The Provision of an EMDR-Based Multicomponent Trauma Treatment With Child Victims of Severe Interpersonal Trauma

Participants

Thirty-four children (18 boys, 16 girls) aged between 9 and 14 years attended the camp. All had been victims of severe interpersonal violence (e.g., rape, sexual abuse, physical and emotional violence, neglect, abandonment); most (n = 32) were victims of rape or sexual abuse. One group (n = 19; 11 boys, 8 girls) of children came from an institution accredited by the Colombian Institute of Family Well-being (ICBF); these children had lived in the streets or had been removed from their families because of their own problematic behavior. The other group (n = 15; 7 boys, 8 girls) of children lived with their families and were victims of rape, sexual abuse, and physical and emotional violence. None of the children had had previous specialized psychological trauma treatment.

Procedure

The camp was conducted from December 1 through 7, 2011. The research was conducted in eight stages.

Test Administrations

The Short PTSD Rating Interview (SPRINT; Connor & Davidson, 2001; Vaishnavi, Payne, Connor, & Davidson, 2006) and the Child’s Reaction to Traumatic Events Scale (CRTES; Jones, 1997) were administered to the children (Stage 3) during the camp prior to provision of EMDR-IGTP and individual EMDR. These measures were also administered at posttreatment (Stage 6) and at follow-up (Stage 8). The testing was conducted by a clinical psychologist who experimented in the EMDR-IGTP. Ratings of SUD (Shapiro, 2001) were taken during the provision of EMDR-IGTP and EMDR, as described in the following text, to monitor the progress of treatment during the session.

Short PTSD Rating Interview

The SPRINT (Connor & Davidson, 2001; Vaishnavi et al., 2006) is an eight-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. Each item is rated on a 5-point scale: 0 (not at all), 1 (a little bit), 2 (moderately), 3 (quite a lot), and 4 (very much). Scores between 18 and 32 correspond to marked or severe PTSD symptoms, 11 and 17 to moderate symptoms, 7 and 10 to mild symptoms, and 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 severity rating. This questionnaire was translated from English to Spanish and from Spanish to English, reviewed, authorized by one of its authors, and adapted for children language. SPRINT performs similarly to the Clinician-Administered PTSD Scale (CAPS) 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).

Child’s Reaction to Traumatic Events Scale

The CRTES (Jones, 1997) was derived from the Impact of Events Scale (Horowitz, Wilner, & Alvarez, 1979). It is a 15-item self-report measure designed to assess psychological responses to stressful life events. Responses are scored according to a Likert scale, where 0 (not at all), 1 (rarely), 3(sometimes), and 5 (often). In addition to a total score, the CRTES provides scores for two subscales: intrusion and avoidance. Scores less than 9 are considered low distress; between 9 and 18, moderate distress; and 19 and over, high distress. Although it is a self-report measure, the questions were read aloud to the younger children by the Emotional Protection Team (EPT) members. Their responses were recorded by the EPT. This measure was administered to the children at pretreatment, at 1-week posttreatment, and at 3-month follow-up.

Subjective Units of Disturbance Scale

A modification of SUD (Shapiro, 2001; Wolpe, 1958) was used. Instead of asking the children to simply rate the level of their disturbance, they were shown a diagram that depicts faces representing different levels of negative emotion (from 0 to 10, where 0 shows no disturbance and 10 shows severe disturbance) and asked to select the face that best represented their emotion and to write the corresponding number on their picture. Children were assisted in this process by members of the psychological recovery camp team.

SUD scores are an integral part of EMDR treatment (Shapiro, 2001), and their use has been demonstrated in EMDR studies with adults who are traumatized. For example, the SUD scale was shown to have a good concordance with pre–post physiological autonomic measures of anxiety (e.g., Wilson, Silver, Covi, & Foster, 1996). Physiological dearousal and relaxation were related to a decrease in the SUD score at the end of a session (Sack, Lempa, Steinmetz, Lamprecht, & Hofmann, 2008), and the SUD was significantly correlated with posttreatment therapist-rated improvement (Kim, Bae, & Park, 2008).

Precamp Workshop for Treatment Providers

Before the fourth camp—and research study—started, the authors conducted a workshop retreat to provide education about trauma therapy and EMDR treatment and theory for the entire adult team (psychologists, social workers, artists, and educational workers) who was going to participate in the camp. It was explained that in the treatment of traumatic complex memories, EMDR is understood as one component of an integrated treatment plan (Tinker & Wilson, 1999).

The focus pointed also toward the importance of reducing the overarousal of the sympathetic nervous system. The value of the camp activities was highlighted because they were designed to facilitate essential experiences of safety and stability (Courtois & Ford, 2009). Special attention was given to the team members always having a deep, loving, and respectful presence in the emotionally difficult moments (Jarero et al., 2008), and it was explained that this adult presence might increase children’s memory networks of positive information and could be a resource for the future. The workshop also provided education about the impact and treatment of trauma and reviewed emotion-focused and emotion regulation strategies (Servan-Schreiber, 2003) and mindfulness.

Overview of Treatment

A multicomponent phase–based trauma treatment approach was conducted during the camp. This approach for complex traumatic stress was recommended by Courtois and Ford (2009). The first phase of treatment focuses on patient safety, symptom stabilization, and improvement in basic life competencies. The second phase includes the exploration of traumatic memories by first reducing acute emotional distress resulting from the memories and then reappraising their meaning and integrating them into a coherent and positive identity.

Empirical studies that have included only those with complex trauma histories have found that memory processing is reasonably well tolerated and of benefit when conducted in a multicomponent fashion (e.g., Chard, 2005). There may be an advantage to integrating EMDR with other treatments when comorbid disorders or social issues also need to be targeted and may influence the treatment response (Fleming, 2012). Tufnell (2005) concluded that EMDR is suitable for use with children and adolescent with comorbid mental health problems when used in conjunction with other treatments.

In this study, the first phase of trauma therapy provided a range of different activities in the context of a therapeutic camp setting to develop stabilization and competencies. This research examined the effectiveness of the second phase of trauma therapy using a combination of group, EMDR-IGTP, and one-on-one EMDR intervention.

First Phase of Trauma Treatment

Please note that the first phase of trauma therapy corresponds to Phases 1 and 2 of standard EMDR and EMDR-IGTP procedures. This phase included the history taking session, which occurred for each child prior to the camp with the agency psychologist—and all of the experiences within the camp setting—from the children’s arrival on December 1 until December 7 when they left the camp.

The camp activities included the following: Children woke up early in the morning, practiced soft gymnastics and hatha yoga. The purpose of this was to support the processes of mental healing (Patanjali, 1991). Yoga practice has been used as an intervention for resolving traumatic stress because it facilitates increased positive mood, acceptance, and a peaceful stance through the care of body and the control of the breath (Van der Kolk, 2012). During each day, the children engaged in various activities and workshops. For example, one day, they visited the Gold Museum in Cali, Columbia, as an experience of participation in city life and for cultural exposure. Each night, before going to bed, the children had a party with stories, relaxation, slow and soft sound, and children’s music. Activities included the following:

Second Phase of Trauma Treatment

Please note that the second phase of trauma treatment corresponds to Phases 3–7 of EMDR therapy (Shapiro, 2001). In this study, we provided EMDR-IGTP to all 34 participants and individual EMDR therapy to 26 participants. The EMDR-IGTP was embedded into the camp activities. The individual EMDR sessions were provided for 7 out of town participants on the last day of the camp and for the other 20 children after completion of the camp activities. These therapies were administered according to the standard protocols (Artigas et al., 2009; Shapiro, 2001) by three therapists who were all EMDR-certified therapists and who all had training and experience working with children and vulnerable populations.

Comparison of the Effect of the Treatment in the Two Different Groups

With the objective to figure out whether differences exist depending on the condition (family or institution), a general linear model was applied. The scores of both instruments (CRTES and SPRINT) were compared for the repeated measurements (pretreatment, posttreatment, and follow-up) for each of the groups (institution and family). The results did not show any significant effects for the interaction between scores of the instruments and the type of group. These results show that the treatment results followed a similar pattern for both groups (institution and family).

The analysis of variance (ANOVA) showed a significant effect of time for both instruments, with all participants (N = 34) showing improvement on the CRTES (F[1, 33] = 520.26, p < .001) and SPRINT (F[1,33] = 259.27, p < .001). All the SPRINT scores at follow-up indicated minimal or mild PTSD symptoms (Figure 2). Also, all CRTES scores on the follow-up indicated low distress (Figure 3).

FIGURE 2

Changes in Short PTSD Rating Interview (SPRINT) scores following treatment.

FIGURE 3

Changes in Child’s Reaction To Traumatic Events Scale (CRTES) scores following treatment.

Planned post hoc t tests were conducted to evaluate change for the total group and each separate group. Significant reduction in symptoms was shown for CRTES (t[33] = 15.49, p < .001) and for SPRINT (t[33] = 19.87, p < .001; see Table 1 and Figures 2 and 3). These findings confirm the effect of the program and its maintenance throughout time. Finally, the rapid shift in SUD ratings during the processing sessions (Figure 1) is consistent with those reported in previous studies.

Multimodal Treatment

Multimodal treatment was provided to the children, with the first phase of therapy occurring in the context of a psychological camp setting. As described previously, the activities were designed to increase self-awareness and self-acceptance. The children learned emotion-focused and emotion regulation strategies as well as mindfulness. These practices have been evaluated by trauma experts as first- and second-line Phase 1 treatments (Cloitre et al., 2011). The multimodal therapy provided in this study addressed many of the children’s disparate therapeutic needs. This 1-week program appeared sufficient to enable preadolescent children suffering from complex trauma to experience significant change so that they could carry on with their lives with new feelings of strength and joy.

From an information processing theoretical perspective (Shapiro, 2001), the authors consider that one of the key benefits of the various activities was the creation and strengthening of positive memory networks. These networks were then available for access to children during EMDR processing of their traumatic memories. It is hypothesized that this allowed the children to focus on the memory without being submerged by emotional disturbances.

This study showed positive results from 1 week of multimodal treatment that included EMDR-IGTP and (for most of the children) one or two individual EMDR sessions. This was a very effective and time-limited treatment. Moreover, treating a large number of children in 1 week is advantageous in terms of costs.

This appears to be an efficient alternative to the type of treatment typically provided to children, which involves group or individual sessions extending over a 2- or 3-month period. Research has demonstrated that children with PTSD substantially improve in therapies lasting 9 and 12 weeks, and the ISTSS survey responses (Cloitre et al., 2011) suggested an even longer treatment course for complex PTSD. We recommend that multimodal treatment with EMDR-IGTP and individual EMDR be considered as a powerful alternative to traditional approaches.

EMDR and EMDR-IGTP

The results of this study demonstrate the effectiveness of a combination of EMDR-IGTP and individual EMDR in resolving PTSD symptoms for children who have experienced interpersonal trauma. The findings are consistent with those of other studies that have investigated the use of these approaches for children who are traumatized. However, the application of EMDR and EMDR-IGTP in this study was unique in several important ways.

The other studies of EMDR-IGTP found it to be an effective and efficient treatment for groups of individuals who have together experienced a specific disaster. In this study, the traumatic events, which were targeted by the children in their EMDR treatment, were individual events. Nevertheless, the group protocol was suitable and effective. It was provided on three occasions for these complex trauma participants, not as a single application as is the more common use in other studies (see Figure 1).

This is also the first study that measured the effects of the combination of EMDR-IGTP plus individual EMDR. It was observed that the three sessions of EMDR-IGTP had the effects of decreasing the SUD ratings associated with the traumatic memory and of increasing the child’s sense of mastery and confidence that they could cope with the terrifying memories. Only one or two individual EMDR sessions were needed by these children who had experienced various severe interpersonal traumas.

It should be noted that although only one memory was targeted, the effects generalized to the entire memory cluster of similar incidents (e.g., rape, sexual abuse, physical and emotional violence, neglect, abandonment). Shapiro (2001) mentioned that when the client chooses for reprocessing one incident that represent a particular cluster, “Clinical reports have verified that generalization will usually occur, causing a reprocessing effect throughout the entire cluster of incidents” (p. 207).

The results in this study suggest that the combination of EMDR-IGTP and EMDR may be a very potent therapeutic approach—one which could be used in various settings.

Recommendations

This program is suitable for such contexts as present-day Colombia. The end of conflicts and the construction of a lasting peace provide an opportunity to reestablish mental health in all individual victims of conflict. The authors propose to implement this program for all Colombian children who have been victims of severe interpersonal trauma.

To date, there are few studies exploring adaptations of, or alternatives to, established PTSD treatment developed specifically for individuals with complex trauma histories (Cloitre et al., 2011). The authors recommend future research on the use of EMDR as part of a multicomponent phase–based trauma treatment approach.