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EMDR Protocol for Recent Critical Incidents: A Randomized Controlled Trial in a Technological Disaster Context

Authors:
  • Latin American and Caribbean Foundation for Psychological Trauma Research, Mexico
  • Asociación Mexicana para Ayuda Mental en Crisis A.C.
  • Instituto Mexicano de Investigación de Familia y Población, Mexico (IMIFAP)

Abstract and Figures

This research evaluated the effectiveness of the Eye Movement Desensitization and Reprocessing (EMDR) Protocol for Recent Critical Incidents (EMDR-PRECI) in reducing posttraumatic stress symptoms related to the explosion in an explosives manufacturing factory north of Mexico City that killed 7 employees. The EMDR-PRECI was administered on 2 consecutive days to 25 survivors who had posttraumatic stress symptoms related to the critical incident. Participants’ mean score on the Short PTSD Rating Interview (SPRINT) was 22, well above the clinical cutoff of 14. They were randomly assigned to immediate and waitlist/delayed treatment conditions and therapy was provided within 15 days of the explosion. Results showed significant main effects for the condition factor, F(1, 80) 5 67.04, p , .000. SPRINT scores were significantly different across time showing the effects of the EMDR therapy through time, F(3, 80) 5 150.69, p , .000. There was also a significant interaction effect, condition by time, F(2, 80) 5 55.45, p , .001. There were significant differences between the two treatment conditions at Time 2 (post-immediate treatment vs. post-waitlist/delayed), t(11) 5 210.08, p , .000. Treatment effects were maintained at 90-day follow-up. Results also showed an overall subjective improvement in the participants. This randomized controlled trial provides evidence for the efficacy of EMDR-PRECI in reducing posttraumatic stress symptoms after a technological disaster.
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JOURNAL OF
EMDR
PRACTICE
AND RESEARCH
www.springerpub.com/emdr
With the Compliments of Springer Publishing Company, LLC
166 Journal of EMDR Practice and Research, Volume 9, Number 4, 2015
© 2015 EMDR International Association http://dx.doi.org/10.1891/1933-3196.9.4.166
Technological Disasters
A technological disaster is the result of a failure of
human-made products (Weisaeth, 1994). In a techno-
logical disaster, a human action or a man-made prod-
uct results in death, injury, and destruction. Examples
of technological disasters are industrial/factory
explosions, nuclear plant accidents, toxic waste, air
crashes, train derailments and collisions, passenger
ship and other maritime catastrophes, large-scale
road accidents, mining disasters, oil blowout, and
so forth.
At 9:45 am on February 20, 2015, a terrible ex-
plosion in an explosives manufacturing fac-
tory located north of Mexico City hit the
32 workers by surprise. The explosion impact, caused
by a human error, was felt more than 2 kilometers
away. Seven workers (four men and three women)
between 22 and 35 years old were killed. The 25 sur-
vivors escaped from the rubble confused and fright-
ened. After medical attention to the physical injuries,
the company requested assistance from the Mexi-
can Association for Mental Health Support in Crisis
(AMAMECRISIS).
ARTICLES
EMDR Protocol for Recent Critical Incidents: A Randomized
Controlled Trial in a Technological Disaster Context
Ignacio Jarero
Susana Uribe
Lucina Artigas
Martha Givaudan
Latin American & Caribbean Foundation for Psychological Trauma Research, Mexico
This research evaluated the effectiveness of the Eye Movement Desensitization and Reprocess-
ing (EMDR) Protocol for Recent Critical Incidents (EMDR-PRECI) in reducing posttraumatic stress
symptoms related to the explosion in an explosives manufacturing factory north of Mexico City that
killed 7 employees. The EMDR-PRECI was administered on 2 consecutive days to 25 survivors who
had posttraumatic stress symptoms related to the critical incident. Participants’ mean score on
the Short PTSD Rating Interview (SPRINT) was 22, well above the clinical cutoff of 14. They were
randomly assigned to immediate and waitlist/delayed treatment conditions and therapy was provided
within 15 days of the explosion. Results showed significant main effects for the condition factor,
F(1, 80) 5 67.04, p , .000. SPRINT scores were significantly different across time showing the ef-
fects of the EMDR therapy through time, F(3, 80) 5 150.69, p , .000. There was also a significant
interaction effect, condition by time, F(2, 80) 5 55.45, p , .001. There were significant differences
between the two treatment conditions at Time 2 (post-immediate treatment vs. post-waitlist/delayed),
t(11) 5 210.08, p , .000. Treatment effects were maintained at 90-day follow-up. Results also
showed an overall subjective improvement in the participants. This randomized controlled trial pro-
vides evidence for the efficacy of EMDR-PRECI in reducing posttraumatic stress symptoms after a
technological disaster.
Keywords: Eye Movement Desensitization and Reprocessing (EMDR) Protocol for Recent Critical Inci-
dents (EMDR-PRECI); technological disaster; early EMDR therapy intervention; posttraumatic stress
disorder (PTSD); industrial explosion
Copyright © Springer Publishing Company, LLC
Journal of EMDR Practice and Research, Volume 9, Number 4, 2015 167
EMDR-PRECI: An RCT After a Technological Disaster
be key to early psychological interventions as a brief
treatment modality (Jarero, Artigas, & Luber, 2011).
The clinical experience and work in the field with EEI
has been extensive (Maxfield, 2008). There is a grow-
ing body of research supporting the use of modified
EMDR therapy protocols to treat PTSD symptoms in
both group and individual formats following natural
and man-made disasters (e.g., Buydens, Wilensky, &
Hensley, 2014; Colelli & Patterson, 2008; Natha &
Daiches, 2014). The primary reason for modifying
the EMDR protocol is that memory consolidation ap-
pears to change in the weeks and months following
a critical incident (F. Shapiro, 2001). See E. Shapiro
(2012) and E. Shapiro and Laub (2015) for a review of
early psychological interventions following traumatic
events in general and the place of EEI in particular
and Luber (2014) for a review of early mental health
interventions for man-made and natural disasters
with EMDR therapy.
Previously, we have argued that acute trauma sit-
uations are related not only to a time frame (days,
weeks, or months) but also to a posttrauma safety
period as well (Jarero & Uribe, 2011, 2012). Our hy-
pothesis is that the continuum of stressful events with
similar emotions and somatic, sensorial, and cogni-
tive information, does not give the state-dependent
traumatic memory sufficient time to consolidate into
an integrated whole. Thus, the memory networks re-
main in a permanent excitatory state, expanding with
each subsequent stressful event to the original critical
incident, analogous to ripples from a rock falling in
the middle of a lake. The risk of PTSD and comor-
bid disorders would therefore grow with the number
of exposures. For example, the case of a patient who
received a cancer diagnosis 18 months ago could be
conceptualized as an acute trauma situation because
after hearing the cancer diagnosis (original critical
incident—the pebble thrown into a pond), there was
no posttrauma safety period. Instead, the client ex-
perienced a continuum of stressful events (the ripple
effect) such as physically grueling investigations and
aggressive treatments, side effects of treatments, sur-
gery and organ mutilation, bodily dysfunction, and so
forth. Thus, the patient’s memory network remains
in a permanent excitatory state, expanding with each
subsequent stressful event in this continuum that ex-
tends until the present moment.
EMDR Protocol for Recent Critical Incidents
The Eye Movement Desensitization and Reprocess-
ing (EMDR) Protocol for Recent Critical Incidents
(EMDR-PRECI) is a modification of F. Shapiro’s
Many classic technological disasters are industrial
and severely affect company employees. In a longi-
tudinal follow-up 2 years after the industrial AZF
disaster (explosion in a petrochemical factory in
Toulouse, France, in 2001 that caused 30 deaths and
injured 2,242 people), researchers evaluated a cohort
of 3,006 people. They found that the prevalence of
psychological distress was 47%, establishing a link
between the technological-industrial disaster and
psychological distress (Cohidon et al., 2009). In an-
other example, Meewisse, Olff, Kebler, Kitchiner, and
Gerson (2011) reported that at 2 years posttechnologi-
cal disaster (huge explosion in a central storage facility
of fireworks factory in the Netherlands), 48.3% of sur-
vivors fulfilled the criteria for a mental health disorder
within the previous 12 months. The most common
disorders were posttraumatic stress disorder (PTSD;
21.8%), specific phobia (21.5%), and depression
(16.1%). High 12-month comorbidity rates among
these three disorders were found, and more than half
of the survivors suffered from two or more coexist-
ing disorders. Some technological disasters, such as
Chernobyl or incidents of toxic waste, are not time-
limited events and do not have a posttrauma safety
period. These latter disasters present a sequence of
events that continues to unfold over the years, creat-
ing a continuum of stressful events that extends until
the present moment.
EMDR Therapy
The World Health Organization (2013) and numerous
international mental health review publications, such
as the Cochrane Review, recommend eye movement
desensitization and reprocessing (EMDR) therapy
for treatment of PTSD in children, adolescents, and
adults (Bisson, Roberts, Andrew, Cooper, & Lewis,
2013). This therapy, developed by Dr. Francine Shapiro
(F. Shapiro, 2001), is a comprehensive approach to
treatment of trauma, adverse life experiences, or psy-
chological stressors.
Early EMDR Therapy Intervention
Early psychological interventions is the term used by
Roberts, Kitchiner, Kenardy, and Bisson (2010) for in-
terventions that begin within the first 3 months after
a traumatic event with the primary aim of prevent-
ing PTSD or ongoing distress in those presenting
with traumatic stress symptoms, or with acute stress
disorder (ASD), or who are at risk for PTSD or other
disorders. Early EMDR therapy intervention (EEI) has
a natural place in the crisis intervention and disaster
mental health continuum of care context and may
Copyright © Springer Publishing Company, LLC
168 Journal of EMDR Practice and Research, Volume 9, Number 4, 2015
Jarero et al.
process, they were continually exposed to horrific
emotional stressors, including ongoing threats to
their own safety. A single individual EMDR session
was provided to 32 workers. Results showed sig-
nificant improvement for both immediate treatment
(N 5 18) and waitlist/delayed treatment (N 5 14)
conditions ( Jarero & Uribe, 2011, 2012), on the Impact
of Event Scale (IES) and Short PTSD Rating Inter-
view (SPRINT; Connor & Davidson, 2001; Vaishnavi,
Payne, Connor, & Davidson, 2006).
Method
The purpose of our research is to evaluate the effec-
tiveness of the EMDR-PRECI to reduce the PTSD
symptoms related to the explosion in an explosives
factory north of Mexico City that killed 7 employ-
ees using a waitlist/delayed treatment control group
design with random assignment to conditions. The
research protocol was reviewed and approved by
the Latin American & Caribbean Foundation for
Psychological Trauma Research review board to en-
sure that the research quality of this study partially
fulfilled the Revised Gold Standard scale (Maxfield
& Hyer, 2002) items. The Gold Standard criteria are
1 5 clearly defined target symptoms, 2 5 reliable
and valid measures, 3 5 use of blind independent
evaluators, 4 5 assessor reliability, 5 5 manualized
treatment, 6 5 random assignment, 7 5 treatment
fidelity, 8 5 no confounded conditions, 9 5 use of
multimodal measures, and 10 5 length of treatment
for participants with single trauma (civilians). The
study fully met Criteria 2, 4, 5, 6, 7, and 8; partially
met Criteria 1 and 3; and did not meet Criteria 9 and
10. All participants gave written informed consent.
Participants
This randomized controlled trial study was con-
ducted in the field in a safe area inside the factory fa-
cilities. The sample comprises 25 explosion survivors.
Participants’ age ranged from 23 to 56 years old
(M 5 38.56 years). There were 13 participants
(11 women and 2 men) in the immediate treatment
condition group and 12 participants (10 women and
2 men) in the waitlist/delayed treatment condition
group. Inclusion criteria were (a) 18 years old or older,
(b) explosion survivor, (c) with posttraumatic stress
symptoms related to the critical incident, (d) had
not received or was not receiving specialized trauma
therapy, and (e) had not received or was not receiving
drug therapy for the posttraumatic stress symptoms.
Exclusion criteria were (a) ongoing suicidal or homi-
cidal ideation, (b) diagnosis of psychotic or bipolar
(2001) Recent Traumatic Events Protocol provided
in an individual treatment format to clients suffering
from ongoing trauma. We developed it in the field to
treat critical incidents where related stressful events
continue for an extended time and where there is no
posttrauma safety period for memory consolidation.
EMDR-PRECI uses an eight-phased protocol.
Phases 1 and 2 are the history taking and preparation
phases. In Phase 3, disturbing memory fragments
are assessed with the client identifying the most
disturbing image, related negative cognition (NC),
emotion, ratings of subjective units of disturbance
(SUD), and body sensation location but no positive
cognition (PC) or rating of validity of positive cog-
nition (VOC). During Phase 4 (desensitization), the
client focuses on each memory fragment, while si-
multaneously engaging in dual attention stimulation
using eye movements (EM) as a first choice and the
butterfly hug (BH; Artigas & Jarero, 2014) as an al-
ternative bilateral stimulation (BLS). Each memory
fragment is processed in turn, using the free associa-
tive processing of the standard EMDR desensitization
phase. When all fragments have been processed with
Phase 4, and the client identifies no further distur-
bance, Phase 5 is applied to the entire extended
event with a PC developed for the entire incident.
Installation of PC does not use frequent checking
of VOC but full reprocessing doing BLS while infor-
mation is moving. A supplemental step is conducted
in this phase to review the whole sequence holding
the PC. Phase 6 uses standard EMDR procedures.
Phase 7 uses our (Jarero & Artigas, 2014) postdisas-
ter self-soothing strategies, and Phase 8 uses standard
procedures. See Jarero et al. (2011) and Jarero and
Artigas (2014) for further details of our protocol.
Previous EMDR-PRECI Studies
After a 7.2-Magnitude Earthquake. EMDR-PRECI
treatment was provided subsequent to a 7.2-magnitude
earthquake in North Baja California, Mexico, accord-
ing to continuum of care principles. One session of
EMDR-PRECI (Jarero et al., 2011; Jarero & Uribe,
2011, 2012) produced significant improvement on
symptoms of posttraumatic stress for both, the im-
mediate treatment (N 5 9) and waitlist/delayed treat-
ment conditions (N 5 9), with results maintained at
a 12-week follow-up, although frequent frightening
aftershocks continued to occur.
After a Human Massacre. After a human massacre
in the Mexican state of Durango, forensic personnel
had the horrific task of recovering 258 mutilated bod-
ies from clandestine graves. During the months-long
Copyright © Springer Publishing Company, LLC
Journal of EMDR Practice and Research, Volume 9, Number 4, 2015 169
EMDR-PRECI: An RCT After a Technological Disaster
(CAPS) in the assessment of PTSD symptoms clus-
ters and total scores. It can be used as a diagnostic
instrument (Vaishnavi et al., 2006). It was found that
in the SPRINT, a cutoff score of 14 or more carried
out a 95% sensitivity to detect PTSD and 96% speci-
ficity for ruling out the diagnosis, with an overall
accuracy of correct assignment being 96% (Connor
& Davidson, 2001).
Procedure
The research was conducted in six stages:
Stage 1. The recruitment of participants took
place 10 days after the explosion (February 20, 2015),
from March 2 to March 10, 2015. During this time,
two qualified, not blind to the research protocol, in-
dependent assessors explained the purpose of the
research, as well as inclusion and exclusion criteria,
obtained the informed consents, collected the clinical
history of each participant, and applied the SPRINT
as a baseline assessment for all participants (Time 1;
Figure 1). During this phase, participants were divided
randomly into two groups (immediate treatment con-
dition and waitlist/delayed treatment condition) and
randomly assigned to the three therapists.
disorder, (c) organic mental disorder, (d) substance
abuse, (e) significant cognitive impairment. All 25 sur-
vivors met inclusion criteria and participated in the
study. Participation was voluntary, and there were no
dropouts throughout the study period.
Measures
Short PTSD Rating Interview. The SPRINT (Con-
nor & Davidson, 2001; Vaishnavi et al., 2006) is an
8-item interview or self-rating questionnaire with
solid psychometric properties that can serve as a reli-
able, valid, and homogeneous measurement of PTSD
illness severity and global improvement as well as a
measure of somatic distress; stress coping; and work,
family, and social impairment. Each item is rated on a
5-point scale: 0 (not at all), 1 (a little bit), 2 (moderately),
3 (quite a lot), and 4 (very much). Scores between 18
and 32 correspond to marked or severe PTSD symp-
toms, between 11 and 17 to moderate symptoms,
between 7 and 10 to mild symptoms, and scores of
6 or less indicate either minimal or no symptoms.
The SPRINT also contains two additional items to
measure global improvement according to percent-
age of change and severity rating. SPRINT performs
similarly to the Clinician-Administered PTSD Scale
FIGURE 1. Short PTSD Rating Interview (SPRINT) means by time and group.
0
5
10
15
20
25
30
SPRINT SCORES
T1. BASELINE T2. POST-PRECI-GROUP 1 T3. POST-PRECI-GROUP 2 T4. FOLLOW-UP
GROUP 1 Immediate Treatment GROUP 2 Delayed Treatment
Copyright © Springer Publishing Company, LLC
170 Journal of EMDR Practice and Research, Volume 9, Number 4, 2015
Jarero et al.
During the reprocessing phases (4–6), therapist
verbal intervention was kept to the minimum only
necessary for the continuity of information repro-
cessing. Clinicians did not use strategies to confine
associations during the reprocessing phases because
EMDR therapy is an inherently client-centered ap-
proach that emphasizes the client’s innate capacity to
heal through the activation of a physiological adap-
tive information processing mechanism that requires
“minimal clinician intrusion” (F. Shapiro, 2001, p. 18).
To control the intensity of processing, keeping the
clients in their window of tolerance and avoiding over-
whelming sensory/emotional stimulation, clinicians
asked the clients to keep their eyes open during the en-
tire reprocessing time, adjusted the EM length of sets
and speed to the client’s needs, and used the BH as an
alternative BLS. It is thought that the control obtained
by the client over his or her stimulation with the BH
may be an empowering factor that aids his or her re-
tention of a sense of safety while processing traumatic
memories (Artigas & Jarero, 2014). Clinical observa-
tions during EMDR-PRECI reprocessing phases (4–6)
using the full power of standard EMDR free associa-
tive processing showed that adjusting the EM length of
sets and speed to the client’s necessities or using the BH
as an alternative BLS resulted in a nonstuck and a rapid
progression of traumatic information processing.
Statistical Analysis
The data were analyzed using factorial analysis of vari-
ance (ANOVA), with the effects of the EMDR-PRECI
evaluated with the SPRINT as dependent variable and
group (two groups of patients: immediate treatment
group and waitlist/delayed treatment group) and
time (four time points) as independent variables. Post
hoc analyses using the Scheffe post hoc criterion for
significance were carried out.
Results
Results are presented in two sections. The first section
describes the qualitative and clinical information. The
second section presents the statistical data analysis.
Pretreatment Phenomenological Data
Symptoms. During the phase of history taking
(Phase 1), participants described disturbances associ-
ated with the following symptoms:
Flashbacks and Intrusive Images. Survivors reported
disturbing intrusive images related to dead bodies such
as “I have disturbing images of one of my dead friend
keep coming at all times . . . he had a dreadful death,
the image of his intestines coming out is driving me
Stage 2. During March 17 and 18, 2015, the EMDR-
PRECI was administered on two occasions to the
13 participants in the immediate treatment condition.
Stage 3. On March 25, 2015, two independent as-
sessors applied the SPRINT to participants in both
groups (Time 2).
Stage 4. During March 26 and 27, 2015, the
EMDR-PRECI was administered on two occasions to
the 12 participants in the waitlist/delayed treatment
condition.
Stage 5. On April 3, 2015, two independent asses-
sors applied the SPRINT only to the waitlist/delayed
treatment condition participants (Time 3) for post-
treatment assessment.
Stage 6. On June 5 and 6, 2015, follow-up assessment
for all participants was conducted 90 days after the
baseline assessment (Time 4) by independent, not
blind to treatment, assessors.
Treatment
In this study, the EMDR-PRECI was selected for the
treatment based in the continuum of stressful events
the participants were currently living (e.g., physical in-
juries, the danger of another explosion, the fear to lose
their jobs, the grieving for the loss of their friends).
The protocol was administered to two groups of par-
ticipants (immediate treatment condition, N 5 13 and
waitlist/delayed treatment condition, N 5 12) on two
consecutive days. Treatment was provided in indi-
vidual sessions that were approximately 60 minutes in
length. The administration of the EMDR-PRECI was
provided by three EMDR Institute and EMDR-Ibero-
America trainers. Treatment fidelity was fulfilled by
strict observance to all steps of the scripted EMDR-
PRECI. To ensure that participants in the waitlist/
delayed treatment condition were not in severe crisis,
one short supportive telephone call was made to each
participant by the clinicians during the waitlist period.
Clinical Treatment Strategies. In all contact with
participants, clinicians in this study strived to develop
rapport, facilitate bonding, and establish a therapeutic
alliance. Their goal was to create an atmosphere of
safety, respect, and trust with the clients, projecting a
stable and confident presence based on honoring and
trusting the process. During all the interventions, ther-
apists maintained a “floating attention” in which they
moved their attention/concentration back and forth
between self and client, scanning their personal so-
matic and affect reactions, to be aware of any adverse
reaction to the client material, stay present, and avoid
unconscious maladaptive responses toward the client.
Copyright © Springer Publishing Company, LLC
Journal of EMDR Practice and Research, Volume 9, Number 4, 2015 171
EMDR-PRECI: An RCT After a Technological Disaster
on . . ., life is meaningless”; “I don’t know when I’ll
overcome this . . . .”; “If I cannot overcome this, I
won’t be able to keep my job . . ., my father told me,
‘You will never get over this.’”
Dead Wishes. “I don’t know why it didn’t happen to
me, I would no longer have problems . . .”
Peritraumatic Dissociation Symptoms. “I felt tears
streaming down my cheeks, but I really didn’t feel
anything. When I got home, I had to look at myself in
the mirror and ask, ‘Am I dead . . .?’ I don’t remember
anything, but the moment of the explosion, after is
like as if someone had teleported me.”
Emotional Symptoms. Fear, anger, guilt, sorrow,
anguish, anxiety, sadness, dismay, remorse, weakness,
uncertainty, helplessness, expressed in words such
as “I feel myself forsaken”; “Sometimes I think I’m
weak”; “I get mad when people laugh”; “I’m so afraid
I think I’m going to die”; “What bothers me the most
is the sadness and I just want to cry, all the time.”
Difficulty Expressing Feelings. “I have been feeling
very sad, although I cannot cry.”
Physical Symptoms. Sleeping problems, cramps in
the body, headaches, mouth herpes, exhaustion, fa-
tigue, tension, stress, profuse swelling, shortness of
breath, “heaviness on the head,” buzzing in the ears
(because of the blast), body aches, deceased vision,
heaviness, dry mouth, tachycardia, pain in the neck.
Behavioral Symptoms. Increase in smoking, fear to
be alone, going to sleep keeping lights and TV on, “I
go to bed with the TV and the lights on, I’m afraid
of darkness”; “I don’t want to get up, I’m so scared, I
just feel safe inside my bed!” Urge to eat sweet things
or losing appetite: “Since that day, I’m craving for
candy”; “I’m not hungry, I eat because I have to . . .”
Some of this changes affected family and friends rela-
tions: “Even my girlfriend despised me”; “I’d become
very irritable, I yell to my kids, they are shocked by
my reactions, I’m not usually like that.”
Avoidance and Isolation. “I don’t want to see any-
body,” “I just want to be alone and cry,” “I tend to start
cleaning the house for no particular reason.”
EMDR Therapy Treatment Effects
ANOVA results showed a significant main effect for the
condition factor, F(1, 80) 5 67.04, p , .000. SPRINT
scores were significantly different across time showing
the effects of the EMDR therapy through time, F(3, 80)
5 150.69, p , .000. There was also a significant interac-
tion effect, condition by time, F(2, 80) 5 55.45, p , .001.
Data indicated that in the pretreatment measures (Time
1), both group means were higher than the SPRINT
cutoff score of 14 (21 for the immediate treatment
crazy”; “Every day I can see the unrecognizable face
of my friend . . .”; “I took the pulse of one of them,
he was already dead, it reminded me of when I saw
my 6-year-old little boy dying and . . . I couldn’t do
anything to save him” (her little boy had passed away
after having choked on candy, 5 years before).
Body Sensations. Others survivors had memories
about body sensations they experienced at that moment:
“The ground was moving so badly, it was horrible, I can-
not lose the sensation . . .” or “Pieces of the roof, fell on
me, and the noise . . ., that sound keeps coming all the
time . . .” A woman diagnosed with a neck sprain said,
“I keep on remembering when the blast pushed me sud-
denly some 3 meters from my worktable . . .”
Flash-Forward. For some of them, the worst is yet
to come. Even when they know working with these
kinds or materials can be dangerous, an incident like
this is a reminder of the fragility of the life: “I’m going
to die, my children will become orphans.” Catastrophic
thinking’s as “I have the feeling that something is going
to happen to me or my family, something horrible.”
Note: In some parts of Mexico, there are beliefs
concerning the ways people die. For example, in trau-
matic accidents, such as this blast, the souls of the dead
may feel lost or confused because of the suddenness of
the event and may come from the afterworld seeking
for help: “I’m afraid to walk into my working area be-
cause of the dead . . . I’m afraid the dead may appear.”
Cognitive Symptoms
Repetitive Thoughts. Frightening thoughts about
the possibility of another explosion: “This is a time
bomb; it’s just a matter of time.” In addition, being
aware that one’s life depends on others: “I love my job,
I do it well, but what if others don’t . . ., we all could
die”; “This could happen again, our lives are in other
people’s hands.”
Guilt. Some of the coworkers noticed that prior to
the explosion, a coworker had not been following the
proper procedures: “If we had warned them, maybe
it wouldn’t have happened”; “It fills me with guilt
that I didn’t dare to say something . . ., I knew they
were doing something wrong! If I had said something
they would still be alive . . .” Feelings of inadequacy
and insecurity such as “If I had known more . . ., I
became a first responder to help, I’m going to give it
up”; “Maybe it was my fault, maybe I did something
wrong”; “I could have done something to prevent it
. . . this is a nightmare, If I made a mistake it could
be fatal!” “I think most of the time: What can I do
to avoid something like this? . . . Everything is my re-
sponsibility, it could have happened to me.”
Sense of Purpose in Life Was Challenged in Some Other
Cases. Thoughts such as “What is the point in going
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172 Journal of EMDR Practice and Research, Volume 9, Number 4, 2015
Jarero et al.
the participants, independently of the group, after re-
ceiving EMDR-PRECI treatment. Results also showed
that the effect of the therapeutic treatment was main-
tained over time (106 days from explosion).
The waitlist design controlled for the effects of
time. It has been suggested (Norris, Hamblen, Brown,
& Schinka, 2008) that symptoms can decrease natu-
rally and spontaneously after a critical incident. This
study showed no spontaneous recovery for partici-
pants in the waitlist condition. This indicates that the
improvement in the immediate treatment condition
can be attributed to the EMDR-PRECI treatment and
not to the passage of time.
In the pretreatment measures (Time 1), both group
means were higher than the SPRINT cutoff score of
14 (21 for the immediate treatment condition group
and 23 for the waitlist/delayed treatment condition
control group). The final measure (Time 4) con-
firmed low scores in SPRINT in both groups (three
for the immediate treatment condition group and two
for the waitlist/delayed treatment condition control
group). Although the score was somewhat lower in
the delayed treatment condition group, the difference
between conditions was not significant. This random-
ized controlled trial study provides evidence on the
EMDR-PRECI efficacy in reducing posttraumatic
stress symptoms after a technological disaster. Future
research in which participants assigned to a control
condition received no therapy postdisaster could
measure if the treatment prevented PTSD; however,
ethical concerns prohibit such a design.
According to Weisaeth (1994), technological di-
sasters generally cause more severe mental health
problems than natural disasters when they are of
roughly the same magnitude because they have
greater unpredictability, uncontrollability, and culpa-
bility. A comprehensive review that analyzed the risk
to health following an explosion in a technological di-
saster was published in 2012 (Finlay, Earby, Baker, &
Murray). The review revealed significant and poten-
tially long-term health implications affecting various
body systems and psychological well-being following
exposure to an explosion. Researchers recommended
an awareness of the short- and long-term health ef-
fects of explosions to identifying latent pathologies
condition and 23 for the waitlist/delayed condition).
By Time 2, patients in the immediate treatment condi-
tion showed significantly lower scores than the patients
in the waitlist/delayed control group, t(11) 5 210.08,
p 5 .000. By Time 3, patients in the waitlist condition
had received EMDR-PRECI treatment, and their scores
were similar to patients in the immediate treatment
condition by Time 2. No measures of SPRINT scores
were done for patients in the immediate treatment con-
dition at Time 3. By Time 4, both groups showed low
scores indicating the maintaining effects of the treat-
ment over time (see Figure 1 and Table 1).
Global Improvement. The SPRINT contains two
items to measure global improvement, one assess-
ing percentage change and the other rating severity.
Item 1: “How much better do you feel since begin-
ning treatment? As a percentage between 0 and 100.”
Item 2: “How much has the above symptoms im-
proved since starting treatment? 1 worse, 2 no change,
3 minimally, 4 much, 5 very much.”
On Item 1, the mean response at follow-up for the im-
mediate treatment group was 95% and for the waitlist/
delayed treatment group it was 97%. On Item 2, the mean
response at follow-up for both groups was (5) very much.
Discussion
The aim of this research was to evaluate the effective-
ness of the EMDR-PRECI in reducing posttraumatic
stress symptoms related to the explosion in an explosives
manufacturing factory north of Mexico City in which
seven employees died. The EMDR-PRECI was admin-
istered for two consecutive days to 25 survivors divided
randomly into two groups; all patients presented PTSD
symptoms related to the critical incident at baseline.
The data were analyzed using factorial ANOVA with
the effects of the EMDR-PRECI, evaluated with the
SPRINT, as dependent variable and group (two groups
of patients: immediate treatment group and waitlist/
delayed treatment group) and time (four time points)
as independent variables. Post hoc analyses using the
Scheffe post hoc criterion for significance were carried
out. Results showed significant main effects for time
and group as well as for the interaction time by group.
Results showed an overall subjective improvement in
TABLE 1. Mean Scores and Standard Deviations on the Short PTSD Rating Interview Scale Assessor’s Rating
Group NTime 1 Time 2 Time 3 Time 4
Immediate treatment condition 13 21.00 (4.22) 3.69 (2.21) 2.61 (2.84)
Waitlist/delayed treatment
condition control group
12 23.08 (4.73) 25.58 (5.82) 3.58 (2.77) 1.91 (2.10)
Total 25 22.00 (4.50) 13.24 (10.99) 3.58 (2.77) 2.28 (2.49)
Copyright © Springer Publishing Company, LLC
Journal of EMDR Practice and Research, Volume 9, Number 4, 2015 173
EMDR-PRECI: An RCT After a Technological Disaster
a human massacre situation. Journal of EMDR Practice
and Research, 6(2), 50–61.
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Models, scripted protocols and summary sheets. New York,
NY: Springer Publishing.
Maxfield, L. (2008). EMDR treatment of recent events
and community disasters. Journal of EMDR Practice and
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Maxfield, L., & Hyer, L. (2002). The relationship between ef-
ficacy and methodology in studies investigating EMDR
treatment of PTSD. Jour nal of Clinical Psychology, 58, 23–41.
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Gerson, B. (2011). The course of mental health disorder
after a disaster: Predictors and comorbidity. Journal of
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Natha, F., & Daiches, A. (2014). The effectiveness of EMDR
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Acknowledgments. To Maria Elena Estevez for her support
in this research.
Correspondence regarding this article should be directed to
Ignacio Jarero, PhD, EdD, Boulevard de la Luz 771, Jardines
del Pedregal, Álvaro Obregón, Mexico City, Mexico 01900.
E-mail: nacho@amamecrisis.com.mx
that could otherwise be overlooked in stressful situa-
tions with other visually distracting injuries.
As developing countries industrialize, technologi-
cal disasters become and increasing threat. We believe
that EEI with evidence-based protocols, such as the
EMDR-PRECI, has a natural place in the response
strategies to reduce the burden of long-term psycho-
logical sequelae after a technological disaster.
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Copyright © Springer Publishing Company, LLC
... Recently, single or double-session brief interventions have emerged as promising early intervention strategies for preventing PTSD [2]. These include Group 512 psychological intervention model from critical incident stress debriefing [21], eye movement desensitization and reprocessing protocol for recent critical incidents [22] and brief dyadic therapy from CBT [23]. Although these interventions with some other single-session therapies [24,25] stem from different treatment orientations, the therapy, as a rule, is organized with psychoeducation, coping or relaxation skills, and resource or motivational enhancement. ...
... Overall, our fining supports use of a single-session intervention for acute phase of trauma. Single-session early interventions that emerged in recent literature targets different populations including military rescue workers [21], technical disaster survivors [22], and disaster volunteers [39], school children witnessing deaths [24], and children inpatients [25]. However, they have very similar composition of the session involving psychoeducation (giving information on trauma reactions and normalization of experience), teaching coping skills to distress (affect regulation or relaxation exercises). ...
... The Acute Stress Syndrome Stabilization (ASSYST) Individual treatment intervention was born during humanitarian fieldwork and is an AIP-informed, evidence-based, carefully field-tested, and user-friendly psychophysiological algorithmic approach, whose reference is the EMDR Protocol for Recent Critical Incidents and Ongoing Traumatic Stress (EMDR-PRECI) [12][13][14][15][16][17][18][19][20]. This treatment intervention is specifically designed to provide in-person or online support to clients who present Acute Stress Disorder (ASD) or posttraumatic stress disorder (PTSD) intense psychological distress and/or physiological reactivity caused by the disorders' intrusion symptoms associated with the memories of the adverse experience(s) (21). ...
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... Раніше вони стверджували, що з точки зору мережі пам'яті (шаблони пов'язаних спогадів) ситуації гострої травми пов'язані не лише з часовими рамками (дні, тижні або місяці), але й із періодом безпеки після травми (Jarero, Artigas & Luber, 2011;Jarero & Uribe, 2011, 2012Jarero et al., 2015a;Jarero et al., 2015b). ...
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... Therefore, the continuum of prolonged adverse experiences creates a cumulative trauma exposure memory network of linked pathogenic memories with similar emotional, somatic, sensorial, and cognitive information, that does not give the cumulative state-dependent traumatic memory network sufficient time to consolidate into an integrated whole [61][62][63]. They believe that this type of prolonged adverse experiences requires an especially designed EMDR treatment protocol [64][65][66][67]. Therefore, Jarero et al., adapted the EMDR-IGTP to treat older children, adolescents, and adults living with recent, present, or past prolonged adverse experiences (e.g., ongoing or prolonged traumatic stress) and developed the EMDR-IGTP for Ongoing Traumatic Stress (EMDR-IGTP-OTS) [68][69][70][71]. ...
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Introduction. - This article evaluates developments in the field of early psychological intervention (EPI) after trauma in general and the place of early eye movement desensitization and reprocessing (EMDR) intervention (EEI) in particular. The issues and dilemmas involved with EPI and EEI will be outlined; related research presented and the current status evaluated. Literature and clinical findings. - Reviewing the literature and drawing on findings from initial research and case studies, the rationale and contribution that EMDR therapy has to offer is discussed relative to current evidence and theory regarding post-traumatic stress syndromes and trauma memories. The relative advantages of EEI will be elaborated. Discussion and conclusion. - It is proposed that EEL, while trauma memories have not yet been integrated, may be used not only to treat acute distress but may also provide a window of opportunity in which a brief intervention, possibly on successive days, could prevent complications and strengthen resilience. Through the rapid reduction of intrusive symptoms and de-arousal response as well as by identifying potential obstructions to adaptive information processing (AIP), EMDR therapy may reduce the sensitisation and accumulation of trauma memories. (C) 2012 Published by Elsevier Masson SAS.
Article
The aim of this study was to investigate the efficacy of early eye movement desensitization and reprocessing (EMDR) intervention using the EMDR recent traumatic episode protocol (R-TEP) after a traumatic community event whereby a missile hit a building in a crowded area of a town. In a waitlist/delayed treatment parallel-group randomized controlled trial, 17 survivors with posttraumatic distress were treated with EMDR therapy using the R-TEP protocol. Volunteer EMDR practitioners conducted treatment on 2 consecutive days. Participants were randomly allocated to either immediate or waitlist/delayed treatment conditions. Assessments with Impact of Event Scale-Revised (IES-R) and the Patient Health Questionnaire (PHQ-9) brief depression inventory took place at pre- and posttreatment and at 3 months follow-up. At 1 week posttreatment, the scores of the immediate treatment group were significantly improved on the IES-R compared to the waitlist/delayed treatment group, who showed no improvement prior to their treatment. At 3 months follow-up, results on the IES-R were maintained and there was a significant improvement on PHQ-9 scores. This pilot study provides preliminary evidence, supporting the efficacy of EMDR R-TEP for reducing posttrauma stress among civilian victims of hostility, and shows that this model of intervention briefly augmenting local mental health services following large-scale traumatic incidents, using an EMDR intervention on 2 consecutive days may be effective.
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The following values have no corresponding Zotero field: ID - 47