The EMDR Integrative Group Treatment Protocol for Patients With Cancer

EMDR Therapy Administered to Patients With Cancer

Overview

An individual history taking and assessment session is conducted for each potential group members to determine their suitability and readiness for EMDR treatment, following standard procedures (Shapiro, 2001). Six group sessions are then provided, on three consecutive days, with sessions in both mornings and afternoons. Phases 2–7 are conducted during each highly structured group session. During this process, the patients follow directions from the team leader and work quietly and independently on their own traumatic memories, using the Adapted EMDR-IGTP (Jarero et al., 2015), as described in Table 1. If in Phase 8 and follow-up recommendations it is determined that an individual patient or patients are still distressed after completion of all group sessions, several individual EMDR sessions or more small (i.e., three to eight participants) group sessions may be administered.

Treatment is provided in an intensive format (twice daily for three consecutive days) because many patients travel to the cancer hospital from long distances and only stay there for a limited time. The intensive format allows patients to complete the full course of treatment in a short period. Treatment can be provided to a large number of patients simultaneously because there is no interaction between group members except for the (rarely used) opportunity for brief dialogue during closure in the last minutes of the session. In EMDR-IGTP, the group setting allows for a group administration of individual treatment, ensuring that many individuals can be treated simultaneously. This is highly valuable in settings where resources are limited.

EMDR-IGTP therapy is very different from traditional group therapy (e.g., Yalom, 1970) which fosters interaction between group members, who provide each other with mutual support and validation, and in which group process is considered a primary mechanism of change. It is also very different from Group Trauma-Focused CBT (TF-CBT) in that TF-CBT practice components include developing a trauma narrative and engaging in vivo gradual exposure (Deblinger & Pollio, 2013). In EMDR-IGTP treatment, the individual initial intake interview is the only occasion during which patients briefly tell their story and verbally express their distress. Another important difference is confidentiality. While in EMDR-IGTP treatment, there is strict confidentiality. As noted by Deblinger, Pollio, and Dorsey (2016) in reference to Group TF-CBT, “Confidentiality issues are handled in a similar manner as individual therapy; however, although group members are encouraged to maintain confidentiality, it is important to note that strict confidentiality by others in the group cannot be guaranteed” (p. 62).

EMDR-IGTP therapists include the team leader and the emotional protection team (EPT) members. A ratio of one EPT member for every 8 to 10 patients is recommended. EPT members are walking among the patients so that they are accessible to them before, during, and after the group procedure. If a patient becomes distressed during the procedure, an EPT member will move to approach quietly beside the patient to show support, and if needed, the member may provide the patient with tissues. This is all done silently, and there is no interaction between patient and the EPT member, so as not to disturb the other patients who are working on their own material. Patients may also share information or ask questions of the EPT member before and after the procedure.

Modification of the EMDR-IGTP

In the standard EMDR-IGTP, the team leader asks patients to “remember what happened during the event” (e.g., hurricane, earthquake). Instead, in this adaptation for ongoing traumatic stress, the team leader asks patients to “run a mental movie of everything that happened just before the original incident (e.g., cancer or other chronic or prolonged illness diagnosis) until now.” The initial treatment target is the most disturbing moment in the mental movie. In subsequent sessions, the team leader asks patients to again run the mental movie and then to target any memory that it is currently disturbing, noticing associated emotions and body sensations (see Table 1 for detailed instructions).

This adaptation to the standard EMDR-IGTP has been made because, in our understanding, the traumatic experience of cancer is not a single event with a posttrauma safety period but an experience marked by repeated traumas and indeterminate length. Therefore, identifying a discrete stressor within the multiple crises that constitute a cancer experience is more difficult than it is for other traumas. The modification to the protocol allows for the targeting and reprocessing of all related incidents.

The Patient

Eva was a divorced 32-year-old woman with two children, aged 7 and 9 years. She lived in a small town about 1 day’s travel from the hospital, and at the time of this intervention, she was staying in the Pink Cross shelter. She was being treated for nonmetastatic breast cancer. She had previously had a mastectomy and was now receiving chemotherapy.

Assessment

Eva presented severe PTSD symptoms. In her individual assessment, she described the following symptoms. Her negative cognitions were “I’m different,” “I’m ugly because my body is disgusting,” and “I’m insignificant,” with repetitive thoughts such as “I’m disfigured” and “I have little time to live.” She reported many flashbacks and intrusive images: (a) after the mastectomy, seeing her mutilated body in the mirror, realizing she did not have a breast; (b) the first time she received chemotherapy; and (c) the face of her friends feeling pity for her. She also had a distressing flash-forward, imagining herself dying alone, “Nobody will take care of me.” Eva was troubled by nightmares in which cancer returns and she receive chemotherapy again and again. She reported experiencing a lot of sadness, despair, anguish, and helplessness, with uncontrollable crying. She avoided people, feeling like an object of morbid curiosity, and had isolated herself from everyone, even from those she loved. She believed that her illness was “a punishment from God because of my sins” and “I’m not going to heaven.”

Eva’s pretreatment score of 18 on the SPRINT (Connor & Davidson, 2001) was above the clinical cutoff of 14 and reflected her distress. The SPRINT is an eight-item interview or self-rating questionnaire with solid psychometric properties. Scores between 18 and 32 correspond to marked or severe PTSD symptoms, between 11 and 17 to moderate symptoms, between 7 and 10 to mild symptoms, and 6 or less to either minimal or no symptoms.

Treatment Response

Session 1 (First Day Morning)

During the first trauma processing session, Eva drew the following sequence of pictures: (a) a face in black crying (Subjective Units of Disturbance Scale [SUDS] = 10), (b) a sad face in blue (SUDS = 8), (c) a happy face in green (SUDS = 5), and (d) a face in black (SUDS = 6). On the back of the paper, an end-of-session SUDS score of 7 and for the future vision: a black hole and the title of the drawing was “There is not hope for us” (see Figure 1).

FIGURE 1

Eva’s drawing, Session 1. Top is four images processed in session. Bottom is future vision; a black hole, with title “There is not hope for us” (SUDS = 7).

Part of the EPT member’s tasks during the group protocol is to be alert to the patient’s reactions (basically to provide tissues but not to interact with them by talking), drawings, SUDS scores, and titles of the future vision drawings. In this particular case, Eva was not crying; therefore, the EPT member just made a mental note about Eva and her future vision page. During the Phase 8 reevaluation procedure, held by the EPT team immediately after each session when the patients leave the room, the team members look carefully at each drawing, SUDS scores, and titles of the future vision drawing and also listen to each EPT member’s reports. In this particular case, the EPT member mentioned Eva. The EPT team decided that before the next group reprocessing, that EPT member should instruct Eva in private to make a minor modification when the leader gave the group the mental movie directions (Phase 3). Eva was told to instead, “Please run a mental movie from today to the future . . . and when you have finished, choose to reprocess anything disturbing at this moment.”

On Session 2 (First Day Afternoon)

During the second trauma processing session, Eva drew the following sequence of pictures: (a) a black spiral (SUDS = 8), (b) a sad green face (SUDS = 5), (c) a pleasant blue face (SUDS = 3), and (d) a happy purple face (SUDS = 2). On the back of the paper, an end-of-session SUDS score of 4 and the future vision was a Christian fish. The title of the drawing was “I have faith in Jesus” (see Figure 2).

FIGURE 2

Eva’s drawing, Session 6. Top is four images processed in session. Bottom is future vision; a sun, with title “I desire to share my happiness” (SUDS = 1).

Posttreatment and Follow-Up

Eva’s pretreatment score of 18 on the SPRINT (Connor & Davidson, 2001) was in the severe range and above the clinical cutoff of 14. At posttreatment, her score was reduced to 9, in the mild symptom range. At 30-day follow-up, it was 5, and at 90-day follow-up, 4, both indicating minimal or no symptoms. It is important to note that the reduction in scores was maintained even though Eva continued in active treatment for her breast cancer, continuing to receive chemotherapy and various follow-up scans and assessments.

Indications and Contraindications for Treatment

We use the selection criteria described in Shapiro (2001). In addition, we have flagged the importance of social support. One of the most important lessons during our research with patients with cancer was that the main difference between the two patients who needed individual therapy after the IGTP and the rest of the group was that the two patients had a complete lack of structural (social) and functional (family) support. We have now added “complete lack of structural (social) and functional (family) support” to our exclusion criteria.

Treatment Tolerance

During our 18 years of experience working in the field with EMDR-IGTP, we have never had a patient leave the group room because they were overly distressed. This may be because we are very careful to apply our selection criteria. However, we also hypothesize that the BH method for bilateral stimulation (Artigas & Jarero, 2014) keeps the patients in their window of tolerance and allow appropriate reprocessing. It may also be that the control obtained by clients over their bilateral stimulation using the BH may be an empowering factor that aids their retention of a sense of safety while processing traumatic memories.

Recommendations

In support of psycho-oncology practice, the first principle of the WHO (2006) constitution prioritizes the contribution of total well-being to the happiness, harmonious relations, and security of all people, stating that “Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.” That is, there can be no health without mental health (Prince et al., 2007). The American College of Surgeons Commission on Cancer has set psychosocial distress screening as a new patient care standard for 2015. The standard requires accredited programs to implement a systematic distress screening protocol for all patients with cancer and provide appropriate follow-up and referral to appropriate professionals when indicated (Kendall, 2015).

Psycho-oncology research and practice has played a key role in reducing cancer risk, improving cancer survivorship, and influencing social and cultural change to eliminate disease-related stigma (Dunn, Adams, Holland, & Watson, 2015). Therefore, we recommend further research on the EMDR-IGTP adapted protocol with randomized controlled studies following the Maxfield and Hyer (2002) methodological recommendations.