Some lessons learned in the EMDR Humanitarian Assistance Program intervention in the Balkans

This is an excerpt of an article by Gerald Puk, Ph.D. and Steven Silver, Ph.D.

Mental health professionals have been trained in using EMDR with trauma victims throughout the world. However, the EMDR-Humanitarian Assistance Program (EMDR-HAP) was formed in 1995 as a nonprofit organization to provide assistance and training to local mental health professionals/psychotherapists within the United States and internationally who are managing the nearly overwhelming task of providing psychotherapy to the victims of large scale traumatic events. This includes natural disasters, e.g.: earthquakes, floods, firestorms, hurricanes; military personnel and civilians in war zones; victims of large scale accidents, e.g.: the family members of the victims of TWA flight #800; and victims of sexual assault and terrorist acts, e.g.: the Oklahoma City bombing. The EMDR-HAP personnel have been trainers and group facilitators from the EMDR Institute who have volunteered their time and expertise to provide treatment and to train local mental health professionals in EMDR.

It has been demonstrated that EMDR can relieve high levels of distress in survivors of a single traumatic event under very chaotic, disorganized and primitive conditions. They report that a group of EMDR-trained clinicians volunteered to provide treatment to some of the survivors of Hurricane Andrew which devastated all of southern Florida. Their results show that one session of EMDR treatment significantly reduced self-reports of client distress (Granger et al., in press). Treatment effects also were measured with the Impact of Events Scale-total score, avoidance symptoms score and intrusive symptoms score showing significant reductions on each of these measures.

Oklahoma City Bombing Relief Project

On April 19, 1995 the worst terrorist act in United States history occurred when the Edward P. Morra Federal Building in downtown Oklahoma City was bombed. Within moments, 168 were killed and more than 800 were physically injured. The number experiencing psychological trauma as a result of this act probably is much greater and its aftereffects may continue for years. Shortly thereafter, the EMDR-Humanitarian Assistance Program was invited by a local community mental health center to help with disaster relief. The EMDR Free Clinic was operational from approximately one week after the bombing until September, 1995. It provided over 700+ hours of EMDR treatment from EMDR trained-clinicians who volunteered their time and expertise to firefighters, rescue workers as well as victims of the bombing. Also EMDR Level 1 and 2 training programs and specialty training in EMDR applications to children were provided to almost 300 local mental health professionals by Drs. Steven Silver, Gerald Puk, Francine Shapiro and Robert Tinker. The goal was for the locally trained psychotherapists to be able to follow through with EMDR treatment for the large percentage of the community that was affected by this terrorist act.

An emphasis for the volunteer clinicians and training staff was to prevent compassion fatigue. Figley (1995) defines secondary traumatic stress or compassion fatigue as "the natural consequent behaviors and emotions resulting from knowing about a traumatizing event experienced by a significant other--the stress resulting from helping or wanting to help a traumatized or suffering person." Considering the high rate of traumatized individuals in the community that the local psychotherapists were beginning to treat, it became essential to address the need to provide for the well-being of the mental health professionals involved in the disaster relief project--both locally and those volunteering from other areas to assist. This was accomplished with frequent debriefings and the development of a group cohesiveness that kept individuals focused on the group goals, e.g.: providing crisis treatment and training local psychotherapists.

For the trainees, the importance of reducing the impact of secondary traumatic stress and vicarious traumatization were emphasized. This could be partially accomplished within the same study groups that they would use for developing their EMDR skills following the Level 1 and Level 2 workshops. While this was a single traumatic event that did not have the on-going components of multiple traumata as in Croatia and Bosnia-Hercegovina, there was still a need to address compassion fatigue with those who volunteered their assistance as well as with local psychotherapists.

The remainder of this paper will discuss the EMDR-HAP interventions in Croatia and Bosnia-Hercegovina. The purpose is to clarify and focus on the lessons learned by the EMDR-HAP personnel who were involved. Clearly, the traumata vary and are complex in each of these situations. However, they dovetail with some of the lessons learned about compassion fatigue during the Oklahoma City Bombing Relief Project. The areas to be focused on include managing compassion fatigue (Figley, 1994) and personal stressors and team building.

EMDR Training in Zagreb, Croatia

In March, 1995, a team of three psychologists consisting of Drs. Steven Silver, Gerald Puk and Geoffrey White provided EMDR Level 1 training to 34 Croatian mental health professionals and three Bosnian psychotherapists from Sarajevo (Silver, 1995). The trainees worked with children and adults who were combat veterans, refugees, displaced persons, torture victims and survivors from concentration camps during the war in the former Yugoslavia. This project was sponsored by the Society for Psychological Assistance and funded through Catholic Relief Services, U. S. AID and the EMDR Institute.

Additionally, as with other EMDR training programs, it was strongly recommended to workshop participants that they meet regularly on a monthly basis in a study group. The purpose of this is to provide peer support in developing EMDR skills clinically and the professional confidence in applying this method of treatment for trauma. The training team was aware that some participants may have only limited experience in treating trauma victims gained only since the beginning of the war. Also, there is a "learning curve" in implementing EMDR treatment and that this may be somewhat more difficult for some of the participants considering that they may be traumatized themselves or exhibiting signs of secondary traumatic stress. In fact, Figley's Compassion Fatigue Self Test for Psychotherapists (Figley, 1995) was informally completed by participants at a study group meeting. These results suggested that many of the participants were at high-risk to develop secondary traumatic stress. Also, a group facilitator was provided for the study group by the Society for Psychological Assistance and clinical consultation was provided by the workshop trainers via fax and e-mail communication.

With regard to the training team, the initial plan called for the three team members living with local families in Zagreb during the project. This was viewed by all as an opportunity to meet and become acquainted with several local families and to learn more in an in-depth and very personal way about the stressors that they were experiencing during the war and what was helping them to cope. However, this initial plan did not come to fruition and the team resided in an apartment provided by a local NGO. This fact became quite important because it inadvertently offered a means for the team members to provide mutual support and spontaneous debriefing to each other particularly about the traumatic material that was disclosed to them during the EMDR training workshops. This included specific traumas experienced by the participants as well as the case material from clients that the participants were treating.

EMDR Training in Sarajevo, Bosnia-Hercegovina

As a result of the EMDR training in Zagreb, Croatia and the experiences of the Croatian trainees and those from Sarajevo, an EMDR training program was organized for Sarajevo and took place in December 1995. This was sponsored by the Catholic Relief Services. The team consisted of four members and this time included a female psychologist specializing in the treatment of war trauma. This was a consequence of our learning that the majority of mental health care providers in Croatia and Bosnia-Hercegovina were female and we believed that it would assist the workshop participants in relating to the team and make the training program more effective.

In two workshops, 31 local psychotherapists were trained in EMDR. As in previous workshops, forming a local study group and regular monthly meetings was encouraged. This group met monthly for 18 months for peer supervision and review of clinical cases treated with EMDR. Clinical consultation was provided by one of the EMDR trainers via e-mail and fax communication. This seemed to be quite effective in providing support to the participants in developing EMDR skills based on participant feedback from each meeting. Noted also is that the group provided a vehicle for the members to debrief their own traumatic experiences and secondary traumatic experiences related to their highly stressful work demands.

We identified recurring patterns of stressors that workshop participants reported both personally and professionally. On a personal level was the trauma of living in a city under siege and the repeated shelling of Sarajevo for 42 months. Some reported personal traumas from the war more generally or from participating in military actions or having to flee from their home town. Also, there were the stressors of everyday living from the impaired infrastructure of the city, increased street crime, lack of heat, gas and electricity, limited and uncertain food supply, and fear for family members. Some discussed the stress and isolation from severely limited access to information and news from outside the city in that it was extremely difficult to maintain those connections to the rest of the world. Some talked of the repeatedly frustrated expectations that the United Nations Protective Forces would eventually do something to significantly change the situation.

On a professional level, the therapists reported work with client complaints which related to the on-going killing of civilians by snipers and shelling of the city; treating combat veterans and war trauma; providing treatment for displaced persons, refugees and torture victims. Unexpectedly, a high rate of motor vehicle trauma was reported. Because of the lack of electricity, traffic lights were inoperative. Drivers would speed to avoid sniper fire and this made for a dangerous situation.

For all, there was the uncertainty for the future. This included concerns for reconstructing the family and where they might live and obtaining employment after the war. A major concern here as we had learned also in Croatia was the focus on the children's welfare and safety and not on the immediacy of any personal danger or threat. Noteworthy, working with traumatized children can leave psychotherapists particularly vulnerable to compassion fatigue (Beaton & Murphy, 1995).

These mental health professionals reported caseloads of 70-90 clients. This is a professional task that is severely isolating and profoundly overwhelming. It created a situation in which self-care by the psychotherapists was extremely difficult to provide. Some reported difficulties relaxing and with concentration. Clearly, there was considerable evidence of depression, PTSD and signs of secondary traumatic stress

Following the training program in Sarajevo, a study group has met monthly for the past 18 months with a CRS staff member as the group facilitator. The participants report that the group is most helpful in several ways. These include the opportunity to discuss with peers their experience using EMDR clinically as a vehicle for case consultation and peer supervision as well as to ask questions about applications of EMDR with specific clients that are in treatment. Consultation is provided through fax or e-mail communication with the training team to provide input regarding specific questions that group members have about EMDR and its clinical applications. The group also provides a means for additional practicum experience. Lastly, the group became a means for the participants to obtain mutual support in managing the many stressors of an overwhelming job and coping with signs of compassion fatigue.

Group members report using EMDR with a range of client problems. These include PTSD, acute stress reactions, adaptive disorders, anxiety disorders including panic, social phobia and agoraphobia, feelings of guilt, prolonged grieving and behavior disorders.

What We Have Learned

There are several lessons that the training team has learned during our work in Zagreb, Croatia and Sarajevo (Silver, 1995; Silver et al., 1996). First, is the recognition of the insidious nature and the impact of compassion fatigue. Our focus as clinicians and mental health professionals is on our clients that we serve and help. We tend to ignore our own post-traumatic symptoms. Even more so, we need to give attention to the signs of secondary traumatic stress and vicarious traumatization in ourselves that develops from listening to far too many "horror stories" from our clients and not having the time to care for ourselves. All of those personal qualities that make us excellent psychotherapists, e.g.: compassion, sensitivity, listening actively and sympathetically, trust and openness, and a willingness to share experiences, are exactly those that make us vulnerable to compassion fatigue and vicarious traumatization. Compassion fatigue is an occupational hazard of which all of us need to be aware (see Figley, 1995). However, compassion fatigue can generally be identified more easily in the United States because it is in direct response to client material. This is more complicated in Croatia and Bosnia-Hercegovina because the psychotherapists are themselves being directly traumatized by the same stressors as those traumatizing their clients.

We have learned that the EMDR study groups that are recommended after the Level 1 training to develop EMDR clinical skills are actually much more than that. They provide a vehicle for the group participants working in war zones, disaster areas and other areas of high traumatization rates to obtain peer support and the chance to debrief some of the clients' traumatic material to which they listen. It offers the opportunity for self-care and the reduction of signs of secondary traumatic stress and vicarious as well as direct traumatization.

We need to encourage the trainees' participation in these study groups. One way to do this is to offer on-site consultation with the training team within 30 days. This can be an opportunity to offer clinical consultation as well as follow-up with clarification about EMDR specifically when helpful. These group meetings can also more rapidly be followed with the EMDR Level 2 training and specialty training regarding applications of EMDR to specific populations, e.g.: children.

We have also gained useful insights relating to team composition and management of personal stressors. This refers specifically to the EMDR training team. Hopefully, it can provide useful insights for other clinicians and administrators faced with assembling a training team to work on a trauma-relief project.

In a disaster or crisis situation, stress levels are very high. The training team is working under the same disaster conditions as those presently affecting the workshop participants, e.g.: intermittent heating, electricity and running, sporadic gunfire, etc. Daily debriefings can facilitate the team's effectiveness as well as assist team members in managing personal stress during the training program. Follow-up with the completion of tasks related to finishing and enhancing the training program becomes more feasible.

It becomes extremely important to choose team members who can work together and have the same goals for being involved in the project. Team members need a "we" focus. "Let those with "big egos" find or be given another task" (Silver, 1995). Mutual support for team members arises from a focus on team goals; that it is important to reduce the interference or distraction by individual and personal needs. Each team member needs to gain their personal satisfaction from satisfactorily completing the team mission.

Lastly, there is a greater awareness of our own personal vulnerability to secondary traumatic stress. As we work under the same highly stressful conditions under which the workshop participants are living, we must remain alert to the need to manage our personal signs of compassion fatigue. Daily debriefing by the training team can help significantly in reaching this goal. Those team members who are experienced in using stress management techniques such as meditation, progressive muscle relaxation, guided imagery and visualization exercises for relaxation should be strongly encouraged to continue using them. Team members who are not skilled in these stress management techniques should be encouraged to learn them. It can be important for the team members to plan leisure time together and to avoid isolated living conditions when possible. This latter issue can be more complicated with teams containing both male and female members.

We must maintain an awareness that our prior personal experiences can and will be "triggered" when entering crisis situations. This can have both positive and negative effects. For example, stimulating the alertness associated with prior military training when entering a war zone to provide humanitarian aid can be beneficial, but accessing earlier personal traumatic experiences that have not been resolved may be detrimental. Also, a sense of humor on the part of team members is crucial as a means to provide support and relief for each other.

Lastly, I wish to end with a question that is addressed to all of us. "If we as caregivers are not caring for ourselves and our colleagues, then who will assist the caregivers and ultimately the healing of the community?"

References

Beaton, R.D. & Murphy, S.A. (1995). Working with People in Crisis: Research Implications. In C.R. Figley (ed.), Compassion Fatigue: Coping with Secondary Traumatic Stress Disorder in Those Who Treat the Traumatized. Brunner/Mazel, New York.

Figley, C.R. (1995). Compassion Fatigue as Secondary Traumatic Stress Disorder: An Overview. In C.R. Figley (ed.), Compassion Fatigue: Coping with Secondary Traumatic Stress Disorder in Those Who Treat the Traumatized. Brunner/Mazel, New York.

Grainger, R.D., Levin, C., Allen-Byrd, L., Doctor, R.M. & Lee, H. (In press). An Empirical Evaluation of Eye Movement Desensitization and Reprocessing (EMDR) with Survivors of a Natural Catastrophe. Journal of Traumatic Stress.

Shapiro, F. (1989). Efficacy of the eye movement desensitization procedure in the treatment of traumatic memories. Journal of Traumatic Stress, 2, 199-223.

Shapiro, F. (1995). Eye Movement Desensitization and Reprocessing: Basic Principles, Procedures and Protocols. Guilford Press, New York.

Shapiro, F. (1996). Eye movement desensitization and reprocessing (EMDR): Evaluation of controlled PTSD research. Journal of behavior therapy and experimental psychiatry, 27, 209-218.

Silver, SM.., Rogers, S. & Puk, G. (1996, June). EMDR Humanitarian Assistance Program: Sarajevo. Paper presented at the Annual Conference of the EMDR International Association, Denver, Colorado.

Silver, S.M. (1995, June). EMDR in Croatia. Paper presented at the International EMDR Conference, Santa Monica, California

Solomon, S.D., Gerrity, E.T. & Muff, A.M. (1992). Efficacy of treatments for posttraumatic stress disorder. Journal of the American Medical Association, 268, 633-638.

Wilson, S.A., Becker, L.A. & Tinker, R.H. (1995). Eye movement desensitization and reprocessing (EMDR) treatment for psychologically traumatized individuals. Journal of Consulting and Clinical Psychology, 63, 928-937.

No Replies