EMDR Integrative Group Treatment Protocol: A Postdisaster Trauma Intervention for Children and Adults

Abstract

Eye movement desensitization and reprocessing (EMDR) is recognized as an effective and efficient treatment for trauma-related issues. This article describes an inte- grated EMDR and group treatment for children and adults traumatized by natural disasters in several Latin American countries. This protocol combines the eight standard EMDR treatment phases with a group therapy model. The hypothesis is that the resulting hybrid offers more extensive reach than did the original EMDR model, which was intended for use with individuals, and takes treatment efficacy and efficiency well beyond that expected from traditional group process. To illus- trate the application of the model, one formally meas- ured field study and nine pilot projects are described. The promising results of this intervention suggest that EMDR is an effective means of providing treatment to large groups of people impacted by large-scale traumatic events (e.g., natural disasters). Controlled research is needed to clarify this issue.

Full text

EMDR Integrative Group Treatment
Protocol: A Postdisaster Trauma
Intervention for Children and Adults
Ignacio Jarero, Lucina Artigas,
and John Hartung
countries is unusually commonplace, challenging to
treat, and difficult to study.
Postdisaster data gathered in 6-month intervals
allowed the researchers in Norris et al. to observe
the progress of PTSD symptoms. They noted that
although the incidence of PTSD declined with
time, this natural recovery continued for 18 months
before leveling off, reflecting how natural healing
can be painfully prolonged. Even by the 18-month
leveling-off period, PTSD rates for the disaster vic-
tims remained higher than the PTSD base-rate in
Mexico. These researchers concluded that their
findings support a call for “early and ongoing inter-
ventions that provide mental health care to disaster
victims in a way that is culturally appropriate and
feasible for places . . . that have few mental health
professionals to draw upon” (Norris et al., 2004,
pp. 290-291).
Eye Movement Desensitization and
Reprocessing
The effectiveness of eye movement desensitization and
reprocessing (EMDR) in the treatment of trauma sur-
vivors has been recognized by a variety of professional
A
lthough the literature on the effects of disas-
ters has been accumulating for more than
2 decades, information on disaster-related
symptomatology among victims in developing coun-
tries is proportionately sparse (Norris et al., 2002).
One tentative conclusion is that natural disasters in
the developing world are particularly complex. In a
recent longitudinal study of the effects of floods and
mudslides in Mexico, a team of international
researchers found that disaster survivors reported a
high prevalence of posttraumatic stress disorder
(PTSD) (24% on average, ranging from 14% at one
site to 47% in another) and a high incidence of
major depressive disorder (Norris, Murphy, Baker, &
Perilla, 2004). Interpretation of these data was com-
plicated by the finding that residents of certain sites
had experienced other potentially traumatic events
during their lives and that their PTSD symptoms
may have predated the disasters studied, lending
support to the observation that trauma in developing
Eye movement desensitization and reprocessing (EMDR)
is recognized as an effective and efficient treatment for
trauma-related issues. This article describes an inte-
grated EMDR and group treatment for children and
adults traumatized by natural disasters in several Latin
American countries. This protocol combines the eight
standard EMDR treatment phases with a group therapy
model. The hypothesis is that the resulting hybrid offers
more extensive reach than did the original EMDR
model, which was intended for use with individuals,
and takes treatment efficacy and efficiency well beyond
that expected from traditional group process. To illus-
trate the application of the model, one formally meas-
ured field study and nine pilot projects are described.
The promising results of this intervention suggest that
EMDR is an effective means of providing treatment to
large groups of people impacted by large-scale traumatic
events (e.g., natural disasters). Controlled research is
needed to clarify this issue.
Keywords: EMDR; Latin America; natural disaster;
posttraumatic stress; trauma; children
From the AMAMECRISIS, Mexico City, Mexico (IJ, LA);
Colorado School of Professional Psychology, Colorado Springs,
CO, USA (JH).
Address correspondence to: Ignacio Jarero, AMAMECRISIS,
Mexico City, Mexico; e-mail: informes@emdrmexico.org.
Traumatology
Volume 12 Number 2
June 2006 121-129
© 2006 Sage Publications
10.1177/1534765606294561
http://tmt.sagepub.com
hosted at
http://online.sagepub.com
121

groups, including the American Psychological
Association (Chambless et al., 1998), the American
Psychiatric Association (2004), the International
Society for Traumatic Stress Studies (Chemtob, Tolin,
van der Kolk, & Pitman, 2000), the Israeli National
Council for Mental Health (Bleich, Kotler, Kutz, &
Shaley, 2002), the Northern Ireland Department of
Health (Clinical Resource Efficiency Support Team,
2003), and the U.S. Departments of Defense and
Veterans Affairs (2004).
Published studies have investigated the effects
of EMDR following manmade and natural disasters
(Fernandez, Gallinari, & Lorenzetti, 2004; Grainger,
Levin, Allen-Byrd, Doctor, & Lee, 1997).
EMDR has been reported as effective in the
treatment of 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
(E. Konuk, personal communication, 2005; Korkmazlar-
Oral & Pamuk, 2002). In all of these studies, stan-
dard EMDR treatment was conducted, that is, each
subject-patient was treated on an individual basis,
one at a time.
Standard EMDR treatment is based on the adap-
tive information processing (AIP) model (Shapiro,
2001). An assumption of the AIP model is that the
human neurobiological system inherently processes
information in a manner that promotes adaptive res-
olution. According to this theory, a person who expe-
riences a crisis or life-threatening event will
generally work through the experience naturally.
Unfortunately, some critical experiences are more
powerful than is the AIP system, such that the event
can overwhelm the system. These events, unprocessed
and unresolved, are said to be stored as traumatic
memories that can trouble the individual for years to
come, affecting past, present, and future. The unre-
solved past is experienced as if it is reoccurring again
and again, rather than as a distant memory. Present-day
symptoms appear in the form of troubling thoughts,
emotions, sensations, and behaviors, and otherwise
innocuous stimuli (such as a car backfiring, or the
grimace of a boss) can remind the person of the
traumatic event and trigger inappropriate reactions.
As a result, the person’s sense of a future is curtailed
and pessimistic.
EMDR appears to facilitate the AIP system so
that the individual is able to process traumatic mem-
ories to a state of natural and appropriate resolution.
The past event becomes only a memory, without its
negative emotional disturbance. Present-day symp-
toms are reduced or eliminated, and previous trig-
gers become simply sounds and pictures. And the
individual dares to dream about future possibilities.
There are eight phases in standard EMDR treat-
ment. In Phase 1, a thorough history is taken to
identify early traumas and present triggers, as well as
to recognize client strengths and resources. In sub-
sequent EMDR treatment, the client will be doing
the work of healing by connecting adaptive informa-
tion already within the AIP system with the unre-
solved traumatic memories. In Phase 2, the client is
helped to become prepared for the unusual speed
and power of EMDR, and additional attention is
given to helping the client to develop internal
resources that can be used during treatment. Phases
3 through 7 involve the processing of traumatic
memories. In Phase 3, assessment, a specific trau-
matic memory is identified along with the client’s
thoughts and feelings about the memory. The client
then rates the disturbing power of that memory with
a variation of the SUD or subjective units of distur-
bance (Wolpe, 1958), where a zero means no distur-
bance whatsoever and a 10 the maximum imaginable.
To stimulate healing possibilities, the client also
rates the believability of a positive self-statement,
this time using a scale that measures how true a
given statement feels to the client.
Phase 4 is treatment proper, or desensitization.
Standardized treatment procedures include having
the client focus on the visual, somatic, and rational
features of the traumatic event while providing bilat-
eral stimulation in the form of alternating eye move-
ments, taps on either side of the body (for example,
on the client’s hands), and/or alternating bilateral
tones. It is theorized that the client is thus enabled
to give dual attention both to the disturbing memory
and to present-day strengths and healing resources.
This is distinct from treatments that encourage a
focus either on the past alone (which can quickly
become overwhelming and even retraumatizing) or
on the present (which can produce rational under-
standing without accompanying emotional change).
During desensitization, the client reports that the
negative emotions and sensations that previously
characterized the traumatic memory are reduced (as
the term implies), and the memory becomes simply
a memory of a past event.
In the next two phases, the client is invited to
strengthen positive ways of thinking and feeling
122 Traumatology / Vol. 12, No. 2, June 2006

about the memory; a body check is done to identify
any residual somatic symptoms. Additional desensi-
tization can be provided if necessary. The seventh
phase involves a special closure to the session to
remind the client that he or she may continue to
process other memories (the AIP is said to be func-
tioning again) between sessions and that it is normal
to experience new insights, feelings, and sensations
(both pleasant and disturbing). This careful atten-
tion to the unexpected as well as the predicted is
repeated in Phase 8, which is a reassessment of the
client’s experiences during the following session.
AMAMECRISIS
The team of the Mexican Association for Crisis
Therapy (Asociación Mexicana para Ayuda Mental en
Crisis – AMAMECRISIS) provides mental health and
other assistance to persons affected by natural and
human-caused disasters. During the 72 hr following a
disaster, the team provides on-the-scene support to
child and adult victims and their families, and to
frontline workers and caregivers such as emergency
personnel, rescue workers, and mental health profes-
sionals. For survivors who develop PTSD or other
trauma symptoms, and for service personnel suffering
from compassion fatigue, innovative mental health
interventions (such as the EMDR protocol to be
described) are offered from 1 to 12 weeks postdisas-
ter or longer, if necessary and feasible.
The EMDR Integrated
Group Treatment Protocol
The current article describes an EMDR integrated
group treatment protocol (EMDR-IGTP) that was
inspired by requests for mental health attention fol-
lowing a massive natural disaster. In 1997, hurricane
Pauline struck the western coast of Mexico. The
AMAMECRISIS team responded quickly to the need
for services and was as quickly overwhelmed by the
extent of the need. The team clinicians thought that
they would conduct one-on-one EMDR with just a
few of the children and adults, who had lost families
and homes; however, on the first day, they were met
by more than 200 distressed youngsters and adults.
The team challenge was how to treat these many
needy children and adults simultaneously with a
powerful trauma treatment (EMDR) that was origi-
nally intended only for use with one patient at a time.
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, Maure, & Alcalá, 1999). The protocol
was originally structured within a play therapy for-
mat and was modified later for use with adults. The
hypothesis is that the resulting hybrid offers more
extensive reach that did the original EMDR model,
which was intended for use with individuals, and
takes treatment efficacy and efficiency well beyond
that expected from traditional group process.
The protocol has been designed to achieve the
following main objectives:
• To identify the patients with symptoms of acute
posttraumatic stress or posttraumatic stress disorder
• To confront the traumatic material
• To bring to conscience aspects of the trauma that
were dissociated
• To facilitate the expression of painful emotions
and/or shameful behaviors
• To offer the patient support and empathy
• To condense the different aspects of the trauma
in representative and more manageable images
• To increase the patient’s perception of domain
over the elements of the traumatic experience
• To reprocess traumatic memories
Professionals who use EMDR will find that the
protocol follows the basic EMDR pattern with sev-
eral modifications: during Phase 1, the clinical his-
tory is obtained of parents and teachers and a formal
evaluation with a properly validated instrument is
taken. During Phase 2, children play specially
designed games to promote rapport and the installa-
tion of the safe/secure place. The information of
Phase 3 is obtained from the client’s first drawing
that draws and colors the critical event instead of
visualizing it mentally. During Phase 4, the clients
provide their own bilateral stimulation using the but-
terfly hug (Artigas et al., 2000); SUD measure is
taken with pictures of faces that represent different
emotions and with repeated drawings of the incident
instead of numbers in a questionnaire. In Phase 5,
the client makes a drawing and a word or written sen-
tence. During Phase 6, the clients scan all their body
and do the butterfly hug. In Phase 7, the clients
return to the safe/secure place to close the session,
and in Phase 8, the clients who show more distress
are assisted using this protocol on an individual basis
or in small groups. Throughout the protocol, the lead
EMDR Integrative Group Treatment Protocol / Jarero et al. 123

therapist is assisted by the Emotional Protection
Team (EPT). Members of the EPT provide individual
help for any child who does not find the group treat-
ment format to be sufficient or comfortable. In some
cases, an individual child will relive (“abreact”) the
traumatic event with such intense emotion that indi-
vidual treatment is required to protect the child and
to complete treatment.
The protocol is still in its experimental stages. As
mentioned above, the controlled research to date
that supports the efficacy of EMDR is applicable
only to individual treatment. Support for the EMDR
group protocol described here has so far been lim-
ited to case studies. Other field studies of the proto-
col have been conducted with children victims of
a flood in Argentina (Adúriz et al., in press) and,
with modifications, with children who witnessed an
airplane crash in Italy (Fernandez et al., 2004) and
Kosovar-Albanian refugee children in Germany
(Wilson, Tinker, Hofmann, Becker, & Marshall,
2000). In this article, we describe additional appli-
cations of the protocol.
A Case Example of the EMDR-IGTP
Piedras Negras, Mexico, lies along the Mexico-USA
border. On April 2, 2004, a flood in this city killed
38 children and adults, and destroyed hundreds of
homes. On April 6, the AMAMECRISIS team
arrived on site with pamphlets on emotional first aid
and conducted the Crisis Management Briefing
Protocol (Mitchell & Everly, 2001). On May 15,
members of the AMAMECRISIS team conducted
EMDR with 44 children, using the EMDR
Integrated Group Treatment Protocol. Twenty-two
of the children were male and 22 were female, rang-
ing in age from 8 to 15 years. All had lost their
homes and, in some cases, loved ones.
During Phase 1 of the protocol, team members
educated teachers, parents, and relatives about the
course of trauma and enlisted these individuals to
identify affected children. At the end of the group
intervention, any child requiring individual attention
was treated separately from the group and was further
assessed for co- or preexisting mental health problems.
Following treatment, all clients were taught basic
affect management techniques to cope with stress and
to prepare for the future. The clinical history is
obtained of parents and teachers, and a formal evalu-
ation with a properly validated instrument is taken.
Phase 2 of the protocol begins with an integration
exercise intended to familiarize the children with the
space and objects included in the intervention, to
establish rapport and trust, and to facilitate group
formation. Although the materials used in the inter-
ventions described here included a Mexican doll
called Lupita, a drum, and a doll dolphin, other
materials may be used. The dolphin is used, for
example, to familiarize the children with their emo-
tions (e.g., they imitate the expressions of the dol-
phin). Once appropriate rapport is established, the
children are guided through a safe/secure place
exercise, which helps them to learn coping skills.
The children are repeatedly validated regarding their
feelings and other symptoms related to the trau-
matic event. As mentioned above in the protocol
description the lead therapist was assisted by the
EPT throughout the intervention.
The figures that follow depict the process of
change during EMDR processing. During Phase 3
of treatment, the children are instructed to think
about the aspects of the event that made them feel
most frightened, angry, or sad, and then to draw that
image on the paper provided (see Figure 1, drawing
A). After rating their level of distress using a modi-
fied version of the SUD scale (pictures of faces sub-
stitute for numbers), the children initiate Phase 4 of
the protocol, focusing on the drawing while tapping
themselves on the chest in bilateral and alternating
fashion (a procedure called the butterfly hug). The
children are then instructed to draw three more pic-
tures of their choosing, each of which is rated
according to level of distress and reprocessed using
the butterfly hug (Figure 1, drawings B, C, and D).
The level of distress associated with the initial target
is then assessed by returning the child’s focus to the
drawing that perturbs the most and identifying the
current SUD level (Figure 2, upper right corner).
In Phase 5, they draw a picture that represents
their future vision of themselves, along with a word
or a phrase that describes that picture (Figure 2).
The drawing and the phrase are also paired with the
butterfly hug. After that, in Phase 6, the children are
instructed to close their eyes, scan their body, and do
the butterfly hug. Finally, in Phase 7, the children
are instructed to return to their safe/secure place.
Phase 8 is initiated at the end of the group interven-
tion. The EPT has a debriefing about the identified
children who need individual attention and have to
be thoroughly evaluated to identify the nature and
extent of their symptoms, and any co- or preexisting
mental health problems. After that evaluation, the
team members keep working with them using the
EMDR-IGTP in small groups or on an individual basis.
124 Traumatology / Vol. 12, No. 2, June 2006

As we explained before, the protocol follows the
basic EMDR model, with several modifications:
• The client (especially in the case of children)
sketches and colors the critical event instead of
mentally visualizing it.
• Instead of relying on the therapist, clients pro-
vide their own alternating bilateral stimulation
with the butterfly hug (Artigas et al., 2000).
• Special attention is given to establishing a safe/
secure place.
• Process measures of subjective distress are con-
ducted with faces representing different emo-
tions, and with repeated sketches of the incident
instead of with numbers on an inventory.
• Several team members work in conjunction so
that any client requiring individual attention can
be identified and treated separately from the
group.
Measurement and Results
Pre- and posttreatment measures were made with
the Child’s Reaction to Traumatic Events Scale
(CRTES) (Jones, 1997) and a modified Subjective
Units of Disturbance Scale (SUDS) (Wolpe, 1958).
The CRTES, which was derived from the Impact of
Events Scale (Horowitz, Wilner, & Alvarez, 1979), is
a 15-item self-report scale intended to measure the
frequency of symptoms related to trauma. In addi-
tion to a total score, the CRTES provides scores for
two subscales: intrusion and avoidance.
In Figures 3 and 4, we can see the correlation
between CRTES and SUDS scores. On May 15,
2004, the pretreatment group average CRTES score
was 32.77, indicating a high degree of distress; the
pretreatment SUDS average was 9.24. Following
treatment on the same date, the final SUDS had
decreased to 1.29.
On Jun 12, 2004, four weeks after beginning treat-
ment, the team returned to Piedras Negras to conduct
a follow-up of the same 44 children using the CRTES.
Mean CRTES scores had decreased significantly from
32.77 (pretreatment) to 8.27 (at 4-week follow-up),
indicating low distress at follow-up (Figure 3).
Other Case Examples
Since 1998, the AMAMECRISIS team followed the
EMDR-IGTP protocol to treat children and adults in
nine pilot studies in Mexico, Nicaragua, El Salvador,
Colombia, and Venezuela after natural mass disas-
ters. Temporary shelters were used as the treatment
site for a transient population, conditions that made
it difficult both to gather formal measurement data
and to conduct follow-up interviews.
As a pretreatment measure, a simplified version
of the Impact of Events Scale (Horowitz et al.,
1979) was used to identify symptoms, and the
SUDS was the measure of process changes over the
course of EMDR treatment.
EMDR Integrative Group Treatment Protocol / Jarero et al. 125
Figure 1. Example of a child’s drawings before, during, and
following eye movement desensitization and reprocessing integrated
group treatment protocol treatment. The numbers represent the
child’s self-reported Subjective Units of Disturbance Scale scores.
Figure 2. Example of a child’s drawing of her imagined
future. The Spanish statement reads, “The future will be
achieved.” The zero represents her self-reported Subjective
Units of Disturbance Scale score.

The results of these studies (Figures 5 and 6)
were consistent with the Piedras Negras findings.
The data from these various projects lend support to
the use of EMDR-IGTP in mass disaster situations.
Discussion
Findings from a field study of the use of an EMDR-
IGTP suggest early intervention following disaster
can produce significant reductions in distress in
children as measured by the CRTES instrument
(Figure 3).
126 Traumatology / Vol. 12, No. 2, June 2006
0
10
20
30
40
Boys & Girls
32.77 8.27
Boys
28.36 8.18
Girls
37.18 8.36
Pre Post
Figure 3. Average pre- and posttreatment Child’s Reaction to
Traumatic Events Scale score, Piedras Negras Study. Pre – May
15, 2004; Post – June 12, 2004.
0
2
4
6
8
10
Boys & Girls 9.24 6.95 4.59 2.61 1.29
Boys 9.13 6.82 4.27 2.4 1.23
Girls 9.36 7.09 4.91 2.82 1.36
SUD
1
SUD
2
SUD
3
SUD
4
SUD
5
Figure 4. Treatment process changes as measured by average
Subjective Units of Disturbance Scale (SUDS) scores. Piedras
Negras Study, May 15, 2004.
0
2
4
6
8
10
SUDS
Acapulco
9.26 6.8 3.54 1.52
Nicaragua
9.34 4.61 2.02 0.96
El Salvador
9.62 8 3.92 0.54
Draw1 Draw2 Draw3 Draw4
Figure 5. Average Subjective Units of Disturbance Scale
(SUDS) scores for children treated at different natural disaster
sites, before (Draw1), during (Draw2, Draw3), and following
treatment (Draw4).
0
2
4
6
8
10
SUDS
Draw1 9.67 7.21 8.54 8.09 7.63 8.24
Draw2 4.47 0.9 1.12 2.73 2.75 3.16
Draw3 3.2 0.79 0.92 2.64 2.42 2.36
Draw4 1.76 0.25 0.77 2.39 1.33 2.52
Colombia
El
Salvador
G1
Venezuela
G2
Venezuela
G3
Venezuela
G4
Venezuela
Figure 6. Average Subjective Units of Disturbance Scale
(SUDS) scores for adult men and women treated at different
natural disaster sites, before (Draw1), during (Draw2, Draw3),
and following treatment (Draw4).

We can see a correlation between the pretreat-
ment measures: CRTES 32.77 (Figure 3), SUD
average in the first drawing is 9.24 (Figure 4), and
the girl’s drawing in the first SUD is 10 (Figure 1).
In Figure 4, we can see how the SUD average
decreases over the course of treatment in correlation
with the girl’s drawing (Figures 1 and 2). The low
distress scores as measured by the CRTES at follow-
up 1 month later (Figure 3) indicate that treatment
benefits were maintained for that period of time.
These changes are also consistent with observa-
tions from the work conducted at a disaster site in
Argentina (following a flood) by Adúriz and her col-
leagues in 2003 (in press), using the EMDR-IGTP
with child victims of the flood. They reported
process changes over the course of treatment, as
measured by subjective reports of distress using the
SUDS and changes on CRTES measures from pre-
to posttreatment that were similar to the Piedras
Negras findings (see Figures 7 and 8 for comparisons
of the results of these two studies). The Argentina
group also reported that positive changes following
treatment were further indicated by behavioral
observations made by teachers before and after
treatment. Positive changes were maintained at
approximately the 3-month follow-up.
The pilot projects preceding the Piedras Negras
study (Figures 5 and 6) are considered only to be
clinically relevant case studies. They enabled our
team to learn how to work under conditions of phys-
ical and social chaos, how to be inventive under
overwhelming demands, and how to strategize for
subsequent data gathering. Also of clinical interest
was the progressive drop in distress as measured by
SUDS scores, changes parallel to the decreases in
CRTES, and SUDS scores observed in the Piedras
Negras study. The nonexperimental design of this
pilot field study has inherent limitations, and these
results must be considered preliminary and heuris-
tic. However, the results indicate that the continued
use of the EMDR-IGTP warrants further and more
rigorous study.
In the absence of any reports of negative impact
resulting from the intervention, we tentatively conclude
that EMDR intervention with children in a group
format can be conducted with both safety and effi-
cacy, and in a relatively short period of time. In our
experience, the whole protocol takes 50 to 60 min.
During that time, the team can work comfortably
with 25 to 30 children and 40 to 50 adults. We
recommend a ratio of one team member for eight
clients/patients.
The protocol application takes between 50 to
60 min. During that time, a team of five clinicians
EMDR Integrative Group Treatment Protocol / Jarero et al. 127
0
2
4
6
8
10
Mexico
9.24 6.95 4.59 2.61 1.29
Argentina 7.25 3.02 2.19 1.41 2.19
SUD 1 SUD 2 SUD 3 SUD 4 SUD 5
Figure 7. Average Subjective Units of Disturbance Scale
(SUDS) score comparison for two eye movement desensitization
and reprocessing integrated group treatment protocol projects
in Mexico and Argentina.
0
5
10
15
20
25
30
35
México 32.77 8.27
Argentina 26.4 10.76
Pre Post
Figure 8. Average pre- and posttreatment Child’s Reaction to
Traumatic Events Scale scores for two eye movement desensiti-
zation and reprocessing integrated group treatment protocol
projects: Mexico (Piedras Negras), treatment on May 15, 2004,
and posttreatment follow-up on June 12, 2004; Argentina
(Santa Fe), treatment on July 28, 2003, and posttreatment
follow-up on November 1, 2003.

(one leading the protocol and four doing the EPT work)
can treat 25 to 30 children. A total of 120 children
in a day.
We recommend a ratio of 8 to 10 children for
1 mental health professional. Teachers can be of great
help to the EPT, helping the children write their
names, ages, and SUD numbers).
Subsequent to group treatment, the team can
treat those who require individual follow-up atten-
tion, using the EMDR-IGTP in small groups or on
an individual basis. Our experience in the field sug-
gests that about 6% of those treated in a group set-
ting require individual follow-up.
We end with a story told by one of the treated
children to remind us of the individual pain and sor-
row that can be overshadowed by the statistics of
large-scale traumatic events. Here is how Rosa Irene
described her drawings in Figures 1 and 2:
When the water came close to their home, her father
helped her to climb up a tree near her house. Her
mother helped Rosa Irene’s siblings (9 and
7 years) to climb a tree in front of the house. The
water destroyed their house and reached the top of
the trees where they were. Her dad holds her very
tightly and she escaped being washed away by the
water. She saw how their mom could not hold her two
siblings, and the smaller one was dragged away by the
water, and on the following day they found him dead.
We are in agreement with Norris et al. (2004) who
called for early and ongoing interventions with dis-
aster victims, and believe the model we described
can be applied in ways that respect cultural values of
victims while offering hope and healing.
Acknowledgments
We thank Judith Boel, Judy Jones, and Judy Albert
for their early support of the crisis work we
described; Tere López Cano, Nicté Alcalá, and
Magaly Mauer for the effective and loving treatment
they provided under difficult conditions; and the
many members of the Latin American EMDR
Institute with whom we have shared the challenge of
trauma work for so many years.
References
American Psychiatric Association. (2004). Practice guideline
for the treatment of patients with acute stress disorder and
posttraumatic stress disorder. Arlington, VA: Author.
Adúriz, M., Bluthgen, C., Gorrini, Z., Maquieira, S., Nofal, S.,
Knopfler, C. (In Press). The flooding in Santa Fé,
Argentina. Journal of Psychotraumatology for Iberoamérica.
Artigas, L., Jarero, I., Mauer, M., López Cano, T., & Alcalá,
N. (2000, September). EMDR and traumatic stress after
natural disasters: Integrative treatment protocol and the
butterfly hug. Poster presented at the EMDRIA Conference,
Toronto, Ontario, Canada.
Bleich, A., Kotler, M., Kutz, E., & Shaley, A. (2002). A posi-
tion paper of the (Israeli) National Council for Mental
Health: Guidelines for the assessment and professional
intervention with terror victims in the hospital and the
community. Tel Aviv: Israel.
Chambless, D. L., Baker, M. J., Baucom, D. H., Beutler,
L. E., Calhoun, K. S., Crits-Christoph, P., et al. (1998).
Update on empirically validated therapies, II. The Clinical
Psychologist, 51, 3-16.
Chemtob, C. M., Nakashima, J., Hamada, R. S., & Carlson,
J. G. (2002). Brief-treatment for elementary school
children with disaster-related posttraumatic stress disorder:
A field study. Journal of Clinical Psychology, 58, 99-112.
Chemtob, C. M., Tolin, D. F., van der Kolk, B. A., & Pitman,
R. K. (2000). Eye movement desensitization and repro-
cessing. In E. B. Foa, T. M. Keane, & M. J. Friedman
(Eds.), Effective treatments for PTSD: Practice guidelines
from the International Society for Traumatic Stress Studies
(pp. 139-155, 333-335). New York: Guilford.
Clinical Resource Efficiency Support Team. (2003). The
management of post traumatic stress disorder in adults.
Belfast: Northern Ireland Department of Health.
Fernandez, I., Gallinari, E., & Lorenzetti, A. (2004). A
school-based intervention for children who witnessed the
Pirelli building airplane crash in Milan, Italy. Journal of
Brief Therapy, 2, 129-136.
Grainger, R. D., Levin, C., Allen-Byrd, L., Doctor, R. M., &
Lee, H. (1997). An empirical evaluation of eye movement
desensitization and reprocessing (EMDR) with sur-
vivors of a natural disaster. Journal of Traumatic Stress,
10, 665-671.
Horowitz, M., Wilner, N., & Alvarez, W. (1979). Impact of
Events Scale: A measure of subjective stress.
Psychosomatic Medicine, 41, 209-218.
Jarero, I., Artigas, L., López Cano, T., Mauer, M., & Alcalá, N.
(1999, November). Children’s post traumatic stress after
natural disasters: Integrative treatment protocol. Poster
presented at the annual meeting of the International
Society for Traumatic Stress Studies, Miami, FL.
Jones, R. (1997). Child’s reaction to traumatic events scale
(CRTES). In J. Wilson & T. Keane (Eds.), Assessing psy-
chological trauma & PTSD. New York: Guilford.
Korkmazlar-Oral, U., & Pamuk, S. (2002). Group EMDR
with child survivors of the earthquake in Turkey.
Association of Child Psychology and Psychiatry (ACPP).
Occasional Papers No. 19, 47-50.
Mitchell, J., & Everly, G. (2001). The basic critical incident
stress management course: Basic group crisis intervention
128 Traumatology / Vol. 12, No. 2, June 2006

(3rd ed.). Ellicott City, MD: International Critical Incident
Stress Foundation.
Norris, F., Friedman, M., Watson, P., Byrne, C., Diaz, E., &
Kaniasty, K. (2002). 60,000 disaster victims speak: Part I.
An empirical review of the empirical literature, 1981-2001.
Psychiatry, 65, 207-239.
Norris, F., Murphy, A., Baker, C., & Perilla, J. (2004). Postdisaster
PTSD over four waves of a panel study of Mexico’s 1999 flood.
Journal of Traumatic Stress, 17, 283-292.
Shapiro, F. (2001). Eye movements desensitization and repro-
cessing. Basic principles, protocols, and procedures (2nd ed.).
New York: Guilford.
Silver, S. M., Rogers, S., Knipe, J., & Colelli, G. (2005).
EMDR therapy following the 9/11 terrorist attacks:
A community-based intervention project in New York
City. International Journal of Stress Management, 12,
29-42.
U.S. Department of Veterans Affairs and U.S. Department of
Defense. (2004). VA/DoD clinical practice guideline for
the management of post-traumatic stress. Washington, DC:
Authors. Retrieved from http://www.oqp.med.va.gov/cpg/
PTSD/PTSD_cpg/frameset.htm.
Wilson, S., Tinker, R., Hofmann, A., Becker, L., & Marshall,
S. (2000, November). A field study of EMDR with
Kosovar-Albanian refugee children using a group treatment
protocol. Paper presented at the annual meeting of the
International Society for the Study of Traumatic Stress,
San Antonio, TX.
Wolpe, J. (1958). Psychotherapy by reciprocal inhibition.
Stanford, CA: Stanford University Press.
EMDR Integrative Group Treatment Protocol / Jarero et al. 129