CRISIS INTERVENTION:

INTEGRATING EMDR PROTOCOLS

FOR PARAPROFESSIONAL USE
WITH CISM INTERVENTIONS

Tony Culnane OAM BTh CertMin GradDipCommCouns

Paul Scott DipCommOrgs(Mgt) BEd(AdEd) MCouns

CIMA Conference, October 2013, Melbourne

ContextualOverview:

CrisisIntervention/EmergencyMentalHealth
Goals:
1)Stabilisation
2)Symptomreduction
3)Returntoadaptivefunctioning,or
4)Facilitationofaccesstocontinuedcare
ContextualOverview:

CRISISINTERVENTIONHISTORY

MilitaryPsychiatry

CommunityMentalHealth

SuicideInterventionInitiatives
ContextualOverview:

CRISISINTERVENTIONHISTORY

WWI(1914 1918)FirstempiricalevidenceCI
reducespsychiatricmorbidityPostesdechirurgie
durgence[PostEmergencySurgery].(1916).

Proximity&Immediacy.Salmon,T.(1917,1919)
ContextualOverview:

CRISISINTERVENTIONHISTORY

Sargent,W.(1942)Immediatefirstaidtxofacute
neurosis

Marshall,S.L.A.(1944)GroupInterventionvia
HistoricalEventReconstruction
ContextualOverview:

CRISISINTERVENTIONHISTORY

WWII(1930 1945)Immediacy,Proximity&
Expectancyidentifiedaseffectiveactiveingredients
Lindemanns(1944)Observationsofgriefreactions
(1950s)CommunitySuicidePrograms
Kardiner(1959)recognisedexhaustion&fear&dont
allowentrenchmentofsymptoms
ContextualOverview:

CRISISINTERVENTIONHISTORY

Caplans(1963/64)3tiersofpreventativepsychiatry
(Primary,Secondary&Tertiaryprevention
(late60s/early70s)CIprinciplesappliedto
chronichospitalpopulations
(1980)DSMIIIlegitimisesPTSD&crisis&traumatic
eventsasthreatstolongtermmentalhealth
ContextualOverview:

CRISISINTERVENTIONHISTORY

(1992)USARedCrosstraininginDisasterMental
Health
(1994)DSMIVrecognisesAcuteStressDisorder
(2002)NIMHGuidelinesonMentalHealth&Mass
Violence(Phasic,Integrated,Multicomponent)
(2002)EAPAGuidelinesondisastermentalhealth
ContextualOverview:

EMDR(EyeMovementDesensitisation&
Reprocessing)
(1987)DrFrancineShapiro(Behaviouralparadigmto
informationprocessingtheory)
Integrativepsychotherapy
Dysfunctionallystoredmemories
Integratesinformationthatissensory,cognitive,
emotional&somatic
ContextualOverview:

EMDR(EyeMovementDesensitisation&
Reprocessing)
AIP AdaptiveInformationProcessing
EMDRsession
Accessamemoryrelevanttocurrentdifficulty
Briefapplicationsofbilateralstimulation(eyemovement,
tactilestimulation,orauditorystimulation)
ContextualOverview:

CISM(CriticalIncidentStressManagement)
DrJeffreyMitchell&DrGeorgeEverly,(1999)
ComprehensiveIntegrativeSystematicMulticomponent
Initialcomponent CISD(Mitchell&Everly,1983)
OutlineofGazaExercise:

ConflictbetweenIsrael&Palestine

Hamas(RuledGazasince2007)

November2012Incident(Warlasted7days)
OutlineofGazaExercise:

WorldVision:CommunityDevelopmentin
HolyLand1975

14Geographicareas:Jerusalem,WestBank&
Gaza

Living&workingingeopoliticalcircumstances
OutlineofGazaExercise:

RecognitionbyWVseniormanagementof
vulnerabilitytopsychologicaltrauma
(Gazabasedstaffinparticular)

33staffandtheirfamilies
OutlineofGazaExercise:
December2012decisiontoimplementStaff
CareIntervention

Plantotransferstaff&familiesfromGazato
SharmElSheikh,Egypt

January2013PeerSupportTeam+2Consultants
conductstaffcareintervention
WhatWeDid:
StaffCareTeam

Ledby2CrisisInterventionMentalHealth
Consultants

5PeerSupportStaff(WVMiddleEast&Eastern
EuropeanRegion)
3ofwhomwerePalestinian(Culture&Language)
3Maleand2Female
WhatWeDid:
AllPeerSupportStafftrainedin6CISMcourses
&WVStaffCareCourses

StaffCareTeamcompleted2dayintensive
EMDREarlyInterventionProtocolsfor
ParaprofessionalUseconductedbyDrIgnacio
JareroinCyprus
TheParticipants:

33staff+somefamilymembers

6dayperiodofrestandrelaxation

SharmElSheikhResort(Goodfacilities)
OutlineofIntervention:
CISM

CrisisManagementBriefings

SAFERRModelforAssistingIndividualsinCrisis
OutlineofIntervention:

EMDRTherapyIntegratedGroupTreatment
Protocol(EMDRIGTP)

EMDRTherapyIndividualProtocolfor
ParaprofessionalUseinAcuteTraumaSituations
(EMDRPROPARA)

CognitiveBehaviouralTherapy(CBT)
ProgramOutline:

Day1:

StaffCareTeamPlanningMeeting
IntroductoryMeetingwithGazaStaff&families
ProgramOutline:

Days2 4(mornings)

LargeGroupsessions
CompleteSPRINTQuestionnaire
Learn&PracticeSelfSoothingTechniques
Drawingpicturesandapplyratings(SUDS)
EMDRIGTP
ProgramOutline:

Days2 4(afternoons&evenings)

ReviewofdrawingsandSUDS
ReviewofSPRINT(Day2only)
StaffCareTeamavailableforindividualsessions
UseofCISMinterventions,EMDRPROPARA,&CBT
ProgramOutline:

Days5 6

StaffCareTeamavailableforindividualsessions
UseofCISMinterventions,EMDRPROPARA,&CBT
ProgramOutline:

Individualsessionsalsoincluded:

Clarification&Feedback SPRINT&Drawings&
SUDS
CISM CrisisManagement
Briefing(CMB):
Structuredmeeting

Information/Educationaboutbasicstress
management&copingstrategies

Resourcesidentified

Controlrumours
CISM SAFERRModelfor
AssistingIndividualsinCrisis:
Stabilisation,includingintroduction
Acknowledgement(Event&PersonsReactions)
FacilitationofUnderstanding(Normalisation)
EncouragingEffectiveCoping(Mechanismsof
Action)
RecoveryorReferral(Facilitateaccesstoassessment
&continuedcare)
CognitiveBehaviouralTherapy
(CBT):
Identifyunhelpfulthoughts&behaviours

Learnorrelearnhealthierskills&habits

*Note oneparticipantdidnotwanttoundertake
EMDRprotocols.CBTwasusedtoaddressPTS,
AngerandStressManagementissues
EMDRIGTP:
DevelopedbyMexicanAssocforMentalHealth
SupportinCrisis(AMAMECRISIS)

DrIgnacioJarero&DrLucinaArtigas

Developedwithencouragement&supportbyDr
FrancineShapiro

Adaptablefornumeroussettingsworldwide
EMDRIGTP:
Combines8standardEMDRtreatmentphases
with;

GroupTherapyModel

ArtTherapyformat

UsesButterflyHug(BilateralStimulation)
originatedbyArtigas
EMDRPROPARA:
ProjectdevelopedatinitiativeofDrF.Shapiroby
DrI.Jarero,etal.

AnadaptationofEMDRPRECI(ProtocolforRecent
CriticalIncidentswhichfollowsonfromShapiros
(2001)RecentTraumaticEventsProtocol
EMDRPROPARA:
Toaddress3clinicalpresentations
TraumaticstressSxthatimpactlifequality

Functional&/orsocialimpairment

SubclinicalreactionsofAcuteStressDisorderor
AcutePTSD
ShortPTSDRatingInterview
(SPRINT):

DevelopedbyDrJonathonR.T.Davidson,MD
(2000)

8 itemintervieworselfratingquestionnaire
ArtTherapy:
(Depictingpersonallydistressing
experiencesindrawing)
Thinkaboutaspectsofrecentdistressingexperience
Angry,frightened,orsad
Crayonsonpaper drawing
UseSUDS(11pointSubjectiveUnitsofDistress
Scale)
UseButterflyHugaftereachrating(4times)
SelfSoothingExercises:

AbdominalBreathing

Concentration

PleasantMemory
ButterflyHug:

DevelopedbyDrLucinaArtigasforherEMDRwork
withchildren

Facilitatesprocessingoftraumaticmemory

Bilateralstimulation
AcademicResearchSupport:
EMDRstateoftheartpsychotherapy

Evidencedbasedtherapygroup

20+randomisedstudiesoftreatmentfortrauma

AIPprovidestheoreticalbasis

Achievestherapeuticeffectsequivalenttoandaslong
lastingasCBT
AcademicResearchSupport:
EMDRPROPARA

(Conducted2012&published2013)RCTwithFirst
RespondersreducingSxofPTS&maintaining
continuousdecreasedespiteongoingexposureto
similarstressfulevents.

Immediatelyand3monthspost
AcademicResearchSupport:
EMDRIGTP[Documentedeffectiveness]

Anecdotalreports(Gelbach&Davis,2007;Luber,
2009)
Pilotfieldstudies(Artigasetal,2000;Jareroetal,1999,
2006)
Casereports(Birnbaum,2007;Erreboetal,2008;
Fernandezetal,2004;Gelbach&Davis,2007;
KorkmazlarOral&Pamuk,2002;Wilsonetal,
2000;ZaghroutHodalietal,2008
AcademicResearchSupport:
CISM

Effectivenesssuggestedthroughqualitativeanalysis
(Everly,Flannery&Mitchell,2000;Everly&Mitchell,
1999;Miller,1999;Dyregrov,1997,1998,1999;Mitchell
&Everly,1997)
AcademicResearchSupport:
CISM

Empiricalinvestigations&MetaAnalyses(Flannery,
1998;Flannery,Penk&Corrigan,1999;Flanneryetal.,
1995;Flanneryetal.,1998;Flanneryetal.,2000;
Mitchell,Schiller,Everly&Eyler,1999;Everly,Flannery
&Eyler,2008;Flannery,Everly&Eyler,2000;Western
ManagementConsultants,1996)
OutcomesAchieved:
SPRINT
18ratedseverePTSDSx
13ratedmoderatePTSDSx
1ratedmildPTSDSx

MostcommentedonreductionofPTSDSx
OutcomesAchieved:
SelfSoothingTechniques
Initialshyness

31participantsderivedbenefit

Observedusingtechniquesoutsideofsessions

Inparticular,manycommentedonpleasant
memorytechnique
OutcomesAchieved:
ArtTherapy/Drawings/SUDS

Initialshyness

Allparticipantsreadilyexpressedtheirtrauma
experiences&SUDSprogressivelydecreased

Veryusefulinindividualsessions
OutcomesAchieved:
EMDRIGTP/EMDRPROPARA/CISM

Capturedaccumulatedtraumaexperiences
Enabledgoodexpression(talk,drawing,rating)
Structuredprotocolsallowedasafe&manageable
condition
Tailoredfortrainedappropriateparaprofessionaluse
Workabledespiteculture,context&language
difference
OutcomesAchieved:
EMDRIGTP/EMDRPROPARA/CISM

28/33reportedrelieffromtheirPTSDSx

Postreportsindicatethatdespitereturningtoanoften
hostile&traumaticenvironment,individualscontinue
tobenefit:
ReductioninPTSDSx
Increasedcomfortgainedthroughapplicationofself
soothingtechniques&ButterflyHugtechnique
FollowUp:
Staffretreatsincorporatingstressmanagement
education
Identify&trainGazapeersupportstaff
FollowupvisitationtoGazastaffbyWVJWGpeers
LeadershipdevelopmentforGazastaff
WVJWGseniorstafftovisitGazastaff(address
operationalmatters&HRinequality)
Skypesupport
Strengthenperformanceexpectations
(encouragement)
Caution:

EMDRforParaprofessionalsisaworkin
progress
ThankYou