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Multisite Randomized Controlled Trial on the Provision of the EMDR Integrative Group Treatment Protocol for Ongoing Traumatic Stress Remote to Healthcare Professionals Working in Hospitals During the Covid-19 Pandemic

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Multisite Randomized Controlled Trial on the Provision of the EMDR Integrative Group Treatment Protocol for Ongoing Traumatic Stress Remote to Healthcare Professionals Working in Hospitals During the Covid-19 Pandemic

Abstract

The aim of this longitudinal multisite randomized controlled trial (RCT), using a waitlist/delayed treatment control group design, was to evaluate the effectiveness of the Eye Movement Desensitization and Reprocessing-Integrative Group Treatment Protocol for Ongoing Traumatic Stress Remote (EMDR-IGTP-OTS-R) in reducing posttraumatic stress disorder (PTSD), depression, and anxiety symptoms in healthcare professionals working in hospitals during the Covid-19 pandemic in Puebla, Mexico. The study was conducted in 2020 in the city of Puebla, Mexico with healthcare professionals (nurses and medical doctors) working in ten hospitals who received Covid-19 patients. A total of 80 healthcare professionals met the inclusion criteria. Participants' ages ranged from 21 to 51 years old (M =33.24 years). In this study, the early EMDR online group therapy intervention was initiated seven weeks after the first Covid-19 patients died in the hospitals. Intensive EMDR group treatment was provided. Data analysis by repeated measures ANOVA, showed that the EMDR-IGTP-OT-R had a significant effect on the explored variables (PTSD, Anxiety, and Depression) in time, group, and interaction time by group. Comparisons within means of the different pairs of longitudinal measurements were also useful to observe the consistency of the data. Results showed a large effect size (Cohen´s d, from 1.93 to 1.25) between the pretest and the first posttreatment assessment, being able to attribute these effects to the EMDR-IGTP-OTS-R treatment. Results were confirmed with the between-group mean comparisons since the waitlist/delayed treatment act as a control group. In this case, the effect size (Cohen´s d) varied from 3.95 to 1.92 showing a large effect of the difference between groups, attributed to the start time of the treatment. Results also showed an overall subjective global improvement in the study participants. No adverse effects (e.g., symptoms of dissociation, fear, panic, freeze, shut down, collapse, fainting), or events (e.g., suicide ideation, suicide attempts, self-harm, homicidal ideation) were reported by the participants during treatment or at three months post-treatment follow-up while all participants were still working in their hospitals receiving COVID-19 patients. None of the participants showed clinically significant worsening/exacerbation of symptoms on the PCL-5 or HADS after treatment. To the best of our knowledge, this is the first RCT on early intervention with an evidence-based trauma-focus (TF) therapy (e.g., EMDR, TF-CBT) provided online in a group format and intensive treatment modality to healthcare professionals working in hospitals during the COVID-19 pandemic. This randomized controlled trial provides evidence for the effectiveness, efficacy, feasibility, and safety of the EMDR-IGTP-OTS-R in reducing posttraumatic stress, anxiety, and depression symptoms for healthcare professionals working in hospitals during the Covid-19 pandemic, expanding the EMDR therapy frontiers.
Abstract
The aim of this longitudinal multisite randomized controlled trial (RCT), using a waitlist/de layed treatment control group design , was to
evaluate the effectiveness of the Eye Movement Desensitization and Reprocessing-Integrative Group Treatment Protocol for Ongoing Trau matic
Stress Remote (EMDR-IGTP-OTS-R) in reducing posttraumatic stress disorder (PTSD), depression, and anxiety symptoms in healthcare
professionals working in hospitals during the Covid-19 pandemic in Puebla, Mexico. The study was conducted in 2020 in the city of Puebla,
Mexico with healthcare professionals (nurses and medical doctors) working in ten hospitals who received Covid-19 patients. A total of 80
healthcare professionals met the inclusion criteria. Participants’ ages ranged from 21 to 51 years old (M =33.24 years). In this study, the early
EMDR online group therapy intervention was initiated seven weeks after the first Covid-19 patients died in the hospitals. Intensive EMDR group
treatment was provided. Data analysis by repeated measures ANOVA, showed that the EMDR-IGTP-OT-R had a significant effect on the explored
variables (PTSD, Anxiety, and Depression) in time, group, and interaction time by group. Comparisons within means of the different pairs of
longitudinal measurements were a
lso useful to observe the consistency of the data. Results showed a large effect size (Cohen´s d, from 1.93
to 1.25) between the pretest and the first posttreatment assessment, being able to attribute these effects to the EMDR-IGTP-OTS-R treatment.
Results were confirmed with the between-group mean comparisons since the waitlist/de layed treatment act as a control group. In this case, the
effect size (Cohen´s d) varied from 3.95 to 1.92 showing a large effect of the difference between groups, attributed to the start time of the
treatment. Results also showed an overall subjective global improvement in the study participants.
No adverse effects (e.g., symptoms of dissociation, fear, panic, freeze, shut down, collapse, fainting), or events (e.g., suicide ideation, suicide
attempts, self-harm, homicidal ideation) were reported by the participants during treatment or at three months post-treatment follow-up
while all participants were still working in their h ospitals receiving COVID-19 patients. None of the participants showed clinically significant
worsening/exacerbation of symptoms on the PCL-5 or HADS after treatment. To the best of our knowledge, this is the first RCT on early
intervention with an evidence-based trauma-focus (TF) therapy (e.g., EMDR, TF-CBT) provided online in a group format and intensive treatment
modality to healthcare professionals working in hospitals during the COVID-19 pandemic. This randomized controlled trial provides evidence for
the effectiveness, efficacy, feasibility, and safety of the EMDR-IGTP-OTS-R in reducing posttraumatic stress, anxiety, and depression symptoms for
healthcare professionals working in hospitals during the Covid-19 pandemic, expanding the EMDR therapy frontiers.
Keywords:
Covid-19 healthcare professionals; Randomized Controlled Trial (RCT); Early EMDR online group therapy; Online group EMDR
therapy; Eye movement desensitization and reprocessing (EMDR) online; EMDR-IG TP-OTS-Remote online; Longitudinal study; Posttraumatic
stress disorder (PTSD); Anxiety; Depression.
Psychology and Behavioral Science
International Journal
ISSN 2474-7688
Research article
Volume 15 Issue 4 - October 2020
DOI: 10.19080/PBSIJ.2020.15.555920
Psychol Behav Sci Int J
Copyright © All rights are reserved by Ignacio Jarero
Multisite Randomized Controlled Trial on the
Provision of the EMDR Integrative Group Treatment
Protocol for Ongoing Traumatic Stress Remote to
Healthcare Professionals Working in Hospitals During
the Covid-19 Pandemic
Pérez María Cristina1, Estévez María Elena2, Becker Yael2, Osorio Amalia1, Jarero Ignacio2* and Givaudan
Martha2
1Department of Research, Ágape Desarrollo Integral, Mexico
2Department of Research, Mexican Association for Mental Health Support in Crisis, Mexico
Submission: September 27, 2020; Published: October 30, 2020
*Corresponding author: Ignacio Jarero, Department of Research, Mexican Association for Mental Health Support in Crisis, Mexico City, Mexico
Introduction
On December 30, 2019, a cluster of pneumonia cases of
unknown etiology was reported in Wuhan, Hubei Province,
China. On 9 January 2020, the China Center for Disease Control
(CDC) reported a novel coronavirus as the causative agent of this
outbreak, which is phylogenetically in the SARS-CoV clade. On
January 30, 2020, the World Health Organization (WHO) declared
the emergence of the novel coronavirus as a public health
Psychol Behav Sci Int J 15(4) PBSIJ.MS.ID.555920 (20
20) 001
Psychology and Behavioral Science International Journal
How to cite: Pérez M C, Estévez M E, Beck er Y, Osorio A, Jarero I, et al. Multisite Randomized Controlled T rial on the Provision of the EMDR
Integrative Group Treatment Protocol for Ongoing Traumatic Stress Remote to Healt hcare Professionals Working in Hospitals During the Covid-
19
Pandemic. Psychol B ehav Sci Int J .2 020; 15(4): 555920. DOI: 10.19080/PBSIJ.2020.15.555920
002
emergency of international concern (PHEIC) [1]. On September 26,
2020, the World Health Organization (WHO) reported 32,429,965
confirmed COVID-19 cases with 985,823 deaths around the world
and 715,457 confirmed cases with 75,439 deaths in Mexico,
being the third country in the world with the highest number
of deaths and the first country with the highest numbers of
healthcare professionals’ deaths [2,3]. The United Nations (UN)
alerted the world about the high risk of a major mental health
crisis caused by the COVID-19 pandemic and recommended the
urgent widespread availability and use of mental health care and
psychosocial support to address this situation [4].
The psychological impact on healthcare professionals
working in hospitals with COVID-19 patients has been severe. In
a study conducted in China by Liu et al., with a sample of 1,563
medical workers, results showed that 73.40% reported stress-
related symptoms, 50.70% depression symptoms, 44.70%
anxiety, and 36.10% insomnia [5]. In another study conducted
with 1,257 healthcare workers from 34 hospitals in China, results
showed high rates of psychological stress: 50.4% had symptoms
of depression, 44.6% symptoms of anxiety, 34% insomnia, and
71.5% general psychological distress. Regarding these outcomes,
nurses, female staff, and staff working directly with patients were
more likely to have severe scores [6]. In a study conducted in a
New York City large medical center during a peak of inpatients
admissions for COVID-19 with a sample of 657 healthcare
professionals, 57% reported acute stress, 48% depression, and
33% anxiety symptoms [7]. Three hundred and thirty health
professionals working in hospitals in the northern regions of
Italy participated in an online survey. 71.2% had scores of state
anxiety (the transitory state of fear and emotional tension as a
response to a perceived threatening situation) above the clinical
cutoff, 26.8% had clinical levels of depression, 31.3% of anxiety,
34.3% of stress, and 36.7% of posttraumatic stress. Predictors of
both emotional exhaustion and depersonalization (40.1%) were:
1) female gender, and 2) being a nurse working in the hospital in
contact with COVID-19 patients [8]. Healthcare frontline workers,
nurses, and nursing students working with COVID-19 patients
are experiencing significant levels of emotional distress and are
exposed to a variety of sources of mental health burden [9,10].
Because of the increased risk for mental health challenges, to
Pearman et al., COVID-19 may function as an occupational hazard
for healthcare professionals and encourage efforts to intervene to
provide relief now and in the future [11].
Transmissibility of COVID-19 via direct contact hinders face-
to-face traditional mental health treatment options. Fortunately,
Telehealth enables mental health professionals to deliver, support,
or enhance mental health services while minimizing in-person
contact. Telehealth is broadly defined as health services that are
delivered via communication technologies, such as telephone
and clinical video teleconferencing (CVT) which enables patients
and mental health professionals to meet synchronously in real-
time through a video platform [12]. The use of Telehealth has
had an exponential increase during the COVID-19 pandemic. For
example, online psychological counseling services, online mental
health education, and online psychological self-help interventions
have been widely used in mainland China, providing free 24-h
services on all days of the week [13]. Individuals with previous
COVID-19 pandemic posttraumatic stress disorder (PTSD) may
experience an increase in symptoms caused for new stressors.
Also, new cases of PTSD may develop following exposure to
COVID-19-related adverse experiences, especially in healthcare
workers (e.g., prolonged exposure to a personal threat and
patient´s suffering and death). Therefore, the need for evidence-
based online therapies to treat PTSD is crucial.
Telehealth has shown to be a promising treatment modality
across a variety of trauma-exposed populations using cognitive
behavioral therapy (CBT)-based interventions [14-16]. To Lewis
et al., the efficacy of internet-delivered CBT for PTSD should be
considered with caution [17]. Regarding online delivered EMDR
therapy for PTSD, we conducted a systematic search for clinical
trials and only found one published study. This uncontrolled
open trial feasibility study examined the efficacy of a 6-week
intervention, combining internet-delivered CBT with a web-based
self-guided EMDR tool with 15 participants. In the first session, the
clients were guided by an EMDR therapist by phone. Subsequent
sessions were unguided. Although results showed potential
efficacy, the study is limited by the lack of a control group, the
small sample, the EMDR clinician minimal participation, and the
unknown of the relative effects of each one of the two interventions
(CBT and EMDR) [18].
EMDR Therapy
Eye Movement Desensitization and Reprocessing (EMDR)
therapy is a structured, eight-phase comprehensive approach
that addresses the past, present and future aspects of adverse
life experiences, and it is guided by the Adaptive Information
Processing (AIP) model [19]. This theoretical model posits that
psychopathology is primarily caused by memories of traumatic or
adverse life experiences that have been inadequately processed
and maladaptively stored in a state-specific form. EMDR therapy
and trauma-focused Cognitive Behavioral Therapy (TF-CBT) are
recommended for the treatment of PTSD by the World Health
Organization (WHO), the American Psychiatric Association (APA),
the American Psychological Association (APA), the International
Society for Traumatic Stress Studies (ISTSS), the National Institute
for Health and Care Excellence (NICE), and the U.S. Department
of Veterans Affairs/Department of Defense treatment guidelines
(VA/DoD) [20-25]. EMDR therapy has shown efficacy as an early
intervention treatment and on being the most cost-effective
intervention for adults with PTSD among 11 evaluated options
(e.g., TF-CBT, combined TF-CBT/SSRIs, combined somatic/
cognitive therapies, self-help with support, psychoeducation)
[26,27].
Psychology and Behavioral Science International Journal
How to cite:
Pérez M C, Estévez M E, Becker Y, Osorio A, Jarero I, et al. Multisite Randomize d Controlled Trial on the Provision of the EMDR
Integrative
Group Treatment P rotocol for Ongoing Traumatic Stress Remote to Healthcare Professionals Working i n Hospitals During the Covid-
19 Pandemic.
Psychol Behav Sci Int J .2020; 15(4): 555920. DOI: 10.19080/PBSIJ .2020.15.555920
003
EMDR-Integrative Group Treatment Protocol for On-
going Traumatic Stress Remote
The EMDR-integrative group treatment protocol (EMDR-IGTP)
for early intervention was developed by members of the Mexican
Association for Mental Health Support in Crisis (AMAMECRISIS)
to deal with the extensive need for mental health services after
Hurricane Pauline ravaged the coasts of the states of Oaxaca and
Guerrero in the year 1997 [28]. It is the first EMDR individual
treatment in a group format protocol. The protocol combines the
eight EMDR treatment phases with a group therapy model and
an art therapy format and uses the Butterfly Hug (BH) as a form
of self-administered bilateral stimulation [29]. This protocol has
a substantial body of research and has been used in its original
format or with adaptations to suit the cultural circumstances, in
numerous places around the world for thousands of survivors of
natural or man-made disasters and with many other populations
and circumstances (e.g, during ongoing war trauma, during an
ongoing geopolitical crisis, with war refugee children, with
children and adolescents who were victims of severe interpersonal
violence, with cancer patients, with caregivers of patients with
dementia, with refugee minors, as an emergency treatment to
children survivors of terrorist attacks, with female survivors of
exploitation, trafficking and early marriage) [30-58].
The risk of PTSD and comorbid disorders increases with the
number of exposures. In contrast to studies of populations
exposed to single-incident traumatic events, McFarlan et al. [59]
mention that “patterns of emerging neurobiological dysregulation
and symptom development with repeated trauma exposure have
been demonstrated to occur on a continuum rather than as a
sudden transition at the diagnosis threshold of full PTSD” (p. 9)
[59]. In their clinical case conceptualization based on the AIP
model, from a memory networks perspective, Jarero & Artigas
assert that for individuals living ongoing traumatic experiences
(like healthcare professionals working in hospitals during the
Covid-19 pandemic) in which there is not a post-trauma safety
window for traumatic memory consolidation, the consolidation of
the traumatic memory is prevented [60]. 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 [61-63]. They believe that this type of prolonged adverse
experiences requires an especially designed EMDR treatment
protocol [64-67]. 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) [68-71]. Due to the
Covid-19 pandemic, and the impossibility to treat the clients in
person, the EMDR-IGTP-OTS was adapted to be provided remotely
(online) and the EMDR-IGTP-OTS-Remote was developed.
Objective
The objective of this longitudinal multisite randomized
controlled trial (RCT) was to evaluate the effectiveness of the
EMDR-IGTP-OTS-R in reducing posttraumatic stress disorder,
depression, and anxiety symptoms in healthcare professionals
working in ten hospitals who received COVID-19 patients during
the pandemic in Puebla, Mexico.
Method
Study Design
To measure the effectiveness of the EMDR-IGTP-OTS-R on the
dependent variables PTSD, Anxiety, and Depression, this study used
a two arms longitudinal multisite randomized control trial (RCT)
design. For ethical reasons (provide therapy to all participants),
we selected a waitlist/delayed treatment control group design,
comparing immediate treatment and waitlist/delayed treatment
groups. PTSD, anxiety, and depression symptoms were measured
in four-time points for all participants in the study: Time 1.
Baseline assessment; Time 2. Immediate treatment group (ITG)
post-treatment assessment; Time 3. Waitlist/delayed treatment
control group (DTG) post-treatment assessment, and Time 4.
Follow-up assessment. The subjective global improvement for all
participants was measured at Time 4 Follow-up.
Ethics and Research Quality
The research protocol was reviewed and approved by the ten
hospitals Institutional Review Boards (IRB): Hospital General
de Traumatología y Ortopedia IMSS Puebla, Clínica 30 del IMSS,
Hospital General la Margarita IMSS Puebla, Clínica 8 del IMSS,
Unidad Médico Familiar del IMSS, Clínica 6 del IMSS, Hospital
General de Zona No. 5 IMSS Metepec, Puebla; Hospital Regional
de Zona No. 36 IMSS Puebla, Clínica 57 IMSS Puebla, Hospital
General de Zona No. 1 “La Loma” IMSS Tlaxcala; in compliance
with the International Committee of Medical Journal Editors
recommendations, the Guidelines for Good Clinical Practice of the
European Medicines Agency (version 1 December 2016) and the
Helsinki Declaration as revised in 2013. The research quality of
this study was based on the Consolidated Standards of Reporting
Trials (CONSORT) 2010 Statement and the Standard Protocol
Items Recommendation for Interventional Trials (SPIRIT) 2013
checklist [72-73].
Participants
This study was conducted in 2020 in the city of Puebla, Mexico
with healthcare professionals (e.g., nurses, medical doctors)
working in ten hospitals who received Covid-19 patients. 93
potential participants were recruited. Inclusion criteria were:
(a) being adult, (b) being a healthcare professional (nurse or
medical doctor) working in one of the ten hospitals who received
Covid-19 patients, (c) voluntarily participating in the study, (d)
not receiving specialized trauma therapy, (e) not receiving drug
therapy for posttraumatic stress disorder symptoms. Exclusion
criteria were: (a) ongoing self-harm/suicidal or homicidal
Psychology and Behavioral Science International Journal
How to cite: Pérez M C, Estévez M E, Beck er Y, Osorio A, Jarero I, et al. Multisite Randomized Controlled T rial on the Provision of the EMDR
Integrative Group Treatment Protocol for Ongoing Traumatic Stress Remote to Healt hcare Professionals Working in Hospitals During the Covid-
19
Pandemic. Psychol B ehav Sci Int J .2 020; 15(4): 555920. DOI: 10.19080/PBSIJ.2020.15.555920
004
ideation, (b) diagnosis of schizophrenia, psychotic or bipolar
disorder, (c) diagnosis of dissociative disorder, (d) organic mental
disorder, (e) a current, active chemical dependency problem,
(f) significant cognitive impairment (e.g., severe intellectual
disability, dementia), (g) presence of uncontrolled symptoms due
to medical illness.
Blind Randomization, Allocation Concealment
Mechanism, and Blinding Procedure
Simple randomization using a computer-generated random-
number list with a 1:1 allocation ratio was used. Two
independent assessors blind to treatment conditions conducted
the randomization process to avoid allocation influence. One of
them provided the random-number list and the other assigned
random identification (ID) codes to each random-number in the
list to protect the participant´s identity. The treatment allocation
sequence with the ID codes was concealed using sequentially
numbered, opaque, sealed, and stapled envelopes. The safekeeping
of the envelopes and the assignment of participants to each arm
of the trial was overseen by a person not involved in the research
study.
The treatment allocation of the participants was blinded for
the research assistants (all mental health professionals) who
conducted the intake interview and the enrollment. All the
assessments, from Time 1 to Time 4, were conducted with the
participants answering the self-administered instruments online
and using an identification code instead of their name to protect
their identity. An independent assessor received the instruments
already answered online and was the safe keeper of all the data.
There was no need to instruct participants to not reveal their
treatment allocation to the persons conducting the assessments
because all the participants answered the assessment instruments
online.
Thirteen potential participants were excluded because they
did not work in the ten hospitals as healthcare professionals (e.g,
teachers, pharmacy employees). A total of 80 participants met the
inclusion criteria. Participants’ age ranged from 21 to 51 years
old (M =33.24 years old). Participation was voluntary with the
participants’ signed informed consent. There were 40 participants
(39 female and 1 male) in the immediate treatment condition
group and 40 participants (30 female and 10 male) in the waitlist/
delayed treatment condition group. See Flow Diagram.
Psychology and Behavioral Science International Journal
How to cite:
Pérez M C, Estévez M E, Becker Y, Osorio A, Jarero I, et al. Multisite Randomize d Controlled Trial on the Provision of the EMDR
Integrative
Group Treatment P rotocol for Ongoing Traumatic Stress Remote to Healthcare Professionals Working i n Hospitals During the Covid-
19 Pandemic.
Psychol Behav Sci Int J .2020; 15(4): 555920. DOI: 10.19080/PBSIJ .2020.15.555920
005
Instruments
1) We used the Posttraumatic Stress Disorder Checklist for
DSM-5 (PCL-5) provided directly by the National Center for
PTSD (NCPTSD) and adapted, with the NCPTSD approval, the
time interval for symptoms to be the past week instead of the
past month [74-75]. The instrument was translated and back-
translated to Spanish. It contains 20 items, including three new
PTSD symptoms (compared with the PTSD Checklist for DSM-IV)
[76]: blame, negative emotions, and reckless or self-destructive
behavior. Respondents indicate how much they have been
bothered by each PTSD symptoms over the past week (rather than
the past month), using a 5-point scale ranging from 0=not at all,
1=a little bit, 2=moderately, 3=quite a bit, and 4=extremely. A total-
symptoms score of zero to 80 can be obtained by summing the
items. The sum of the scores yields a continuous measure of PTSD
symptom severity for symptom clusters and the whole disorder.
Psychometrics for the PCL-5, validated against the Clinician-
Administered PTSD Scale-5 (CAPS-5) diagnosis, suggest that a
score of 31-33 is optimal to determine probable PTSD diagnosis
[77-78], and a score of 33 is recommended for use at present. The
PCL-5 is intended for a variety of clinical and research assessment
tasks, including quantifying PTSD symptom severity, measuring
the underlying construct of PTSD, establishing a provisional
PTSD diagnosis, and estimating the presumed prevalence of
PTSD. A score decrease between five to ten points demonstrates
a clinically significant change. Decision rules for PTSD diagnosis
based on PCL-5 are very accurate compared to CAPS diagnosis
results. It is important to mention that at the first assessment,
before answering the PCL-5, all participants were asked to
focus specifically on the worst Covid-19 work-related event that
currently bothered them the most; then at each subsequent
assessment, they were asked to focus on the same event.
2) The Hospital Anxiety and Depression Scale (HADS) has
been extensively used to evaluate these psychiatric comorbidities
in various clinical settings at all levels of healthcare services and
with the general population [79-80]. The instrument was
translated and back-translated to Spanish. It is a 14-item self-
report scale to measure the anxiety (7 items) and depression (7
items) of patients with both somatic and mental problems using a
4-point Likert scale ranging from 0 to 3. The response descriptors
of all items are Yes, definitely (score 3); Yes, sometimes (score 2);
No, not much (score 1); No, not at all (score 0). A higher score
represents higher levels of anxiety and depression: a domain
score of 11 or greater indicates anxiety or depression; 810
indicates borderline case; 7 or lower indicates no signs of anxiety
or depression.
3) We used the Short PTSD Rating Interview Scale (SPRINT)
to measure the subjective global improvement of the study
participants at Time 4 Follow-up assessment. The SPRINT is an
8-item interview or self-rating questionnaire with solid
psychometric properties that can serve as a reliable, 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 [81]. The
SPRINT contains two items to measure global improvement, one
assessing percentage change and the other rating severity. Item
1: “How much better do you feel since beginning treatment? As
a percentage between 0 and 100.” Item 2: “How much have the
above symptoms improved since starting treatment? 1 worse, 2
no change, 3 minimally, 4 much, 5 very much.”
Procedure
Enrolment, Assessments Times, Blind Data Collection,
and Confidentiality of Data
Each hospital sent an institutional email to their healthcare
personnel (nurses and medical doctors) inviting them to
participate in the study and giving them a phone number for
the intake interview. Immediate treatment and waitlist/delayed
treatment group participants completed the self-administered
instruments online on an individual basis in the four different
measurement moments. During time 1, research assistants (all
mental health professionals) blind to treatment allocation,
conducted the intake interview by phone, assessed potential
participants for eligibility based on the inclusion/exclusion
criteria, collected their data (e.g., name, age, gender, profession,
email, telephone), obtained signed informed consent, enrolled
participants in the study, sent the participant’s data to the data
safe keeper independent assessor and sent to the treatment
allocation envelope´s safe keeper only the participant’s name and
email.
After this procedure, the treatment allocation envelope’s safe
keeper (not involved in the research study) sent to each enrolled
participant the link to answer the assessment instruments
online, their ID codes, and the treatment dates. The data safe
keeper independent assessor received the names, ID codes, and
participant’s allocation on each arm of the study from the
envelope´s safe keeper, and also the participant’s instruments that
were already answered online. Time 2 and Time 3 assessments
were conducted online 15 days after the completion of each
group treatment. Time 4 assessment was conducted online 90-
days after the waitlist/delayed group treatment’ completion. All
data was collected, stored, and handled in full compliance with
the hospital´s Institutional Review Board (IRB) requirements to
ensure confidentiality. Each study participant gave their consent
for access to their data, which was strictly required for study
quality control. All persons involved in this research project were
subject to professional confidentiality.
Withdrawal from the Study
All research participants had the right to withdraw from the
study without justification at any time and with assurances of no
prejudicial result. If participants decided to withdraw from the
Psychology and Behavioral Science International Journal
How to cite: Pérez M C, Estévez M E, Beck er Y, Osorio A, Jarero I, et al. Multisite Randomized Controlled T rial on the Provision of the EMDR
Integrative Group Treatment Protocol for Ongoing Traumatic Stress Remote to Healt hcare Professionals Working in Hospitals During the Covid-
19
Pandemic. Psychol B ehav Sci Int J .2 020; 15(4): 555920. DOI: 10.19080/PBSIJ.2020.15.555920
006
P
P
P
study, they were no longer followed up in the research protocol.
There were six withdrawals for personal reasons not related to
the study. See Flow Diagram.
Treatment
In this study, intensive early group EMDR online therapy was
provided. Evidence suggests that more frequent scheduling of
treatment sessions maximizes PTSD treatment outcomes,
improves treatment response, and reduces treatment dropout
[82-85]. Participants completed a total of four online group
treatment sessions provided once a day during interspersed days
(i.e., Monday, Wednesday, Friday, Sunday).
Therapists and Treatment Fidelity
EMDR-IGTP-OTS-R was provided online by 21 licensed EMDR
clinicians formally trained in the protocol administration using
a Zoom HIPAA Compliance program. Videos and screenshots of
each online intervention were allowed and accepted by each
participant in the informed consent and were used by independent
raters to monitor the treatment fidelity and adherence to all steps
of the protocol.
EMDR-IGTP-OTS-R Treatment Description and Safety
Measure
The intake interview was made by phone for each potential
group participant. Each of the participants received an average
of 4.5 hours of online treatment, provided during four online
group treatment sessions, once a day during four interspersed
days. Treatment focused only on the distressing memories related
to their work as healthcare professionals working in a hospital
who received COVID-19 patients and did not address any other
memories. During this process, participants followed directions
from the team leader and worked quietly and independently on
their distressing memories. The first treatment session lasted an
average of 90 minutes. Subsequent treatment sessions lasted an
average of 60 minutes. To encompass the whole ongoing traumatic
stress spectrum lived by the participants, the team leader asked
each of the participants to “Run a mental movie of everything that’s
happened in your work as a health professional, from right before
the beginning of the first COVID-19 patient’s death until today,
or even looking into the future.” The initial treatment target was
the worst part of the mental movie. In subsequent sessions, the
team leader asked participants to run the mental movie again and
target any other memory that was currently disturbing, noticing
associated emotions and body sensations. Participants in this
study used the Butterfly Hug (BH) 24 times as a self-administered
bilateral stimulation method to process traumatic material. All
participants reprocessed more than one distressing memory. As
a safety measure, participants were instructed to immediately
report to the EMDR clinician’s coordinator any adverse effects
(e.g., symptoms of dissociation, fear, panic, freeze, shut down,
collapse, fainting), events (e.g., suicide ideation, suicide attempts,
self-harm, homicidal ideation), or symptoms worsening, during
the entire study time-frame.
Examples of Worst Experiences Reprocessed During
the Online Treatment
Generally, the worst experiences that the participants
reprocessed were related to having to work with infected patients
and fear of getting the virus themselves. In other cases, the worst
experience was feeling like they had symptoms such as fever or
headache and thinking that they might be sick and die or that they
could infect a family member. Other participants reported that the
worst experience was witnessing patients or co-workers suffer
and die from the disease, causing fear and frustration. Some other
experiences relate to not having adequate material or space to
care for the large number of patients who showed up to the health
centers and this made them feel helpless and angry. Also having
to wear protective material, such as mouth covers and masks, for
eight hours straight caused them physical injuries and they still
had to continue using them. Some were afraid of losing their jobs.
Statistical Analysis
Statistical analysis was conducted for those participants, in
both Immediate Treatment Group (ITG) (N=35) and Waitlist/
Delayed Treatment Control Group (DTG) (N=39), who completed
all the four assessment times. Analyses of variance (ANOVA) for
repeated measurements were used to analyze the effect of time
and group for PTSD, Anxiety, and Depression; t-test and Cohen´s
d effect size was calculated using within and between designs for
mean comparison among the different measurements.
Results
PTSD (PCL-5).
Data analysis by repeated measures ANOVA revealed a
significant effect for time (F (3, 216) = 594.54 p <.001, η 2 =
.892), a significant effect for group (F (1, 72 = 26.57, p<.001, η 2
= .270) and a significant interaction between time and group, (F
(3, 216) = 150.84, p <.001, η 2 = .677). Comparison by group at
base line did not show significant differences for time 1. For time
2 significant differences between the Immediate Treatment Group
(ITG) and the Waitlist/Delayed Treatment Control Group (DTG)
were found, t (72) = - 13.27, p <.001, d = 3.95. Differences among
groups continued over time. For time 3, t (72) = - 3.43 p <.001, d
= .79, and for time 4, t (72) = -2.48, p <.01, d=.58. In both ITG and
DTG, mean scores showed a significant decrease after the first
treatment session, t (34) = 36.21, p<.000, d = 1.75 (comparison
between T1 and T2) for the ITG and t (38) = 37.24, p <.000, d =
1.87 for the DTG (comparison between T2 and T3). There was
also a significant decrease in the last following measurements in
each group, t (34) = 2.76, p<.01, d = .111 for ITG, and t (38) = 5.47
p<.001, d = .229 for the DTG. In the DTG significant differences
were also found between baseline and time 2, t (38) = -3.0, p<.005,
d = .33. Means showed an increase in PCL-5 scores for this group
during the waiting time for treatment. See Figure 1 and Table 1.
Psychology and Behavioral Science International Journal
How to cite:
Pérez M C, Estévez M E, Becker Y, Osorio A, Jarero I, et al. Multisite Randomize d Controlled Trial on the Provision of the EMDR
Integrative
Group Treatment P rotocol for Ongoing Traumatic Stress Remote to Healthcare Professionals Working i n Hospitals During the Covid-
19 Pandemic.
Psychol Behav Sci Int J .2020; 15(4): 555920. DOI: 10.19080/PBSIJ.2020.15.555920
007
P
P
P
Anxiety
Repeated measures analysis of variance (ANOVA) for anxiety
showed a significant effect for time (F (3, 216) = 279.29, p <.001,
η 2 = .795) and a significant effect for group (F (1, 72) = 11.01, p
<.001, η 2= .133). Significant interaction effect was found for time
and group (F (3, 216) = 47.72 p<.001, η 2 = .399. Mean comparison
between groups did not show significant differences at baseline.
For time 2, significant differences between groups were found, t
(72) = 8.98, p<.001, d = 2.09, which remain in time 3, t (72) = 2.54,
p<.01, d = .59. No significant differences between groups were
found by time 4. Results analyzing differences by group show that
for the ITG there were significant differences comparing baseline
and time 2, t (34) = 12.15, p<.00, d = 1.37, as well as comparing
time 2 and time 3, t (34) = 3.89, p<.001, d = .25. No differences
were found between time 3 to time 4. For the DTG no differences
were found between base line and time 2. Significant differences
were found between time 2 and time 3 (after the first treatment
session), t (38) = 18.50, p<.001, d= 1.25 and between time 3 and
time 4, t (38) = 8.52, p<.001, d= .59. See Figure 2 and Table 1.
Table 1: Mean scores (M) and standard deviations (SD) for Immediate Treatment Group (ITG) and Delayed Treatment Group (DTG) on the base-
line and follow up measurements.
Time 1 Time 2 Time 3 Time 4
M SD M SD M SD M SD
PTSD
ITG 35.85 6.42 21.22 5.29 19.4 5.55 18.54 5.45
DTG 35.48 3.64 37.64 5.32 23.69 5.21 21.87 5.99
Anxiety
ITG 14.45 2.63 9.48 2.48 8.42 3.28 8.11 2.8
DTG 14.15 2.68 14.28 2.1 9.89 1.42 8.66 1.53
Depression
ITG 12.94 2.54 7.31 3.29 6.62 3.29 6.11 3.29
DTG 12.71 2.58 12.84 2.43 7.58 1.81 6.3 1.68
Figure 1: Mean scores and standard error for PTSD symptoms by time and group.
Psychology and Behavioral Science International Journal
How to cite: Pérez M C, Estévez M E, Beck er Y, Osorio A, Jarero I, et al. Multisite Randomized Controlled T rial on the Provision of the EMDR
Integrative Group Treatment Protocol for Ongoing Traumatic Stress Remote to Healthcare Professionals Working in Hospitals During the Covid-
19
Pandemic. Psychol B ehav Sci Int J .2 020; 15(4): 555920. DOI: 10.19080/PBSIJ.2020.15.555920
008
P
P
P
Figure 3: Mean scores and standard error for Depression by time and group.
Depression
About depression, significant effects were found through
ANOVA repeated measurement analysis for time (F (3, 216) =
414.98, p <. 001, η 2 = .852). Results also showed significant
interaction effects between time and group (F (3, 216) = 80.82,
p <.001, η 2 = .529) and significant effects for group, F (1,72) =
8.18, p<.05, η 2 = .102. Comparison between groups did not
showed significant differences at baseline. For time 2 significant
differences were found between groups, t (72) = 8.26, p<.001, d =
1.92. No other intragroup differences were found in the following
comparisons. For the ITG significant differences were found in all
comparisons. Between baseline and time 1, t (34) = 14.55, p<.001,
d = 1.93, between time 2 and time 3, t (34) = 4.08, p<.001, d = .14
and between time 3 and time 4, t (34) = 4.09, p<.001, d = .11. For
the DTG, no differences were found between base line and time
1. Significant differences were found between time 2 and time 3,
(after the first treatment session), t (38) = 18.99, p<.001, d = 1.73,
and between time 3 and time 4, t (38) = 6.98, p<.000, d =.51. See
Figure 3 and Table 1.
Global Improvement
Results of the Short PTSD Rating Interview Scale (SPRINT)
showed that for item 1: “How much better do you feel since
beginning treatment? The mean response at follow-up for the ITG
was 84.6% (N= 74) and for DTG it was 83.59% (N=74). About item
Figure 2: Mean scores and standard error for Anxiety by time and group.
Psychology and Behavioral Science International Journal
How to cite:
Pérez M C, Estévez M E, Becker Y, Osorio A, Jarero I, et al. Multisite Randomize d Controlled Trial on the Provision of the EMDR
Integrative
Group Treatment P rotocol for Ongoing Traumatic Stress Remote to Healthcare Professionals Working i n Hospitals During the Covid-
19 Pandemic.
Psychol Behav Sci Int J .2020; 15(4): 555920. DOI: 10.19080/PBSIJ .2020.15.555920
009
2: “How much have the above symptoms improved since starting
treatment? the mean response at follow-up for both groups was
(4) much.
Safety and symptoms worsening
There were no adverse effects (e.g., symptoms of dissociation,
fear, panic, freeze, shut down, collapse, fainting), or events (e.g.,
suicide ideation, suicide attempts, self-harm, homicidal ideation)
reported by the participants during treatment or at three months
post-treatment follow-up while all participants were still working
in their hospitals receiving COVID-19 patients. None of the
participants showed clinically significant worsening/exacerbation
of symptoms on the PCL-5 or HADS scores after treatment.
Discussion
The aim of this longitudinal multisite randomized controlled
trial (RCT) was to evaluate the effectiveness of the EMDR-IGTP-
OTS-R in reducing posttraumatic stress disorder, depression, and
anxiety symptoms in healthcare professionals working in ten
hospitals during the Covid-19 pandemic in Puebla, Mexico. A total
of 80 healthcare professionals met the inclusion criteria and were
randomly assigned to an immediate treatment group (ITG) or a
deleted treatment group (DTG). Participants’ ages ranged from
21 to 51 years old (M =33.24 years). Participation was voluntary
with the participants’ signed informed consent. In this study,
the early EMDR online group therapy intervention was initiated
seven weeks after the first Covid-19 patients died in the hospitals.
Intensive EMDR group treatment was provided online by twenty-
one licensed EMDR clinicians formally trained in the protocol
administration using a HIPAA Compliant Zoom program.
Analyses of variance for repeated measurements were used as
well as t-test for between and within mean comparisons, including
the calculation of Cohen´s d effect size. Results were consistent
for the three studied variables (PTSD, anxiety, and depression). In
all cases, significant effects for time, group, and interaction time
by group were found. Comparisons within means of the different
pairs of longitudinal measurements were also useful to observe
the consistency of the data in the three included variables in both
groups. Results showed a large effect size (Cohen´s d, from 1.93 to
1.25) between the pretest and the first posttreatment evaluation,
being able to attribute these effects to the EMDR-IGTP-OTS-R
treatment. Results were confirmed with the between-group mean
comparisons since the DTG act as a control group. In this case,
the effect size (Cohen´s d) varied from 3.95 for PTSD to 1.92 for
depression showing, in all cases, a large effect of the difference
between groups, attributed to the start time of the treatment.
Specifically, it is interesting to note that there was a significant
PTSD symptom’s increment in the DTG between the first and
the second assessments, reinforcing the recommendation for
early EMDR treatment as soon as possible under these or similar
circumstances. Time 4 assessment conducted online 90-days
after the waitlist/delayed group treatment’ completion showed a
significant decrease in scores for PCL-5 in both groups denoting an
effect of the treatment in PTSD symptoms reduction even though
the study participants continued working with infected patients,
witnessing deaths, and facing their own and their families risk for
the disease.
During the COVID-19 pandemic, front-line workers such
as staff in administrative and logistic departments, emergency
responders, medical technicians, and healthcare professionals
(medical doctors and nurses) around the world, have been
working in challenging environments (e.g., shortage of personal
protective equipment’s and medical supplies, longer working
hours, risk of personal illness or death, fear of infecting their
families), exposed to numerous stressors and tremendous
pressure (e.g., choose which patients to save, exposure to the death
and suffering of their patients), witnessing their colleagues dying,
and suffering significant trauma with mental health implications
in the short and long-term. Therefore, ensuring their mental
health using evidence-based and cost-effective online therapies
that can be delivered in group and individual formats is an ethical
imperative. EMDR-IGTP-OTS-R can help upscale the Telehealth
options and can reduce cultural resistance to treatment because it
is minimally intrusive and does not require creating a narrative of
the traumatic experience, verbal or written disclosure of details,
the prolonged reliving of traumatic experiences, or homework
relieving the adverse experience.
Conclusion, Limitations, and Future Directions
During the Covid-19 pandemic, healthcare professionals
working in hospitals who received Covid-19 patients around
the world presented posttraumatic stress, depression, and
anxiety symptoms, among others (e.g., insomnia). The study
results showed that the EMDR-IGTP-OTS-R can effectively and
safely be provided online in a group format and in an intensive
treatment modality to healthcare professionals living work-
related prolonged adverse experiences, to reduce PTSD, anxiety,
and depression symptoms.
Besides the multiple strengths of this study, a limitation is the
lack of a formal diagnosis of PTSD in the researched population and
the 90-days follow-up. There is an imperative need to examine the
effects of online-delivered EMDR therapy for PTSD in individual
and group formats. We recommend randomized controlled trials
using an instrument to conduct formal PTSD diagnosis (e.g.,
Clinician-Administered PTSD Scale-5), comparing EMDR therapy
with other online-delivered therapies, and with follow-up at six or
twelve months to evaluate the long-term treatment effects.
Conflict of Interest and Founding
The authors declare that they have no competing interests.
Acknowledgments
We want to express our gratitude to all the EMDR clinicians and
research assistants that participated in this study, and especially
to: Alma Belén Vergara Sánchez, Carlos Gancedo del Río, Araceli
Psychology and Behavioral Science International Journal
How to cite: Pérez M C, Estévez M E, Beck er Y, Osorio A, Jarero I, et al. Multisite Randomized Controlled T rial on the Provision of the EMDR
Integrative Group Treatment Protocol for Ongoing Traumatic Stress Remote to Healt hcare Professionals Working in Hospitals During the Covid-
19
Pandemic. Psychol B ehav Sci Int J .2 020; 15(4): 555920. DOI: 10.19080/PBSIJ.2020.15.555920
0010
López Tlaque, Carmen María Priante Bretón, Carmen Rangel
Calderón, Claudia Eugenia Tarasco Michel, Claudia Beatriz Varela
Cabral, Carolina Domínguez Baron, Denisse Talamás Salazar, Edda
Gabriela Pelayo Maurer, Giselle Ortiz Carreto, Graciela Verónica
Guillén Sojo, Leticia Miranda Alamo, Marcela Obeso Fernández,
Miryam Sandra del Carmen Jiménez Alarcón, Paola García Mier
y Terán, Paula Ehlinger Escudero, Verónica Quintana Osorio,
Viviana Triana, and Lynne Levinson.
References
1. Euro surveillance Editorial, T (2020) Note from the editors: World
Health Organization declares novel coronavirus (2019-nCoV) sixth
public health emergency of international concern. Euro Surveillance.
2. World Health Organization Coronavirus disease (COVID-19) Situation
Report 115 (2020).
3. Forbes México (2020).
4. Policy Brief: COVID-19 and the Need for Action on Mental Health.
(2020) United Nations.
5. Liu S, Yang L, Zhang C, Xiang YT, Liu Z, et al. (2020) Online mental health
services in China during the COVID-19 outbreak. Lancet Psychiatry 7 :
e17e18.
6. Lai J, Ma S, Wang Y, Cai Z, Hu J, et al. (2020) Factors associated with
mental health outcomes among health care workers exposed to
coronavirus disease. JAMA Network Open 3: e203976.
7. Shechter A, Diaz F, Moise N, Anstey DE, Ye S, et al. (2020) Psychological
distress, coping behaviors, and preferences for support among New
York healthcare workers during the COVID-19 pandemic. Gen Hosp
Psychiatry 66: 1-8.
8. Giusti EM, Pedroli E, D’Aniello GE, Stramba Badiale C, Pietrabissa G,
et al. (2020) The Psychological Impact of the COVID-19 Outbreak on
Health Professionals: Cross-sectional Study. Front Psychol 11: 1684.
9. Jackson D, Bradbury-Jones C, Baptiste D, Gelling L, Morin K., et al.
(2020) Life in the pandemic: some reflections on nursing in the context
of COVID-19. J Clin Nurs 29: 2041-2043.
10. Tomlin J, Dalgleish Warburton B, Lamph G (2020) Psychosocial
Support for Healthcare Workers During the COVID-19 Pandemic. Front
Psychol 11: 1960.
11. Pearman A, Hughes ML, Smith EL, Neupert SD (2020) Mental Health
Challenges of United States Healthcare Professionals During COVID-19.
Front Psychol 11: 2065.
12. Brown FW (2017) Telepsychiatry and health technologies: A guide for
mental health professionals. The American Journal of Psychiatry 174:
11261126.
13. Liu S, Yang L, Zhang C (2020) Online mental health services in China
during the COVID-19 outbreak. Lancet Psychiatry 7: E17-E18.
14. Gros DF, Lancaster CL, López CM, Acierno R (2018) Treatment
satisfaction of home-based telehealth versus in-person delivery of
prolonged exposure for combat-related PTSD in veterans. Journal of
Telemedicine and Telecare 24: 5155.
15. Morland LA, Mackintosh MA, Greene CJ, Rosen C, Chard K, et al.
(2014) Cognitive processing therapy for posttraumatic stress disorder
delivered to rural veterans via Tele Mental health: A randomized
noninferiority clinical trial. Journal of Clinical Psychiatry 75: 470476.
16. Morland LA, Mackintosh M, Rosen CS, Willis E, Resick P, et al. (2015)
Telemedicine vs. in-person delivery of cognitive processing therapy
for women with posttraumatic stress disorder: A randomized non-
inferiority trial. Depression and Anxiety 32: 811-820.
17. Lewis C, Roberts NP, Simon N, Bethell A, Bisson JI (2019) Internet-
delivered cognitive behavioral therapy for post-traumatic stress
disorder: systematic review and meta-analysis. Acta Psychiatr Scand
140 (6): 508521.
18. Spence J, Titov N, Johnston L, Dear BF, Wootton B, et al. (2013)
Internet-delivered eye movement desensitization and reprocessing
(iEMDR): an open trial. F1000research, 2.
19. Shapiro F (2018) Eye movements desensitization and reprocessing.
Basic principles, protocols, and procedures (3rd Edtn) Guilford Press,
New York, United States.
20. Author (2013) Guidelines for the management of conditions that are
specifically related to stress. World Health Organization, Geneva,
Switzerland.
21. Guideline Watch (2009) Practice Guideline for the Treatment of
Patients with Acute Stress Disorder and Posttraumatic Stress Disorder.
American Psychiatric Association.
22. Clinical Practice Guideline for the Treatment of PTSD in Adults. (2017)
American Psychological Association.
23. ISTSS Guidelines Committee (2019) Posttraumatic stress
disorder prevention and treatment guidelines methodology and
recommendations. Oakbrook Terrace.
24. National Institute for Health and Clinical Excellence (2018) Post-
traumatic stress disorder. Evidence reviews on care pathways for
adults, children and young people with PTSD.
25. VA/DoD Clinical Practice Guideline for the Management of
Posttraumatic Stress Disorder and Acute Stress Disorder (2017)
26. Shapiro E, Maxfield L (2019) The Efficacy of EMDR Early Interventions.
Journal of EMDR Practice and Research 13(4): 291-301.
27. Mavranezouli I, Megnin-Viggars O, Grey N, Bhutani G, Leach J, Daly
C, et al. (2020) Cost effectiveness of psychological treatments for
posttraumatic stress disorder in adults. PLoS ONE 15 (4): e0232245.
28. Jarero I, Artigas L (2009) EMDR integrative group treatment protocol.
Journal of EMDR Practice & Research 3(4): 287288.
29. Artigas L, Jarero I, (2014) The Butterfly Hug. In M. Luber (Ed.)
Implementing EMDR Early Mental Health Interventions for Man-Made
and Natural Disasters .Springer, New York, United States pp.137-130.
30. Artigas L, Jarero I, Alcalá N, López Cano T (2014) The EMDR Integrative
Group Treatment Protocol (IGTP) for children. In M. Luber (Ed.),
Implementing EMDR early interventions for man-made and natural
disasters. Springer, New York, United States pp.237-251.
31. Jarero I, Artigas L (2014) The EMDR Integrative Group Treatment
Protocol (IGTP) for Adults. In: M Luber (Ed.) Implementing EMDR
Early Mental Health Interventions for Man-Made and Natural Disasters
Springer, New York, United States pp.253-265.
32. Adúriz ME, Knopfler C, Bluthgen C (2009) Helping child flood victims
using group EMDR intervention in Argentina: Treatment outcome and
gender differences. International Journal of Stress Management 16(2):
138153.
33. Gelbach R, Davis K (2007) Disaster response: EMDR and family systems
therapy under communitywide stress. In: F Shapiro, FW Kaslow, L
Maxfield (Eds.), Handbook of EMDR and family therapy processes,
Wiley, New York, United States pp.387-406.
Psychology and Behavioral Science International Journal
How to cite:
Pérez M C, Estévez M E, Becker Y, Osorio A, Jarero I, et al. Multisite Randomize d Controlled Trial on the Provision of the EMDR
Integrative
Group Treatment P rotocol for Ongoing Traumatic Stress Remote to Healthcare Professionals Working i n Hospitals During the Covid-
19 Pandemic.
Psychol Behav Sci Int J .2020; 15(4): 555920. DOI: 10.19080/PBSIJ .2020.15.555920
0011
34. Maxfield L (2008) EMDR treatment of recent events and community
disasters. Journal of EMDR Practice & Research 2(2): 74-78.
35. Jarero I, Artigas L (2012) The EMDR Integrative Group Treatment
Protocol: EMDR group treatment for early intervention following
critical incidents. European Review of Applied Psychology 62: 219-
222.
36. Jarero I, Artigas L, Uribe S, Miranda A (2014) EMDR Therapy
Humanitarian Trauma Recovery Interventions in Latin America and
the Caribbean. Journal of EMDR Practice and Research 8(4): 260-268.
37. Jarero I, Artigas L, Hartung J (2006) EMDR integrative treatment
protocol: A post-disaster trauma intervention for children & adults.
Traumatology 12: 121-129.
38. Adúriz ME, Salas C (2014) Aplicación del Protocolo Grupal e Integrativo
con EMDR a las Víctimas de un Alud en Tartagal-Salta-Argentina.
Revista Iberoamericana de Psicotraumatología y Disociación 6(2): 1-
12.
39. Salas C (2014) Aplicación del Protocolo Grupal e Integrativo con EMDR
a las Víctimas de un Alud en Angastaco-Argentina. Iberoamerican
Journal of Psychotraumatology and Dissociation 6(2): 1-11.
40. Mehrotra S (2014) Humanitarian Projects and Growth of EMDR
Therapy in Asia. Journal of EMDR Practice and Research 8(4): 252-259.
41. Jarero I, Artigas L, Montero M (2008) The EMDR integrative group
treatment protocol: Application with child victims of a mass disaster.
Journal of EMDR Practice and Research 2(2): 97105.
42. Fernandez I, Gallinari E, Lorenzetti A (2003) A school-based
intervention for children who witnessed the Pirelli building airplane
crash in Milan, Italy. Journal of Brief Therapy 2(2): 129136.
43. Maslovaric G, Zaccagnino M, Mezzaluna C, Perilli S, Trivellato D, et
al. (2017) The Effectiveness of Eye Movement Desensitization and
Reprocessing Integrative Group Protocol with Adolescent Survivors of
the Central Italy Earthquake. Front Psychol 8: 1826.
44. Zaghrout Hodali M, Alissa F, Dodgson P (2008) Building resilience and
dismantling fear: EMDR group protocol with children in an area of
ongoing trauma. Journal of EMDR Practice and Research 2(2): 106
113.
45. Jarero I, Artigas L (2010) EMDR integrative group treatment protocol:
Application with adults during ongoing geopolitical crisis. Journal of
EMDR Practice and Research 4(4): 148155.
46. Allon M (2015) EMDR group therapy with women who were sexually
assaulted in the Congo. Journal of EMDR Practice and Research 9(1):
28-34.
47. Jarero I, Roque-López S, Gómez J (2013) The Provision of an EMDR-
Based Multicomponent Trauma Treatment with Child Victims of
Severe Interpersonal Trauma. Journal of EMDR Practice & Research
7(1): 17-28.
48. Jarero I, Roque-López S, Gómez J, Givaudan M (2014a) Second Research
Study on the Provision of the EMDR Integrative Group Treatment
Protocol with Child Victims of Severe Interpersonal Violence.
Iberoamerican Journal of Psychotraumatology and Dissociation 6(1):
1-24.
49. Jarero I, Roque-López S, Gómez J, Givaudan M (2014b) Third Research
Study on the Provision of the EMDR Integrative Group Treatment
Protocol with Child Victims of Severe Interpersonal Violence.
Iberoamerican Journal of Psychotraumatology and Dissociation 6(2):
1-22.
50. Jarero I, Rake G, Givaudan M (2017) EMDR Therapy Program for
Advance Psychosocial Interventions Provided by Paraprofessionals.
Journal of EMDR Practice and Research 11(3): 122-128.
51. Passoni S, Curinga T, Toraldo A, Berlingeri M, Fernandez I, et al. (2018)
Eye Movement Desensitization and Reprocessing Integrative Group
Treatment Protocol (EMDR-IGTP) applied to caregivers of patients
with dementia. Frontiers in Psychology 9: 967.
52. Harris H, Urdaneta V, Triana V, Vo CS, et al. (2018) A Pilot Study with
Spanish-Speaking Latina Survivors of Domestic Violence Comparing
EMDR & TF-CBT Group Interventions. Open Journal of Social Sciences
6: 203-222.
53. Hurn R Barron I (2018) The EMDR Integrative Group Treatment
Protocol in a Psychosocial Program for Refugee Children: A Qualitative
Pilot Study. Journal of EMDR Practice and Research 12(4): 208-223.
54. Perilli S, Giuliani A, Pagani M, Mazzoni GP, Maslovari G, et al. (2019)
EMDR Group Treatment of Children Refugees -A Feasibility Field Study.
Journal of EMDR Practice and Research 13(3): 143-155.
55. Smyth Dent KL, Fitzgerald J, Hagos Y (2019) A Field Study on the
EMDR Integrative Group Treatment Protocol for Ongoing Traumatic
Stress Provided to Adolescent Eritrean Refugees Living in Ethiopia.
Psychology and Behavioral Science International Journal 12(4): 1-12.
56. Marie-Jo Brennstuhl, Fanny Bassan, Anne-Marie Fayard, Mathieu
Fisselbrand, Amandine Guth, et al. (2019) Immediate treatment
following the November 13 attacks: Use of an EMDR emergency
protocol. European Journal of Trauma and Dissociation 3: 17-21.
57. Smyth-Dent K, Walsh SF, Smith S (2020) Field Study on the EMDR
Integrative Group Treatment Protocol for Ongoing Traumatic Stress
with Female Survivors of Exploitation, Trafficking and Early Marriage
in Dhaka, Bangladesh. Psychology and Behavioral Science International
Journal 15(3): 1-8.
58. Molero RJ, Jarero I, Givaudan M (2019) Longitudinal Multisite
Randomized Controlled Trial on the Provision of the EMDR Integrative
Group Treatment Protocol for Ongoing Traumatic Stress to Refugee
Minors in Valencia, Spain. American Journal of Applied Psychology
8(4): 77-88.
59. McFarlane AC, Lawrence Wood E, Van Hooff M, Malhi GS, Yehuda
R (2017) The need to take a staging approach to the biological
mechanisms of PTSD and its treatment. Current Psychiatry Reports
19(2): 10.
60. Jarero I, Artigas L (2018) AIP model-based Acute Trauma and Ongoing
Traumatic Stress Theoretical Conceptualization. Iberoamerican
Journal of Psychotraumatology and Dissociation 10(1): 1-7.
61. Jarero I, Amaya C, Givaudan M, Miranda A (2013) EMDR Individual
Protocol for Paraprofessionals Use: A Randomized Controlled Trial
Whit First Responders. Journal of EMDR Practice and Research 7(2):
55-64.
62. Centonze D, Siracusane A, Calabresi P, Bernardi G (2005) Removing
pathogenic memories. Mol Neurobiol 32: 123-132.
63. van der Kolk BA, van der Hart O (1991) The intrusive past: The
flexibility of memory and the engraving of trauma. American Imago
48(4): 425-454.
64. Jarero I, Uribe S, Artigas L, Givaudan M (2015) EMDR protocol for recent
critical incidents: A randomized controlled trial in a technological
disaster context. Journal of EMDR Practice and Research 9(4): 166-
173.
65. Jarero I, Schnaider S, Givaudan M (2019) EMDR Protocol for Recent
Critical Incidents and Ongoing Traumatic Stress with First Responders:
A Randomized Controlled Trial. Journal of EMDR Practice and Research
13(2).
Psychology and Behavioral Science International Journal
How to cite: Pérez M C, Estévez M E, Beck er Y, Osorio A, Jarero I, et al. Multisite Randomized Controlled T rial on the Provision of the EMDR
Integrative Group Treatment Protocol for Ongoing Traumatic Stress Remote to Healt hcare Professionals Working in Hospitals During the Covid-
19
Pandemic. Psychol B ehav Sci Int J .2 020; 15(4): 555920. DOI: 10.19080/PBSIJ.2020.15.555920
0012
66. Encinas M, Osorio A, Jarero I, Givaudan M (2019) Randomized
Controlled Clinical Trial on the Provision of the EMDR-PRECI to Family
Caregivers of Patients with Autism Spectrum Disorder. Psychology and
Behavioral Science International Journal 11(1): 1-8.
67. Estrada BD, Angulo BJ, Navarro ME, Jarero I, Sánchez-Armass O
(in press) PTSD, Immunoglobulins, and Cortisol Changes after the
Provision of the EMDR- PRECI to Females Patients with Cancer-Related
PTSD Diagnosis. American Journal of Applied Psychology.
68. Jarero I, Artigas L, Uribe S, García LE, Cavazos MA, et al. (2015) Pilot
Research Study on the Provision of the EMDR Integrative Group
Treatment Protocol with Female Cancer Patients. Journal of EMDR
Practice and Research 9(2): 98-105.
69. Jarero I, Artigas L, Uribe S, García LE (2016) The EMDR Integrative
Group Treatment Protocol for Patients with Cancer. Journal of EMDR
Practice and Research 10(3): 199-207.
70. Jarero I, Givaudan M, Osorio A (2018) Randomized Controlled Trial
on the Provision of the EMDR Integrative Group Treatment Protocol
Adapted for Ongoing Traumatic Stress to Patients with Cancer. Journal
of EMDR Practice and Research 12(3): 94-104.
71. Osorio A, Pérez MC, Tirado SG, Jarero I, Givaudan M (2018) Randomized
Controlled Trial on the EMDR Integrative Group Treatment Protocol for
Ongoing Traumatic Stress with Adolescents and Young Adults Patients
with Cancer. American Journal of Applied Psychology 7(4): 50-56.
72. Consolidated Standards of Reporting Trials (CONSORT) 2010
Statement (2010) BMJ 340: c869.
73. Standard Protocol Items Recommendation for Interventional Trials
(SPIRIT) 2013 Checklist.
74. Weathers FW, Litz BT, Keane TM, Palmieri PA, Marx BP, et al. (2013) The
PTSD Checklist for DSM-5 (PCL-5) Scale available from the National
Center for PTSD.
75. Bovin MJ, Marx BP, Weathers FW, Gallagher MW, Rodriguez P, et al.
(2016) Psychometric properties of the PTSD checklist for diagnostic
and statistical manual of mental disorders- Firth edition (PCL-5) in
veterans. Psychol Assess 28(11): 1379-1391.
76. American Psychiatric Association (2000) Diagnostic and statistical
manual of mental disorders (4th edtn) Text Revised) Arlington, Virginia.
77. Weathers FW, Blake DD, Schnurr PP, Kaloupek DG, Marx BP, et al.
(2013a) Clinician-administered PTSD Scale for DSM-5. National
Center for Posttraumatic Stress Disorder, Boston.
78. Franklin CL, Raines AM, Cucurullo LA, Chambliss JL, Maieritsch KP, et
al. (2018) 27 ways to meet PTSD: Using the PTSD-checklist for DSM-5
to examine PTSD core criteria. Psychiatry Research 261: 504-507.
79. Zigmond AS, Snaith RP1 (1983) The Hospital Anxiety and Depression
Scale. Acta Psychiatrica Scandinavica 67: 361-370.
80. Ying Lin C, Pakpour AH (2017) Using Hospital Anxiety and Depression
Scale (HADS) on patients with epilepsy: Confirmatory factor analysis
and Rasch models. Seizure (45): 42-46.
81. Connor KM, Davidson JRT (2001) SPRINT: A brief global
assessment of post-traumatic stress disorder. International Clinical
Psychopharmacology 16(5): 279-284.
82. Sciarrino N, Warnecke AJ, Ellen J Teng E (2020) A systematic review
of intensive empirically supported treatments for posttraumatic stress
disorder. Journal of Traumatic Stress 33(4): 443-454.
83. Hurley EC (2018) Effective Treatment of Veterans With PTSD:
Comparison Between Intensive Daily and Weekly EMDR Approaches.
Front Psychol 9: 1458.
84. Bongaerts H, Van Minnen A, de Jongh A (2017) Intensive EMDR to treat
patients with complex posttraumatic stress disorder: A case series.
Journal of EMDR Practice and Research 11(2): 84-95.
85. Gutner CA, Suvak MK, Sloan DM, Resick PA (2016) Does timing matter?
Examining the impact of session timing on outcome. Journal of
Consulting and Clinical Psychology 84: 1108-1115.
This work is licensed under Creative
Commons Attributio n 4.0 License
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... The group protocol (EMDR-IGTP) combines standard 8-phase EMDR therapy with a group therapy model (Jarero et al., 1999;Artigas et al., 2000) and uses of a form of bilateral stimulation called the Butterfly Hug (Artigas and Jarero, 2014;Jarero, 2020) along with drawing tasks (Maxfield, 2008). Given the benefits of group therapy and the proven effectiveness of EMDR Integrative Group Treatment Protocol (EMDR-IGTP), we tested an online adaptation of the group EMDR protocol intended to respond to the needs generated by the current emergency, as also reported in recent literature (Luber, 2020;Pérez et al., 2020;Tarquinio et al., 2020;Fisher, 2021). ...
... It is of economic value because it lowers the cost of downstream management of mental health problems (de Bont et al., 2019). Our results are in line with those of other studies in showing that the standard EMDR protocol can be successfully adapted for use online to conduct EMDR therapy online (e.g., Fisher, 2021), including on workers involved in healthcare during the COVID-19 emergency (Pérez et al., 2020;Tarquinio et al., 2020). Still, they cannot be considered conclusive due to the small size of our treatment groups and the lack of a control group. ...
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We report the results of a pilot study regarding the adaptation of the group eye movement desensitization and reprocessing (EMDR) protocol for the treatment online, for the management of trauma associated with the COVID-19 Pandemic in Italy. The target group were healthcare workers in a nursing home (Residenza sanitaria assistita, RSA) who decided to live and stay on site during the most acute phase of the Pandemic in order to protect the residents of the home. Scores for perceived post traumatic stress disorder (PTSD) symptoms and quality of emotional experience improved significantly following participation in the therapy programme. These preliminary results confirm the innovative potential of the EMDR protocol when used online on early intervention, to prevent the development of later psychological disturbances.
... Найчастішими емоціями, які вони демонструють, є страх, безпорадність і невпевненість. У нещодавно опублікованому дослідженні (Pérez et al., 2020) за участю медичних працівників десяти лікарень, пов'язаних з COVID-19, які отримували Tele Mental Health, найгірший досвід, про який повідомляли учасники, був пов'язаний з роботою з інфікованими пацієнтами та страхом заразитися самим. В інших випадках найгіршим було відчуття, ніби у них були такі симптоми, як лихоманка чи головний біль, і думка про те, що вони можуть захворіти та померти, або що вони можуть заразити члена сім'ї. ...
Technical Report
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AIP. (Шостий перегляд, 16 квітня 2022 р.) Ігнасіо Хареро та Люсіна Артігас (Ignacio Jarero & Lucina Artigas) Ця стаття має на меті дати концептуалізацію клінічного випадку гострої травми та триваючого травматичного стресу на основі теоретичної моделі адаптивної обробки інформації (AIP) д-ра Франсін Шапіро, яка може служити основою для робочої гіпотези для розширення клінічних і дослідницьких горизонтів щодо інтервенції, заснованих на АІР для окремих осіб і груп. Ключові слова: десенсибілізація та повторна обробка рухів очей (EMDR); Адаптивна модель обробки інформації (AIP); Втручання, інформовані AIP; гостра травма; триваючий травматичний стрес. Модель адаптивної обробки інформації (AIP) Терапія EMDR керується теоретичною моделлю адаптивної обробки інформації (АДІ, англ. AIP) (Шапіро, 2001; 2018), яка стверджує, що мережі пам'яті є основою патології та здоров'я. Коротко кажучи, AIP-це пов'язана з пам'яттю модель для розвитку патологічних процесів та можливих змін. Ця унікальна теоретична модель стверджує, що психопатологія в основному спричинена спогадами про несприятливий життєвий досвід, які були неадекватно оброблені та дезадаптивно збережені у формі, що залежить від стану (це означає, що інформація, отримана під час події-зображення, звуки, афекти, фізичні відчуття-зберігається в тому ж вигляді, в якому воно було спочатку пережито). Ці спогади зберігаються шляхом асоціації та утворюють мережі пам'яті, які пов'язують теперішній досвід із минулим досвідом і можуть бути викликані поточними внутрішніми та зовнішніми подразниками, сприяючи теперішній дисфункції. AIP є наріжним каменем терапії EMDR, оскільки він інтерпретує клінічні явища, прогнозує успішні результати лікування та спрямовує клінічну практику. Нещодавні травматичні події Доктор Франсін Шапіро (2001; 2018) стверджує, що давні травматичні спогади, як правило, можна лікувати, зосередившись на одній частині травматичної події, і що націлювання на цю одну частину зазвичай призводить до повторної обробки всього спогаду. Це тому, що ефект повторної обробки стає узагальненим для всієї пам'яті. Після землетрусу в районі затоки Сан-Франциско в 1989 році доктор Шапіро виявила, що концентрація на одній частині події не вплинула на пам'ять про будь-яку іншу частину події. На певному рівні обробки інформації пам'ять про подію не мала достатньо часу, щоб консолідуватися в єдине ціле. Д-р Шапіро припустила, що хоча пам'ять про ізольовану недавню травматичну подію (після посттравматичного безпечного
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In this report, you will find the references of the 52 peer-reviewed published or in-press studies of the Jarero, Artigas, and Smyth-Dent EMDR Protocols and ASSYST procedures for early intervention and prolonged adverse experiences. Update on September 20, 2022. No Poster, Conference Presentations, or Newsletter Publications are included.
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The aim of this longitudinal multisite randomized controlled trial (RCT) was to evaluate the effectiveness of the EMDR-Integrative Group Treatment Protocol for Ongoing Traumatic Stress (EMDR-IGTP-OTS) in reducing severe posttraumatic stress disorder, depression, and anxiety symptoms in refugee minors living in Valencia, Spain. The study was conducted in 2019 in the city of Valencia, Spain, in six sites for refugees (homes or residences). A total of 184 minors (all males) met the inclusion criteria. Participants' ages ranged from 13 to 17 years old (M =16.36 years). Participants' time since the arrival to the sites in Valencia varied from January 2018 to March 2019. Participation was voluntary with the participants and their legal guardian's consent. In this study, intensive EMDR therapy was provided. This intensive format allowed the participants to complete the full course of treatment in a short period. Treatment was provided simultaneously by eighteen licensed EMDR clinicians formally trained in the protocol administration divided into six teams. Each of the treatment group participants received an average of eight hours of treatment, provided during nine group-treatment sessions, three times daily during three consecutive days in a setting inside the six refugee sites. EMDR-IGTP-OTS treatment focused only on the distressing memories related to their life as refugees and did not address any other memories. No adverse effects were reported during treatment or at three-month post-treatment assessment. Data analysis by repeated measures ANOVA showed that the EMDR-IGTP-OTS was effective in reducing PTSD symptoms in the treatment group (F (2, 122) = 43.17p <.001, η P 2 =.414). A significant effect for group (F (1, 61 = 5.52, p<.05, η P 2 =.898) and a significant interaction between time and group for this variable, (F (2, 122) = 11.10, p <.001, η P 2 =.154) confirmed the effects of the treatment. Significant effects for time (F (1, 61) = 7.46, p <.001, η P 2 =.109) and for interaction between time and group (F (1, 61) = 6.13, p <.01, η P 2 =.091) were found for both, anxiety and depression, (F (1, 61) = 7.02, p <. 01, η P 2 =.104) and (F (1, 61) = 7.92, p <.001, η P 2 =.116). The study results indicate that the intensive administration of the EMDR-IGTP-OTS could be a feasible, cost-effective, time-efficient, culturally sensitive, and effective component of a multidisciplinary psycho-social group-based program to address PTSD, depression, and anxiety symptoms among refugee minors.
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The main objective of this study was to evaluate the effectiveness of the EMDR-integrative group treatment protocol for ongoing traumatic stress (EMDR-IGTP-OTS) in reducing posttraumatic stress disorder (PTSD), depression, and anxiety symptoms in adolescent refugees living inside the Shimelba refugee camp in Shiraro, Ethiopia. A secondary objective was to present one clinical case of a male Eritrean refugee adolescent with characteristics of selective mutism and with symptoms of PTSD, anxiety and depression. A total of 48 Eritrean refugee adolescents were treated simultaneously with intensive EMDR therapy using the EMDR-IGTP- OTS. Each of the treatment group participants received an average of five hours of treatment, provided during six group-treatment sessions, over two consecutive days in a setting inside the refugee camp. EMDR- IGTP-OTS treatment focused only on the distressing memories related to their life as refugees and did not address any other memories. No adverse effects were reported during treatment or at one-month post-treatment assessment. The Hospital Anxiety and Depression Scale (HADS) and the Post-traumatic Stress Disorder Checklist for DSM-5 (PCL5) were used as pre and post-treatment assessments measuring each client’s anxiety, depression, and PTSD symptoms, respectively. Statistical analysis showed a significant difference between pre-test (M=42.63, SD=14.69) and post-test (M=27.46, SD=16.83); t(47) = 4.43, p<0.0001 in PTSD symptoms, depression symptoms pre-test (M=9.31, SD=3.71) and post-test (M=5.88, SD=4.88); t(47) = 4.43, p<0.0001, and in anxiety symptoms pre-test (M=10.65, SD=4.03) and post-test (M=6.73, SD=4.89); t(47) = 3.99, p<0.001. The study results show that the EMDR- IGTP-OTS could be an important component of a multidisciplinary approach to reducing or eliminating PTSD, depression and anxiety symptoms in adolescent refugees living in refugee camps.
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Objective The mental health toll of COVID-19 on healthcare workers (HCW) is not yet fully described. We characterized distress, coping, and preferences for support among NYC HCWs during the COVID-19 pandemic. Methods This was a cross-sectional web survey of physicians, advanced practice providers, residents/fellows, and nurses, conducted during a peak of inpatient admissions for COVID-19 in NYC (April 9th–April 24th 2020) at a large medical center in NYC (n = 657). Results Positive screens for psychological symptoms were common; 57% for acute stress, 48% for depressive, and 33% for anxiety symptoms. For each, a higher percent of nurses/advanced practice providers screened positive vs. attending physicians, though housestaff's rates for acute stress and depression did not differ from either. Sixty-one percent of participants reported increased sense of meaning/purpose since the COVID-19 outbreak. Physical activity/exercise was the most common coping behavior (59%), and access to an individual therapist with online self-guided counseling (33%) garnered the most interest. Conclusions NYC HCWs, especially nurses and advanced practice providers, are experiencing COVID-19-related psychological distress. Participants reported using empirically-supported coping behaviors, and endorsed indicators of resilience, but they also reported interest in additional wellness resources. Programs developed to mitigate stress among HCWs during the COVID-19 pandemic should integrate HCW preferences.