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Abstract
Humanitarian outreach is a significant part of the practice of eye movement desensitization and reprocessing (EMDR) therapy. The development of training in Arabic and provision of EMDR in areas of ongoing conflict including Palestine, Libya, Syria, and Iraq is described, and brief accounts of clients and therapists illustrate the help that EMDR has brought to survivors of conflict, imprisonment, and torture. Three clients, each with a diagnosis of posttraumatic stress disorder, are briefly presented here: one from a refugee camp in Palestine, one from a Syrian refugee camp in Jordan, and the other from a war zone in Libya.
Palestine, Libya, Syria, and Iraq are areas of humanitarian need, including psychological as well as material help. Among the features of humanitarian work are the need for sensitivity to the culture and language in which survivors and therapists are living; the need for an effective and timely treatment approach; and the need to help people rebuild their lives in a sustainable, hopeful, and resilient way. Eye movement desensitization and reprocessing (EMDR), an integrative psychotherapy approach to the treatment of trauma, has provided a therapeutic approach that can meet those needs. It is culture sensitive, timely, and effective and has enabled people in humanitarian crises to rebuild their lives following natural disasters, ongoing conflict, and torture.
EMDR was devised by Shapiro (2001) and builds on her adaptive information processing model. It is an integrative psychotherapy with protocols that include the use of bilateral stimulation and focus on past trauma, present situations, and future possibilities in enabling the client to reprocess disturbing memories to an adaptive resolution. It is recognized as an effective treatment for posttraumatic stress disorder (PTSD) in national and international guidelines including the World Health Organization (2013), the United States’ Substance Abuse and Mental Health Services Administration’s National Registry of Evidence-based Programs and Practices (2010), and the International Society for Traumatic Stress Studies (Foa, Keane, Friedman, & Cohen, 2009).
EMDR Humanitarian Initiatives and Outreach
This article focuses on an ongoing EMDR humanitarian project that began with the training of Palestinian therapists working in areas of ongoing conflict and developed into EMDR training in Arabic of therapists working in humanitarian projects in the Middle East and North Africa.
In 2005, the EMDR Humanitarian Assistance Program (HAP), in partnership with the East Jerusalem Young Men’s Christian Association (EJ YMCA), which provides humanitarian assistance throughout the West Bank, supported the training of 17 Palestinian therapists in EMDR. The purpose of the training was to work with existing nongovernmental and governmental HAPs to provide EMDR therapy in areas of need, including Palestinian refugee camps, and to train experienced EMDR practitioners as EMDR facilitators, consultants, and trainers. The humanitarian program had two strands. The first was in training therapists and trainers. The second was in providing direct pro bono clinical services to survivors of humanitarian crises and supporting those services with supervision and consultation.
EMDR was successful in this setting, and people saw positive changes in individuals and their communities. Other agencies, including those outside Palestine, asked for EMDR help, and it became clear that the most effective way to meet the increasing demand was to provide more training that would enable others to provide more direct humanitarian help to more people. To date, as a result of the initial HAP/YMCA project, 294 therapists have completed training and are working in humanitarian programs with refugees and others in situations of ongoing conflict, including Syria, Iraq, Libya, Lebanon, Egypt, and Palestine. Projects have been part funded by the EMDR Trauma Recovery HAP and EJ YMCA and by other agencies including EMDR HAP UK and Ireland.
The situation in the Middle East and in North Africa has seen a rise in the need for EMDR humanitarian work in the Arabic-speaking regions and, as one experienced trainee said at a recent training, EMDR is effective and quicker than traditional approaches. We have tried, where possible, to respond to requests for training and have completed 12 two-part trainings and consultation between 2005 and 2014. Trainees have included counselors, psychotherapists and psychoanalysts, clinical psychologists, and psychiatrists working in humanitarian settings.
The overall program does not have a formal structure. There is a core team of an EMDR trainer and consultants whose first language is Arabic and who provide trainings in Arabic and one-to-one support face-to-face or through e-mails and telecommunications. This support is vital to the success of the overall project, especially when developing EMDR in often remote and always troubled settings. Training in such settings is difficult. It has not been possible to provide training in Syria or Iraq, but this has been provided for therapists from those countries in Turkey and Jordan. Training in Libya has been under tight security and training in Gaza has not been possible. In the West Bank, the work is frequently disrupted or delayed because of roadblocks and checkpoints.
Results of HAP Initiatives, Lessons Learned, and Ongoing Programs
Some of the results of the humanitarian initiatives are an increased confidence that the therapists have in their work and effectiveness and increased motivation in their clients. Three of their clients’ stories, each diagnosed with PTSD, are briefly presented here: from a refugee camp in Palestine, from a Syrian refugee camp in Jordan, and from a war zone in Libya. These illustrate the difference in outcome between EMDR and previous counseling, the importance of addressing earlier traumatic events in a person’s life that feed into the present trauma, and the building of resilience and hope in situations of ongoing trauma. All were treated as part of humanitarian outreach programs.
Clinical Vignettes
Raheem, a Young Man From Palestine.
Raheem is from Palestine. We worked with him in two phases: before the therapist had been trained in EMDR and 9 years later when the same therapist was an experienced EMDR practitioner.
When he was 11 years old, Raheem was injured in his face from a shooting by soldiers. It had a very bad impact on his life; his face was disfigured and he felt rejected, isolated, and unacceptable. He was not able to go back to school. In counseling, he worked on how to accept himself and was eventually able to return to school, but not to the place where he had been shot or near it. The second phase was when Raheem was 20 years old, following his release from prison where he had been held from the age of 16 years and had been tortured.
EMDR, working with the past, present, and future, includes identifying the “touchstone” event, an event in the person’s life that strongly influences the person’s sense of self (Shapiro, 2001) and often charges the impact of the more recent trauma with thoughts, feelings, and sensations from the past. For Raheem, the most disturbing thing in his life was not his recent experience of imprisonment but the shooting when he was 11 years old. Although at that time he had received counseling, it seems clear that this was only on the surface. EMDR enabled him to work on the earlier incident at greater depth, reprocessing the memory of the incident itself before working on the recent trauma. It was only after this that he could go back to the actual place where he had been injured when he was 11 years old, stand there, and feel all right. He could also now speak about the experience in a stable way, and he was able to reprocess his recent memories of detention and torture. Raheem’s life has changed. He is happy: bright eyes, full of hope for the future, and plans to go to university. Although for so many years he had felt driven by what happened to him when he was 11 years old, now he is able to do things differently. He has hope.
Karima, a Syrian Refugee in Jordan.
Karima is married with children. She was imprisoned, with her daughter, during the civil war in Syria. They were “tortured and made to watch others being tortured.” As a refugee in Jordan, Karima came to an EMDR therapist who was trained as part of the humanitarian program. She did not feel any good in anything, worthless. Her anger used to erupt, like a volcano, in front of her daughter. She was very anxious that she would not be able to control this and distressed that she could not give her daughter the support she needed. There were also earlier incidents in her life. Her mother died when she was 5 years old, and she was abused by her stepmother, burning her with hot pans from the stove and hitting her violently. She felt, “I’m weak. I can do nothing. I am helpless.”
Although Karima had presented with her recent experience of imprisonment and torture, it was when she reprocessed the earlier abuse that she began to see positive changes and her belief about herself began to be “I’m strong. I’m strong enough,” and she was able to reprocess the recent memories of internment. As a result, she could see herself having strength and she was able to care for others. She could support her daughter and family, and people commented on the positive changes in her. At follow-up, Karima said, “As refugees, we are still facing very difficult circumstances and stresses, but I feel I’m strong and capable, able to confront anything I face and to go on with my life.”
Radwan, a Libyan Man in a War Zone.
Radwan, a Libyan man, after the revolution was with his close friends in the war zone in the desert when there was an attack. “Bombing happened” all around him. The sand was “like the rain coming down because of the explosions,” and he could see that most of his friends, his closest friends, were killed. After what happened, he left his family and isolated himself from everybody because he was anxious about hitting others. He was in a constant state of arousal and experienced flashbacks and intrusive thoughts. He did not even want to go to his work because he would have had to pass through the desert, and wherever he could see the desert, it would bring the incident back to him.
After EMDR, the anger and intrusive images stopped, and he was able to go to work. He could walk through the area where the shelling and bombing had happened. He got engaged and is currently making plans for his house. Now, he wants to continue his study. He said, “I’m safe now; I’m still alive and I did not lose any part of my body. I now have lots of hopes for the future; I’ll go on to make them happen.”
Therapist Experiences
These experiences and others like them have enabled therapists to work effectively with survivors of political violence, imprisonment, and torture as well as other trauma. We asked three senior practitioners in Palestine, one in Libya, and a Syrian therapist working with Syrian refugees in Jordan about their experience of EMDR.
All the therapists said that EMDR had given them more confidence. It was more immediate, and it was possible to see subtle physical reactions during the course of therapy as well as often dramatic changes in their clients’ lives. Interestingly, although the protocol format was initially thought to be a difficulty, therapists commented that it made the work very clear, gave a sense of direction, and was easy to follow. EMDR was also deeper. “Before, we used to work on the symptoms of the problem, but now we are working on the problem itself, on its base. So the client knows from why and where the problem began. There is a mutual understanding between us. It seems that part of the process is educative. The client is educated about him or herself.”
Therapists also noted that survivors have often experienced things they do not want to talk about in detail and “with the EMDR, they can go to the incident, and they can see the details that they don’t want to speak about. It’s like a puzzle when they put them together, when they remember all the parts that they faced, then, only then they become more adapted, they become better. The client can remember the incident—and me as a therapist, I’m just helping her to pass through it.”
The Future
Now that there is EMDR training in Arabic in different countries, we are working toward an EMDR Arabic association whose purpose will be to maintain standards and support research. Two of the trainees intend to do PhDs on an EMDR topic, and there is current research in Palestine with ex-detainee children.
It is important to train experienced clinicians, and we have set criteria for accepting trainees. The next stage of the development is to train facilitators and trainers to provide training and supervision in the countries in which they are working and within their own structures. The trainees themselves often live in the same situation as their clients and face ongoing trauma. In training, it was difficult for them to find a simple incident to work on in practice and in the practical it takes more time, but the participants begin to feel for themselves what EMDR can do for them and for the people that they serve in humanitarian need.
References
- E. B. Foa, T. M. Keane, M. J. Friedman, & J. A. Cohen (2009). Effective treatments for PTSD: Practice guidelines from the International Society for Traumatic Stress Studies (2nd ed.). New York, NY: Guilford Press.
- F. Shapiro (2001). Eye movement desensitization and reprocessing: Basic principles, protocols and procedures (2nd ed.). New York, NY: Guilford Press.
- Substance Abuse and Mental Health Services Administration’s National Registry of Evidence-based Programs and Practices. (2010). Eye movement desensitization and reprocessing. Retrieved from http://nrepp.samhsa.gov/ViewIntervention.aspx?id=199
- World Health Organization. (2013). Guidelines for the management of conditions specifically related to stress. Geneva, Switzerland: Author.
Acknowledgments.
I express thanks to the therapists whose work is reported here, including Imad Alarda, Dr. Ghalia Alasha, Fatema Almaqrehy, Faten Alshobi, and Salam Hamarsheh, and the people who have helped me in writing this article.
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