The EMDR Protocol for Recent Critical Incidents: Follow-Up Report of an Application in a Human Massacre Situation

Background

Over the past several years, Mexico has suffered from drug-trade-related violence, which has been extraordinarily intense and grisly even by criminal market standards. Its drug trafficking organizations have been engaged in ever-spiraling turf wars over smuggling routes and corruption networks, turning the streets of some Mexican cities into macabre displays of gun fights and murders. In 5 years, the total casualties of this war number more than 50,000 people, including organized crime members, soldiers, police officers, innocent adult civilians, and 1,400 children. In comparison, during almost nine years of war in Iraq, the U.S. military suffered 4,000 casualties. Criminal groups have shown a determined willingness to fight Mexican law enforcement and security forces—an increasing ambition to control other illicit and informal economies in Mexico and to extort legal businesses.

Finding Mexican police forces pervaded by corruption and lacking the capacity to effectively deal with organized crime, President Felipe Calderón dispatched the military into Mexico’s streets. Yet although having some success in capturing prominent drug traffickers, the military has also found it enormously difficult to suppress violence and reduce the insecurity of Mexican citizens. Institutional reforms to improve the police forces and justice system, although crucial for expanding the rule of law in Mexico, have been slow and will inevitably require years of committed effort. Meanwhile, patience among many Mexicans for the battle against criminal groups is starting to run out (Felbab-Brown, 2011). Horror and violence are an almost daily occurrence, and many live in fear and terror, frequently exposed to the inhumanity and brutality of this war.

In April 2011, 218 decomposing and mutilated corpses were discovered in seven clandestine graves in the Mexican state of Durango. It was said that these mass graves probably contained the bodies of executed drug gang rivals, or kidnap victims, or even some police. The task of body recovery and identification was conducted by the State Attorney General forensic personnel, who were very traumatized by this massive and horrific task. They also became the target of death threats from the warring gangs.

In May 2011, Durango’s State Attorney General asked the Mexican Association for Mental Health in Crisis to provide support for their forensic personnel who were working in the clandestine graves and in the morgue (DNA identification, fingerprints, forensic anthropology work). The Mexican National Human Rights Commission sponsored the clinicians’ travel expenses. The clinicians provided the EMDR-PRECI (Jarero et al., 2011). A field study was conducted to evaluate the treatment’s effectiveness in this setting (Jarero & Uribe, 2011).

Procedure

The research was conducted in four phases: Phase 1 was the baseline assessment; Phase 2 was the treatment and assessment of the immediate treatment group; Phase 3 was the treatment and assessment of the waitlist/delayed treatment group; and Phase 4 was the two follow-up assessments of both treatment groups. Phases 1–3 were conducted during May to July, 2011, and the results were reported in an earlier publication (Jarero & Uribe, 2011). The current article summarizes the earlier findings and reports on the two follow-up assessments conducted at 3 and 5 months posttreatment in September and November 2011.

Measures

The IES (Horowitz, Wilmer, & Alvarez, 1979) and the Short PTSD Rating Interview (SPRINT; Connor & Davidson, 2001; Vaishnavi, Payne, Connor, & Davidson, 2006) were administered at baseline, pretreatment, posttreatment, and two follow-up assessments by two independent professionals.

The IES is a 15-item widely used self-report questionnaire. It is a reliable measure of subjective posttraumatic stress to a stressful or traumatic life event. Responses are scored according to a Likert scale, where 0 = not at all, 1 = rarely, 3 = sometimes, and 5 = often. Scores between 0 and 8 are considered subclinical, scores between 9 and 25 are considered low or mild distress, scores between 26 and 43 are considered moderate distress, and scores between 44 and 75 are considered high or severe distress.

The SPRINT is an eight-item interview or self-rating questionnaire with solid psychometric pro-perties 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. Each item is rated on a five-point scale: not at all (0), a little bit (1), moderately (2), quite a lot (3), and very much (4). Scores between 18 and 32 correspond to marked or severe PTSD symptoms, 11 and 17 to moderate symptoms, 7 and 10 to mild symptoms, scores of 6 or less indicated either no or minimal symptoms. The SPRINT also contains two additional items to measure global improvement according to percentage change and by severity rating. This questionnaire was translated from English to Spanish, back translated from Spanish to English, and reviewed and authorized by one of its authors. SPRINT performs similarly to the Clinician-Administered PTSD Scale (CAPS) rating scale in the assessment of PTSD symptoms clusters and total scores and can be used as a diagnostic instrument (Vaishnavi et al., 2006). In the SPRINT, a cutoff score of 14 or more was found to carry a 95% sensitivity to detect PTSD and 96% specificity for ruling out the diagnosis, with an overall accuracy of correct assignment being 96% (Connor & Davidson, 2001).

Participants

At the beginning of the study, a preliminary psychometric assessment was conducted with all the 60 State Attorney General employees who were working with the corpses. The assessment established a triage criterion for the next phases and provided baseline measures. The IES and SPRINT were administered, and the 32 individuals whose baseline scores indicated moderate-to-severe posttraumatic stress and PTSD symptoms were assigned to two groups. Those with severe scores were assigned to immediate treatment (N = 18; 8 females, 10 males), and those with moderate scores were assigned to waitlist/delayed treatment (N = 14; 8 females, 6 males). The 28 participants with lower scores did not receive any treatment because research has shown that minor distress may resolve on its own, or with less intensive interventions such as crisis counseling (Norris, Hamblen, Brown, & Schinka, 2008). As planned, there was a significant difference at baseline between the scores of immediate treatment and the waitlist/delayed treatment groups (Jarero & Uribe, 2011) on both the SPRINT and IES measures (see Figures 1 and 2).

FIGURE 1

Mean IES scores at baseline, pretreatment, posttreatment, and two follow-up assessments.

FIGURE 2

Mean SPRINT scores at baseline, pretreatment, posttreatment, and two follow-up assessments.

After receiving the single session of EMDR-PRECI and completing the posttreatment measures, the participants continued to work on the forensic project during the duration of the study and had continual exposure to horrific stressors. All participants completed the follow-up assessments at 3 and 5 months. Their attendance in treatment was voluntary and not mandated by their employer. There were no dropouts in the study.

Treatment

Members of immediate and waitlist/delayed treatment groups were treated with one session of EMDR-PRECI. Each individual client session lasted between 90 and 120 min (Phases 1 and 2 lasted 30–35 min; reprocessing phases lasted between 50 and 65 min). Only one treatment session was provided to each participant. This limitation in treatment provision was a factor of the dangerous environment, as the clinicians’ time on site was restricted because of safety concerns.

Results of the Pre-Post Comparison

Results reported in the pre-post study (Jarero & Uribe, 2011) showed that IES and SPRINT scores increased in both groups between baseline and pretreatment administrations, with a worsening of symptoms before the start of treatment. A statistical comparison of the posttreatment scores of the immediate treatment and pretreatment scores of the waitlist group indicated the treated group had significantly lower scores than the waitlist group. This finding occurred even though the original baseline scores of the waitlist/delayed treatment group were significantly less than those of the immediate treatment group. A comparison of pretreatment and posttreatment scores showed significant improvement on self-report measures of posttraumatic stress and PTSD symptoms for both the immediate and delayed treatment groups, providing preliminary evidence for the effectiveness of one session of EMDR-PRECI (see Figures 1 and 2).

Results of the Follow-Up Assessments

The present follow-up study reports on Phase 4 of the field research study, which included follow-up assessments with study participants conducted on September 30 and November 30, 2011. In the period between the follow-up assessments, two more clandestine graves were discovered with another 40 bodies, requiring forensic work by the participants. The participants also received renewed threats of violence from organized crime members and endured the same extreme stressful circumstances in a horrific work environment.

Comparisons of the Immediate and Waitlist/Delayed Treatment Groups

The two treatment groups were created by placing those participants with lower scores into the waitlist/delayed treatment group and those with more severe scores into the immediate treatment group. This was done for ethical reasons, to provide faster relief for those with more intense suffering.

The study did not have the capacity to examine the specific reasons why there was a differential response to the trauma, why some individuals experienced more severe symptoms than others. A number of factors could explain these differential responses. Perhaps those with more intense symptoms had some preexisting psychological problems, personality factors, or other risk factors rendering them more vulnerable to develop PTSD; perhaps they had more intense exposure to the trauma in the work setting, or were more directly or personally impacted by the massacre or by the threats to themselves and their families. Future research is needed to investigate these various possibilities.

The differences between the two groups were maintained throughout the study. Although treatment was very helpful to those with severe symptoms, their scores did not attain the lesser level of those who began with less distress. The significant difference between the two groups was apparent at baseline, posttreatment, and at both follow-ups, with the delayed group consistently showing less severe symptoms. Although a second treatment session may have been beneficial for those participants with more severe scores, the clinicians’ time on site was restricted because of safety concerns in the dangerous environment, and it was not possible to provide more than one treatment session to each participant. Also, it should be noted that the finding that those with severe symptoms at baseline had more severe symptoms at follow-up is consistent with research investigating individual predictors of the longitudinal course of PTSD (e.g., Ehlers, Mayou, & Bryant, 1998; Marmar et al., 1999).

EMDR-PRECI and the Prevention of Chronic Post-Traumatic Stress Disorder

Expeditious diagnostic assessment of PTSD is often very relevant in times of mass trauma (Vaishnavi et al., 2006). Unfortunately, because of time limitations (structured interviews sometimes required as much as 45 min of a clinician’s time), the therapists in this study were unable to administer a structured interview such as CAPS to assess for the diagnosis of PTSD. However, SPRINT has performed similarly to the CAPS in the assessment of PTSD symptoms clusters and total scores; it can be used as a diagnostic instrument and only takes an average of 5–10 min to complete. In the SPRINT, a cutoff score of 14 or higher was found to carry a 95% sensitivity to detect PTSD and 96% specificity for ruling out the diagnosis, with an overall accuracy of correct assignment being 96% (Connor & Davidson, 2001).

At the beginning of this study (Jarero & Uribe, 2011), baseline measures were administered to participants as a screening tool, and those participants whose SPRINT scores met or exceeded the cutoff criteria of 14 were assigned to treatment. Based on the 95% sensitivity of the SPRINT, we can assume that at pretreatment, acute PTSD (duration of symptoms was less than 3 months) was present for all participants in both groups. In the follow-up assessments, reported in this study, the SPRINT scores at Time 5 were 9.27 and 6.21, indicating that chronic PTSD (symptoms last 3 months or longer) was not present in either group. Not one of the participants had a score over 14, suggesting that none would meet diagnostic criteria for chronic PTSD. Statistical results and SPRINT sensitivity lead the authors to conclude that one session of EMDR-PRECI helped to prevent the development of chronic PTSD in this study population.

Because this was a field study, it was not ethically possible to maintain an untreated control group for the 6 months of the study. However, the comparison of untreated waitlist group with the treated immediate treatment group provides a limited control for the effects of time. In this 1-month period, the symptoms of the untreated waitlist group deteriorated and were significantly worse than those of the treated participants who showed a significant improvement (Jarero & Uribe, 2011).

Although it has been shown that improvement in symptoms over time is the common course observed in longitudinal studies (Orcutt, Erickson, & Wolfe, 2004), in these circumstances, participants were continually exposed to the horrors of human massacre and were themselves often threatened by the warring crime lords. Intensity and duration of exposure to trauma have been shown to play an important role in symptom development (Norris et al., 2002). It would be anticipated that these individuals would have been likely to develop chronic PTSD, which is tenacious and disabling (Kessler, 2000). Developing interventions to prevent PTSD is a pressing public health need (Institute of Medicine of the National Academies, 2011).

These results are relevant in comparison to prolonged exposure (PE) or cognitive therapy (CT). A recent study by Shalev et al. (2011) was conducted in a hospital setting with survivors of traumatic events who met PTSD diagnostic criteria. The participants were not engaged in further stressful events. They received 12 weekly 1.5 hr sessions of CT or PE (with prolonged imaginal exposure to traumatic memories and in vivo exposure to avoided situations). Results showed that the proportion of participants who continued to meet diagnostic criteria for PTSD 5 months after the traumatic event (and 2 months posttreatment) was 21.6% for PE and 20.0% for CT. Partial or noncompleters proportion (dropouts) was 44.4% for PE and 40% for CT. Shalev et al. concluded that PE and CT effectively prevented chronic PTSD in recent survivors. We compare that to the results in this study where one session of therapy significantly reduced symptoms at 3- and 5-month follow-up, where there were no dropouts, and where the SPRINT scores of all participants were far below PTSD cutoff levels (see Table 4). Researchers have viewed EMDR as more effective than exposure-based CBT, both in vivo and imaginal, in improving the PTSD symptoms because of its rapid effects, low drop-out rates, and lower ratings of distress following treatment (Fleming, 2012).

EMDR-PRECI and the Possible Development of Resilience

Before treatment, the participants expressed that they were very overwhelmed by their work with the mutilated decomposing bodies and by the ongoing dangers in the workplace. By the end of the EMDR-PRECI treatment session, clinicians observed important indicators of change in the clients such as distancing themselves from the trauma, having access to more adaptive information, negative affect reduction, reduction in ratings of subjective disturbance, and an increase in validity of positive cognitions. Examples of positive cognitions mentioned by clients during the EMDR-PRECI global installation phase were, “I can,” “I do the best I can,” “I can choose whom to trust,” “I’m strong,” “I learned from it,” “I deserve to live,” “I deserve good things,” “I’m a good person,” “I now have choices,” “I’m now in control,” “I can make my need known,” “I’m intelligent,” “I can be trusted,” “I deserve to be happy,” “I’m honorable.” It appears that this confidence in self-mastery and self-efficacy continued for months after the treatment ended, even though they continued to work on site under new organized crime threats, new clandestine graves with more bodies, and the same extreme stressful circumstances in a horrific work environment.

Although resilience was not measured directly, statistical results indicate that ongoing exposure to a traumatic work environment and subsequent similar incidents no longer elicited the same distressing symptoms after EMDR treatment but, in turn, created less distress for the participants. Based on these results, we can conclude that participants appeared to have developed psychological and emotional resilience.

These results also provide some preliminary support for hypotheses deriving from Shapiro’s (2001, 2006) AIP model: Adaptive resolution of disturbing memories should lead to a shift in symptoms, personal characteristics, and the sense of self; and effective EMDR treatment should give the individual access to a wider range of memory and experience and the potential for resilience in situations of ongoing trauma. According to this model, when the dysfunctional stored memories have been processed and assimilated into adaptive memory networks, the learning that has taken place becomes the functional basis for interpretation and response to any newly encountered situation. The application of this model is indicated in this study: It appears that when the treated participants coped effectively with similar incidents, the information was connected with adaptive networks, expanding them, increasing the learning and the positive resources; therefore, in each new similar event, participants responded with more and more resources and a sense of resourcefulness and resilience. These hypotheses need to be tested more directly.

EMDR-PRECI as an Intervention in an Ongoing Trauma Situation

Ongoing traumatic situations such as the urban disasters in this study—war, ethno-political violence, and natural or human-provoked disasters—can cause deleterious effects. War-related traumas tend to include repeated exposures. Their negative impact on health may be more persistent and pervasive in the long term, with the development of lasting symptoms and suffering over decades. Identifying traumatized individuals in the early aftermath and providing access to mental health care if suffering persists may prevent long-term effects (Holgersen, Klöckner, Boe, Weisaeth, & Holen, 2011).

Disasters are collectively experienced traumatic events with a severe impact, which affect large numbers of people. Following a disaster, survivors may start to suffer from mental health disturbance, such as PTSD, depressive disorders, substance abuse, and anxiety disorders (e.g., specific phobia). For example, Meewisse, Olff, Kebler, Kitchiner, and Gerson, (2011) reported that at 2 years postdisaster (huge explosion in a central storage facility of fireworks factory in the Netherlands), 48.3% of survivors fulfilled the criteria for a mental health disorder in the past 12 months. The most common disorders were 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 coexisting disorders. The prevalence of psychopathology at 3 years after the 1999 earthquake in Turkey was similar for PTSD (11.7%), depression (10.5%), and specific phobia (10.0 %) (Onder, Tural, Aker, Kiliç, & Erdğoan, 2006). Haiti 2010 earthquake survivors may deal with the aftermath for months or years to come as they cope with the reminders of the destruction (Jordan, 2010).

The possibility of utilizing EMDR-PRECI as one component of a comprehensive system to prevent psychopathology in those at risk, to develop resilience, and break the suffering cycle has important global implications. Some of the protocol benefits include transportability and its ease of use for both new and experienced EMDR practitioners. It is time effective—only one session was needed to achieve resolution of posttraumatic symptoms (Jarero & Uribe, 2011). There is no need for homework, thus facilitating a short duration of work in the field. It is likely that EMDR-PRECI will also have that same cross-cultural effectiveness as the standard EMDR therapy protocol for PTSD (Maxfield, 2008, 2009).

These study results lend support to the view that the EMDR-PRECI can be used effectively as an early intervention in a natural setting of a human massacre situation to a group of traumatized adults working under extreme stressors when there is no posttrauma period of safety for memory consolidation by reducing self-report measures of posttraumatic stress and PTSD symptoms, helping to prevent the development of chronic PTSD, and developing mechanisms of psychological and emotional resilience.

The authors recommend future research on the EMDR-PRECI to better understand the early phases of trauma where there seems to be lack of memory consolidation due to the lack of a posttrauma safety period that prevents the consolidation of the original critical incident in memory or in long-lasting unresolved events (e.g., traumatic bereavement on prolonged grief reactions, posttraumatic stress symptoms, and general mental health).