
and an average of two individual sessions to children
in a school-based intervention. They found that the
grief-focused treatment was effective in reducing
PTSD symptoms and halting the progression of de-
pression. In another study in Athens, Giannopoulou,
Dikaiakou, and Yule (2006) provided a 7-week group
CBT treatment to children traumatized by an earth-
quake. Results showed improvement in symptoms
of PTSD and depression that continued at follow-up.
These studies suggest that the postdisaster imple-
mentation of mental health intervention programs to
children can reduce trauma-related psychopathology.
However, all of these treatments required the chil-
dren’s attendance over a period of several weeks, a
requirement that may be hard to implement in some
disaster or refugee settings.
The EMDR Integrative Group
Treatment Protocol
The EMDR Integrative Group Treatment protocol
(EMDR-IGTP) was developed by members of AM-
AMECRISIS when they were overwhelmed by the
extensive need for mental health services after Hur-
ricane Pauline ravaged the western coast of Mexico in
1997. The team arrived expecting to provide one-on-
one EMDR to just a few individuals but were greeted
by more than 200 distressed children and adults who
had lost families and homes. The challenge was how
to treat so many people simultaneously with a pow-
erful trauma therapy (EMDR) that was originally in-
tended for use with only one patient at a time ( Jarero,
Artigas, & Hartung, 2006). The result was the EMDR-
IGTP, a protocol that combines the eight standard
EMDR treatment phases with a group therapy model
(Artigas, Jarero, Mauer, López Cano, & Alcalá, 2000;
Jarero, Artigas, López Cano, Mauer, & Alcalá, 1999).
It is hypothesized that the resulting format offers more
extensive reach than individual EMDR applications
and that the treatment may produce a more effective
outcome than that expected from traditional group
therapy.
We recommend that the EMDR-IGTP be part
of comprehensive programs for trauma treatment
with victims of disasters. Because of its utility, it has
been used in multiple settings around the world. For
example, Fernandez, Gallinari, and Lorenzetti (2004)
reported that the group intervention appeared to
successfully alleviate symptoms for all but 2 of the
236 students who witnessed an airplane crash in Italy.
Adúriz and colleagues (in press) used the EMDR-IGTP
with 220 child victims of a fl ood in Santa Fe, Argen-
tina, in 2003 and reported signifi cant improvement
that was maintained at 3-month follow-up. Similarly,
results with 44 children following the Piedras Negras
fl ood in Mexico in 2004 ( Jarero et al., 2006) showed the
effi cacy of the approach. Scores on the Subjective Units
of Disturbance Scale (SUDS) and the Child’s Reaction
to Traumatic Events Scale (CRTES) showed large
changes from pretreatment to posttreatment and at
follow-up (see Table 1).
Anecdotal reports in other situations are consistent
with these results. Gelbach and Davis (2007) stated that
the EMDR Humanitarian Assistance Program (HAP)
regularly teaches this approach to local clinicians.
It . . . seems to be equally effective cross-culturally,
and it has the advantage of reaching more people
more quickly, involving larger segments of the
community. Paraprofessionals can be taught to
lead the groups under supervision of a clinician,
which allows wide application in societies that
have a few clinicians. For instance, in Guajarat,
India, after a major earthquake, newly trained
clinicians conducted group sessions that reached
thousands of symptomatic children. In Chennai,
Journal of EMDR Practice and Research, Volume 2, Number 2, 2008 99
The EMDR Integrative Group Treatment Protocol
India, after the tsunami, HAP-trained clinicians
treated 5,000 children in these groups in 1 year.
(p. 399)
EMDR-IGTP has also been used in its original for-
mat or with adaptations to meet the circumstances to
assist victims of fl ooding in Acapulco, México, 1997,
Posoltega, Nicaragua, 1998, Caracas, Venezuela, 1999,
Santa Fé, Argentina, 2003, and Piedras Negras, México,
2004; earthquake survivors in Pereira and Armenia in
Colombia, 1999, Adapazari, Turkey, 1999, and San
Salvador, El Salvador, 2001; child refugees of the Alba-
nia and Kosovo War, in Germany, 1999; and survivors
of the tsunami (Adúriz et al., in press; Artigas et al.,
2000; Gelbach & Davis, 2007; Jarero et al., 2006; Jarero
et al., 1999; Korkmazlar-Oral & Pamuk, 2002; Wilson,
Tinker, Hofmann, Becker, & Marshall, 2000).
Description of the Procedure
EMDR-IGTP is administered by an EMDR clinician
who leads the team and who is assisted by other
clinicians or paraprofessionals previously trained in
this protocol. The assisting clinicians or paraprofes-
sionals are called the “Emotional Protection Team”
(EPT). Teachers can also be of great assistance, help-
ing the children write their names, ages, and SUD
numbers.
The protocol application takes 50 to 60 minutes.
A ratio of 8–10 children for each mental health profes-
sional is recommended. A team of fi ve clinicians (one
leading the protocol and four doing the Emotional
Protection Team work) can treat 40–50 children, a
total of 160–200 children in 4 hours of work.
Phase 1—Client History
During Phase 1 of the protocol, team members edu-
cate teachers, mothers, and relatives about the course
of trauma and enlist these individuals to identify chil-
dren who have been affected by the traumatic event.
Team members have to be aware of the needs of the
clients within their extended family, community, and
culture.
Phase 2—Preparation
Phase 2 of the protocol begins with an exercise in-
tended to familiarize the children with the space and
objects included in the intervention, to establish rap-
port and trust, and to facilitate group formation. Toys
such as a doll dolphin can be used to familiarize the
children with the expression of emotions (e.g., they
imitate the expressions of the dolphin). Once appro-
priate rapport is established, the children are guided
through a safe/secure place exercise, which provides
them with a coping skill. The children are repeatedly
validated regarding their feelings and other posttrau-
matic symptoms.
Phase 3—Assessment
Instead of being asked to visualize the target incident,
as in traditional EMDR, the children are instructed to
think about the aspects of the event that made them
now feel most frightened, angry, or sad, and then to
draw that image on the paper provided (see Figure 1,
drawing A). They are then shown a diagram that
depicts faces representing different levels of nega-
tive emotion (from 0 to 10, where 0 shows no distur-
bance and 10 shows severe disturbance) and asked to
select the face that best represents their emotion and
to write the corresponding number on their picture,
thus providing the team with ratings of subjective dis-
turbance (SUD).
Phase 4—Desensitization
The children are asked to look at their picture (e.g.,
Figure 1, drawing A) and to provide their own alter-
nating bilateral stimulation with the Butterfl y Hug
(Artigas et al., 2000) by crossing their arms and tapping
TABLE 1. Results From the EMDR-IGTP Studies in Mexico and Argentina
Study
Number of
Participants
SUD Scores CRTES Scores
Pretreatment
Immediate
Posttreatment Pretreatment
1-Month
Follow-Up
3-Month
Follow-Up
Piedras Negras,
Mexico 44 9.2 1.3 32.8 8.3
Santa Fe,
Argentina 220 7.3 2.2 26.4 10.8
Source. Adúriz et al., in press; Jarero et al., 2006
100 Journal of EMDR Practice and Research, Volume 2, Number 2, 2008
Jarero et al.
themselves on the chest in a bilateral alternating fash-
ion. The children are then instructed to draw another
picture of their own choice, related to the event, and
rate it according to its level of distress. Processing
continues with the child looking at the second picture
and using the Butterfl y Hug. The process is repeated
twice more so that there are four pictures (Figure 1).
The level of distress associated with the incident is
then assessed by asking the child to focus on the draw-
ing that is most disturbing and to identify the current
SUD level. This number is then written on the back of
the paper (see Figure 2, upper left corner).
Phase 5—Future Vision (Replacing
Installation)
Phase 5 of the standard EMDR protocol cannot be
conducted in large groups since each participant may
have a different SUD level. Also, some children can-
not progress any further in the group protocol to
reach an ecological level of disturbance. This may be
because they have blocking beliefs, previous prob-
lems or trauma, and/or require additional time for
processing. Consequently, the group protocol utilizes
the future vision to identify adaptive or nonadaptive
cognitions (e.g., I want to die and be with my dad in
heaven) that are helpful in evaluating the child at the
end of the protocol. The children draw a picture that
represents their future vision of themselves, along
with a word or a phrase that describes that picture
(see Figure 2). The drawing and the phrase are then
paired with the Butterfl y Hug.
Phase 6—Body Scan and Phase 7—Closure
In Phase 6, the children are instructed to close their
eyes, scan their body, and do the Butterfl y Hug.
Finally, in Phase 7, the children are instructed to re-
turn to their safe/secure place.
Phase 8—Re-Evaluation
Phase 8 takes place immediately after the group inter-
vention: The team leader and the Emotional Protec-
tion Team members have a debriefi ng about which
identifi ed children may need individual attention and
which may need thorough evaluation to identify the
FIGURE 1. Example of a child’s drawings before and during EMDR-IGTP treatment.
Note. The numbers represent the child’s self-reported SUD scores.
A) Drawing A: The fi gures trapped inside the mine (his father one of them) are saying: “Ha,” “Help,”
“Help us” (SUDS = 5).
B) Drawing B: “Me” and “Picture of my Dad” (SUDS = 10).
C) Drawing C: “My mother,” “me,” “Bertha,” “Martha” (his sisters) (SUDS = 0).
D) Drawing D: “My Dad” (SUDS = 0).
Journal of EMDR Practice and Research, Volume 2, Number 2, 2008 101
The EMDR Integrative Group Treatment Protocol
nature and extent of their symptoms and any comor-
bid or preexisting mental health problems. Determi-
nation is made by considering the reports of their
teachers and relatives, the CRTES results, the entire
sequence of pictures and SUD ratings, body scan,
the future vision cognition, and the Emotional Pro-
tection Team Report. After the evaluation, the team
members work with the identifi ed children by using
the EMDR-IGTP in smaller groups or by providing
individual treatment.
Method
Procedure
In June 2006 the treatment team provided the above-
described protocol with children whose fathers had
died in the mine explosion. Measurements were taken
at pretreatment, posttreatment, after 1 week, and at
3 months.
Treatment Team
The team consisted of four professionals from AMA-
MECRISIS and eight local mental health professionals
who had received training in EMDR and EMDR-IGTP
from AMAMECRISIS.
Participants
Sixteen children whose fathers had died in the mine
participated in the fi eld study. They ranged in age from
6 to 12 years; 11 were male, 5 female. All of their mothers
and teachers participated in the Phase 1 procedure and
provided information about the children’s diffi culties.
Measures
The Child’s Reaction to Traumatic Events Scale (CRTES;
Jones, Fletcher, & Ribbe, 2002) was derived from the
Impact of Events Scale (Horowitz, Wilner, & Alvarez,
1979). It is a 15-item self-report measure designed to as-
sess psychological responses to stressful life events. Re-
sponses are scored according to a Likert scale, where
0 = not at all, 1 = rarely, 3 = sometimes, and 5 = often.
In addition to a total score, the CRTES provides scores
for two subscales: intrusion and avoidance. Scores less
than 9 are considered low distress, between 9–18 mod-
erate distress, 19 and over high distress. Although it is
a self-report measure, the questions were read aloud
to the younger children by the EPT members. Their
responses were recorded by the EPT. This measure
was administered to the children at pretreatment, at
1-week posttreatment, and at 3-month follow-up.
FIGURE 2. Example of the same child’s drawing of his imagined future.
Note. The Spanish statement reads “Feliz = Happy. Pintor = Painter.” The zero represents the child’s
self-reported SUD score at the end of Phase 4 for the most disturbing drawing.
102 Journal of EMDR Practice and Research, Volume 2, Number 2, 2008
Jarero et al.
A modifi cation of the Subjective Units of Distur-
bance Scale (SUD; Shapiro, 2001; Wolpe, 1958) was
used. Instead of asking the children to simply rate the
level of their disturbance, they were shown a diagram
that depicts faces representing different levels of nega-
tive emotion (from 0 to 10, where 0 shows no distur-
bance and 10 shows severe disturbance) and asked to
select the face that best represented their emotion and
to write the corresponding number on their picture.
Children were assisted in this process by members of
the EPT. SUD ratings were taken for each of the four
pictures, and at the end of Phase 4 for the most dis-
turbing drawing.
Results
Sixteen bereaved children participated in the study.
All of the children completed the EMDR-IGTP and
two required individual therapy. There were no dif-
ferences in response between the girls ( n = 5) and
( n = 11) boys.
The changes during the treatment process are
evident in the content of the children’s drawings (see
Figure 1) and are refl ected in their SUD scores. As
shown in Figure 3, the SUD scores decreased for each
subsequent picture. The fi nal score was reported for
the “most disturbing” picture. There was a decrease
in SUD ratings from a mean of 8.6 before processing
to 1.0 at the end of Phase 4.
At pretreatment, the children’s scores on the CRTES
measure placed them in the high distress range, in-
dicating a high level of psychological response to a
stressful life event. The posttreatment CRTES scores
were obtained after 1 week. They indicated a low
level of distress and showed a signifi cant decrease ( t =
8.09, p ≤ .001) from the pretreatment scores. Follow-
up scores taken at 3 months showed a maintenance of
treatment effect and a signifi cant difference from the
pretreatment scores ( t = 8.30, p ≤ .001; see Tables 2
and 3 and Figure 4).
Discussion
The present study was an uncontrolled fi eld study,
with treatment provided in a natural setting to a
group of traumatized and bereaved children follow-
ing a man-made disaster. The results indicated sig-
nifi cant improvement on measures of self-reported
distress and posttraumatic stress. The low scores on
the CRTES measure at 3-month follow-up (Figure 4)
suggested that the treatment benefi ts were maintained
for that period of time. Also of clinical interest was the
progressive drop in distress measured by SUD scores.
It should be noted that these results are based on an
uncontrolled fi eld study and that the conclusions are
limited by this methodology. One cannot state with
certainty that the results can be fully attributed to the
treatment. However, the rapid shift in SUD ratings
0
2
4
6
8
10
Boys & Girls
8.63 3.54 2.68 2.09 1.05
Boys
7.27 5.09 3.36 2.18 0.09
Girls
10 2 2 2 2
SUD
1
SUD
2
SUD
3
SUD
4
SUD
5
FIGURE 3. Treatment process changes as measured by mean SUD scores for
the four pictures and for the most disturbing picture at the end of Phase 4.
Journal of EMDR Practice and Research, Volume 2, Number 2, 2008 103
The EMDR Integrative Group Treatment Protocol
during the session and corresponding changes in
CRTES scores suggest that the treatment was a causal
factor. Although controlled research is needed to es-
tablish the effi cacy of this intervention, preliminary
results from this fi eld study suggest that early inter-
vention following man-provoked disaster may pro-
duce signifi cant reductions in children’s symptoms of
posttraumatic stress. A further limitation of this study
is the lack of formal diagnosis. However, diagnosis and
formal assessment are time-consuming and may not
be readily available in rural settings, third-world coun-
tries, or communities devastated by disaster. Conse-
quently the application of this simple group procedure
to alleviate distress and to identify individuals requir-
ing more extensive treatment has great utility. Further
assessment can then be conducted for those individu-
als identifi ed in the group protocol, and individual
treatment can subsequently be provided.
EMDR-IGTP has been used in its original format or
with adaptations to meet the circumstances in multiple
settings around the world after natural or human-pro-
voked disasters. The protocol offers an extensive out-
reach, with a team of fi ve clinicians able to treat 160–200
children in a 4-hour period. The preliminary results
suggest that the EMDR-IGTP could be an effective
means of providing treatment to large groups of people
TABLE 3. Comparison of Pretreatment Scores
With Posttreatment and Follow-Up Scores on
the CRTES Measure
Pre-Post
(1 Week)
Pre-Follow-Up
(3 Months)
Boys
t = 7.30 (df, 10)
p ≤ .000
t = 6.77 (df, 10)
p ≤ .000
Girls
t = 3.48 (df, 4)
p ≤ .025
t = 3.34 (df, 4)
p ≤ .012
Boys &
Girls
t = 8.09 (df, 15)
p ≤ .000
t = 8.30 (df, 15)
p ≤ .000
TABLE 2. Scores on the CRTES Measure
Pre
Post
(1 Week)
Follow-Up
(3 Months)
Boys 39.00 (12.46) 14.36 (2.73) 12.91 (3.36)
Girls 37.20 (12.26) 14.80 (3.42) 12.60 (3.13)
Boys & Girls 38.44 (12.00) 14.50 (2.85) 12.81 (3.19)
Note. Mean and standard deviations for the pre and post and
follow-up scores on the Child’s Reaction to Traumatic Events
Scale.
0
10
20
30
40
Boys & Girls
38.44 14.5 12.81
Boys
39 14.36 12.91
Girls
37.2 14.8 12.6
Pre Post
Follow-
up
FIGURE 4. Mean scores on the CRTES measure.
Note. Scores on the Child’s Reaction to Traumatic Events Scale taken at pretreatment, 1-week
posttreatment, and 3-month follow-up.
104 Journal of EMDR Practice and Research, Volume 2, Number 2, 2008
Jarero et al.
impacted by large-scale critical incidents (e.g., human-
provoked disasters, terrorism, natural disasters).
This is consistent with the fi ndings of other studies
that have investigated the application of EMDR-IGTP
with groups of children subsequent to man-made
and natural disasters. In Italy, Fernandez et al. (2004)
described sustained reduction of symptoms for over
95% of 244 children. In Colombia, Adúriz and col-
leagues (in press) reported signifi cant improvement
for children that was maintained at 3-month follow-
up. Similarly in Mexico, Jarero et al. (2006) described
positive results with the treatment of 44 children (see
Table 1). Anecdotal reports in other situations have
included the application of the protocol with trau-
matized adults and are consistent with these results
(Gelbach & Davis, 2007).
We are in agreement with Norris and colleagues
(2002, 2004), who called for early and ongoing inter-
ventions with disaster victims. More research is needed
to investigate this protocol and to evaluate its effi cacy.
This protocol should be applied only to a group of
persons who have experienced the same critical inci-
dent. The use of this protocol is not recommended,
for example, for a group of children who have had dif-
ferent childhood traumatic experiences. The IGTP is a
modifi cation of standard EMDR protocols and allows
the treatment to be provided simultaneously to a large
number of traumatized individuals who have survived
a community disaster. The results of the current study
suggest that the therapy effectively decreases the dis-
tress related to the critical incident.
Some of the benefi ts of EMDR-IGTP are its trans-
portability; it can be easily implemented in most com-
munities, and few supplies are needed. It is very brief,
requiring only 2 hours. Distressed children are identi-
fi ed through this process so that they can be provided
with further treatment. In addition, based on our ex-
perience in other studies using the protocol and from
anecdotal reports, it appears that the model can be
applied in ways that respect cultural values of vic-
tims. Given the multiple large-scale critical incidents
that occur frequently on our planet and the resultant
suffering and posttraumatic distress, the potential for
offering hope and healing is encouraging. The pre-
liminary and promising results of this study strongly
suggest the importance of future controlled research
to evaluate this protocol.
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Correspondence regarding this article should be directed to
Ignacio Jarero, Boulevard de la Luz 777, Jardines de Pedregal,
M
éxico City, 01900. E-mail: informes@emdrmexico.org
