The EMDR Protocol for Recent Critical Incidents: Follow-Up

Report of an Application in a Human Massacre Situation

Ignacio Jarero
Susana Uribe
Asociación Mexicana Para Ayuda Mental en Crisis
Latin American & Caribbean Foundation for Psychological Trauma Research Mexico City, Mexico

This article reports the follow-up results of our field study (Jarero & Uribe, 2011) that investigated the
application of the eye movement desensitization and reprocessing (EMDR) Protocol for Recent Critical
Incidents (EMDR-PRECI) in a human massacre situation. A single individual session was provided to
32 forensic personnel of the State Attorney General in the Mexican state of Durango who were working
with 258 bodies recovered from clandestine graves. Pre-post results showed significant improvement for
both immediate treatment and waitlist/delayed treatment groups on the Impact of Event Scale (IES) and
Short PTSD Rating Interview (SPRINT). In this study, we report the follow-up assessment, which was
conducted, at 3 and 5 months posttreatment. Follow-up scores showed that the original treatment results
were maintained, with a further significant reduction of self-reported symptoms of posttraumatic stress
and PTSD between posttreatment and follow-up. During the follow-up period, the employees continued
to work with the recovered corpses and were continually exposed to horrific emotional stressors, with
ongoing threats to their own safety. This suggests that EMDR-PRECI was an effective early intervention,
reducing traumatic stress for a group of traumatized adults continuing to work under extreme stressors in
a human massacre situation. It appears that the treatment may have helped to prevent the development
of chronic PTSD and to increase psychological and emotional resilience.

Keywords: EMDR-PRECI; early EMDR intervention; EMDR and prevention of PTSD; human massacre
mental health; posttraumatic stress; resilience

E
ye movement desensitization and ­reprocessing an adaptive manner. The eight-phase, three-pronged
(EMDR) is an evidence-based psychotherapy process of EMDR is said to facilitate the resumption of
for post-traumatic stress disorder (PTSD), with normal information processing and integration. This
approximately 15 randomized clinical trials demon- treatment approach, which targets past experience,
strating its efficacy in reducing and ­eliminating PTSD current triggers, and future potential challenges, can
symptoms. It has been shown to provide outcomes often result in the alleviation of presenting symptoms;
similar to those achieved by cognitive ­behavioral with a decrease or elimination of distress related to
­approaches (Bisson & Andrew, 2007), with effects the targeted memory, improved view of the self, ­relief
maintained at follow-up. There is also preliminary from bodily disturbance, and resolution of present
support for its application in the treatment of other and future anticipated triggers (EMDR International
psychiatric disorders, for various mental health prob- Association [EMDRIA], 2011).
lems, and somatic symptoms.
In her adaptive information processing (AIP) ­model,
EMDR and Early Intervention
Shapiro (2001) posits that much of psychopathology
is due to the maladaptive encoding in memory and/ The authors view early EMDR intervention as ­having
or ­incomplete processing of traumatic or disturbing a natural place in the crisis intervention and disaster
adverse life experiences. This is thought to impair the ­mental health continuum of care context and have
individual’s ability to integrate these experiences in ­argued that EMDR may be key to early ­intervention

50 Journal of EMDR Practice and Research, Volume 6, Number 2, 2012

© 2012 Springer Publishing Company  http://dx.doi.org/10.1891/1933-3196.6.2.50
as a brief treatment modality (Jarero, Artigas, & VOC but full ­reprocessing ­doing BLS while informa-
Luber, 2011). In some critical incidents (e.g., earth- tion is moving. A supplemental step is conducted in
quake, flooding, landslides, tsunamis), related stress- this phase to ­review the whole ­sequence holding the
ful events continue for an extended time (often more PC. Phase 6 uses standard EMDR procedures. Phase
than 6 months). We have argued that this lack of a 7 uses Jarero and Artigas’s postdisaster self-soothing
posttrauma period of safety prevents the consoli- strategies (Jarero et al., 2011), and Phase 8 uses stan-
dation in memory of the original critical incident dard procedures.
(Jarero et al., 2011). Accumulated traumatic memo- There is preliminary evidence supporting the ef-
ries may be a possible factor in sensitizing the indi- ficacy of EMDR-PRECI in reducing symptoms of
vidual to painful or threatening triggers, resulting in posttraumatic stress in adults and maintaining those
the development of later disorders, with sensitization effects despite ongoing threat and danger in a disas-
increasing with the number of exposures to similar ter mental health continuum of postincident care
traumatic situations (McFarlane, 2009; Suliman et al., ­context. EMDR-PRECI was shown to produce sig-
2009). In addition to treating present distress for a spe- nificant ­improvement on self-report measures of
cific recent event, early interventions may be essential ­posttraumatic stress symptoms for adults trauma-
to help prevent sensitization or the progressive accu- tized by an earthquake (Jarero et al., 2011). This
mulation of trauma memories or negative ­associative randomized, controlled group field study was con-
links (Tofani & Wheeler, 2011). ducted subsequent to a 7.2 earthquake in North
Baja California, Mexico. Treatment was provided to
The EMDR Protocol for Recent 18 individuals who had high scores on the Impact
Critical Incidents of Events Scale (IES). One session of EMDR-PRECI
EMDR Protocol for Recent Critical Incidents (EMDR- produced ­significant ­improvement on symptoms
PRECI) is a modification of Shapiro’s (2001) Recent of posttraumatic stress for the immediate and the
Traumatic Events Protocol provided in an individual waitlist treatment groups, with results maintained at
treatment format to clients suffering from recent 12  weeks follow-up, even though frightening after-
­ongoing trauma. It was developed in the field to shocks continued to occur frequently.
treat critical incidents where related stressful events
Resilience and the Adaptive Information
­continue for an extended time and where there is no
Processing Model
posttrauma period of safety for memory consolida-
tion (see Jarero et al., 2011 for a detailed description Resilience is a growing area of interest in the field of
of the protocol). trauma (Harvey, 2007). The American ­Psychological
EMDR-PRECI uses an eight-phased protocol. Association (APA, 2003) described resilience as the pro-
Phases 1 and 2 are the history taking and preparation cess of adapting well in the face of adversity, trauma,
phases. In Phase 3, disturbing memory fragments tragedy, threats, or even significant sources of stress
are assessed with the client identifying the most such as family and relationship problems, ­serious
­disturbing image, related negative cognition (NC), health problems, or workplace and financial stres-
emotion, ­ratings of subjective units of disturbance sors. Resilience also has been described as a dynamic
(SUD), and body sensation location but no posi- process where people exhibit positive behavioral
tive cognition (PC) or rating of validity of positive ­adaptation when they encounter significant adversity
cognition (VOC). During Phase 4 (desensitization), or trauma (Luthar, Cicchetti, & Becker, 2000).
the client focuses on each ­memory fragment, while According to Shapiro’s (2001) AIP model, ­resilience
simultaneously ­engaging in dual ­attention stimula- can be understood as a manifestation of the adaptive
tion using eye movements (EM) as a first choice and information networks that include the fully processed
the butterfly hug (BH; Artigas, & Jarero, 2009) as an memories of previously adverse or traumatizing events,
­alternative bilateral stimulation (BLS). Each memory which are no longer disturbing. A subsequent stressful
fragment is processed in turn, using the free associa- situation is thus understood to stimulate the adaptive
tive processing of the standard EMDR desensitization memories, which then provide a base of stability, com-
phase. When all fragments have been processed prehension, and manageability when ­experiencing
with Phase 4, and the client identifies no further dis- new trauma. In other words, when people are con-
turbance, Phase 5 is ­applied to the entire extended fronted by a new adversity or traumatizing event, they
event with a PC developed for the entire incident. are able to access adaptive information stored in their
Installation of PC does not use frequent checking of memory networks to cope with the challenge.

Journal of EMDR Practice and Research, Volume 6, Number 2, 2012 51

EMDR-PRECI Follow-Up Report of an Application in a Human Massacre Situation
 In AIP terms (Shapiro, 2001), a lack of resilience is organized crime members, ­soldiers, police ­officers,
seen when the associated memories contain negative i­nnocent adult civilians, and 1,400 children. In com-
information; that is, when past disturbing life experi- parison, during almost nine years of war in Iraq,
ences have not been fully processed and have become the U.S. military suffered 4,000 ­casualties. ­Criminal
dysfunctionally stored in memory. When these nega- groups have shown a determined ­willingness to fight
tive memories are activated by present stressors, Mexican law enforcement and security ­forces—an
the individual reexperiences past distress and may ­increasing ambition to control other illicit and in-
feel emotionally overwhelmed, resulting in present formal economies in Mexico and to extort legal
maladaptive behavior, negative emotions, negative businesses.
self-beliefs, and diminished capacity to cope. In turn, Finding Mexican police forces pervaded by corrup-
the negative effects of diminished coping may also tion and lacking the capacity to effectively deal with
be stored in these same memory networks, lowering organized crime, President Felipe Calderón dispatched
resilience, thereby creating further vulnerability for the military into Mexico’s streets. Yet although having
future stressful situations. some success in capturing prominent drug traffickers,
EMDR is designed to identify and process the past the military has also found it enormously difficult
memories that underlie such difficulties in coping, to to suppress violence and reduce the insecurity of
address present situations that trigger disturbances, Mexican citizens. Institutional reforms to improve
and to enable the development of a positive ­memory the police forces and justice system, although crucial
template for future adaptive behavior (Shapiro, for expanding the rule of law in Mexico, have been
2001, 2006). The reprocessing of pivotal memories is slow and will inevitably require years of committed
thought to facilitate a rapid learning experience that effort. Meanwhile, patience among many Mexicans
transforms negative perspective and affects into more for the battle against criminal groups is starting to run
neutral or even positive ones. These then are said to out (Felbab-Brown, 2011). Horror and violence are
become the basis of resilience by enhancing the ability an almost daily occurrence, and many live in fear and
to cope effectively with subsequent related stressors. terror, frequently exposed to the inhumanity and bru-
According to Jarero (2010), EMDR reprocessing of tality of this war.
dysfunctionally stored memories that underlie ­current In April 2011, 218 decomposing and mutilated
maladaptive behaviors can lead to a profound restruc- corpses were discovered in seven clandestine graves
turing of the personality’s intrapsychic matrix. He in the Mexican state of Durango. It was said that
proposed that the reprocessing of disturbing memories these mass graves probably contained the bodies of
may enable an individual to employ the full potential ­executed drug gang rivals, or kidnap victims, or even
of his or her functional capacity and available ­personal some police. The task of body recovery and identifi-
resources in future adverse circumstances. Where cation was conducted by the State Attorney General
previously the individual may have been vulnerable forensic personnel, who were very traumatized by
to psychological distress, it is hypothesized that now this massive and horrific task. They also became the
he or she will have the potential for resilience in situ- target of death threats from the warring gangs.
ations of repeated trauma. The role of psychological In May 2011, Durango’s State Attorney General
therapy in relation to resilience needs to be explored asked the Mexican Association for Mental Health in
more fully (Alayarian, 2007). Crisis to provide support for their forensic personnel
who were working in the clandestine graves and in
Method the morgue (DNA identification, fingerprints, forensic
anthropology work). The Mexican National Human
Background
Rights Commission sponsored the clinicians’ travel
Over the past several years, Mexico has suffered from expenses. The clinicians provided the EMDR-PRECI
drug-trade-related violence, which has been extraor- (Jarero et al., 2011). A field study was conducted to
dinarily intense and grisly even by criminal market evaluate the treatment’s effectiveness in this setting
standards. Its drug trafficking organizations have been (Jarero & Uribe, 2011).
engaged in ever-spiraling turf wars over smuggling
routes and corruption networks, turning the streets
Procedure
of some Mexican cities into ­macabre displays of gun
fights and murders. In 5 years, the total casualties of The research was conducted in four phases: Phase 1
this war number more than 50,000 people, including was the baseline assessment; Phase 2 was the treat-

52 Journal of EMDR Practice and Research, Volume 6, Number 2, 2012

Jarero and Uribe
 ment and assessment of the immediate treatment SPRINT, a cutoff score of 14 or more was found to
group; Phase 3 was the treatment and assess- carry a 95% sensitivity to detect PTSD and 96% speci-
ment of the waitlist/delayed treatment group; and ficity for ruling out the diagnosis, with an overall
Phase 4 was the two follow-up assessments of both accuracy of correct ­assignment being 96% (Connor &
­treatment groups. Phases 1–3 were conducted dur- Davidson, 2001).
ing May to July, 2011, and the results were reported
in an ­earlier publication (Jarero & Uribe, 2011). The
Participants
current ­article summarizes the earlier findings and
reports on the two follow-up assessments conducted At the beginning of the study, a preliminary psycho-
at 3 and 5 months posttreatment in September and metric assessment was conducted with all the 60 State
­November 2011. Attorney General employees who were working with
the corpses. The assessment established a triage crite-
rion for the next phases and provided baseline mea-
Measures
sures. The IES and SPRINT were administered, and
The IES (Horowitz, Wilmer, & Alvarez, 1979) and the 32 individuals whose baseline scores indicated
the Short PTSD Rating Interview (SPRINT; ­Connor moderate-to-severe posttraumatic stress and PTSD
& ­Davidson, 2001; Vaishnavi, Payne, Connor, & symptoms were assigned to two groups. Those with
­Davidson, 2006) were administered at baseline, pre- severe scores were assigned to immediate treatment
treatment, ­posttreatment, and two follow-up assess- (N 5 18; 8 females, 10 males), and those with moder-
ments by two independent professionals. ate scores were assigned to waitlist/delayed treatment
The IES is a 15-item widely used self-report (N 5 14; 8 females, 6 males). The 28 participants with
questionnaire. It is a reliable measure of subjective lower scores did not receive any treatment ­because
posttraumatic stress to a stressful or traumatic life research has shown that minor distress may resolve
event. Responses are scored according to a Likert on its own, or with less intensive interventions such as
scale, where 0 5 not at all, 1 5 rarely, 3 5 sometimes, crisis counseling (Norris, Hamblen, Brown, & Schinka,
and 5 5 often. Scores between 0 and 8 are considered 2008). As planned, there was a significant ­difference at
subclinical, scores between 9 and 25 are considered baseline between the scores of ­immediate treatment
low or mild distress, scores ­between 26 and 43 are and the waitlist/delayed treatment groups (Jarero &
considered moderate distress, and scores ­between 44 Uribe, 2011) on both the SPRINT and IES measures
and 75 are considered high or severe distress. (see Figures 1 and 2).
The SPRINT is an eight-item interview or self- After receiving the single session of EMDR-PRECI
­rating questionnaire with solid psychometric pro- and completing the posttreatment measures, the par-
perties that can serve as a reliable, valid, and ticipants continued to work on the forensic project
­homogeneous measurement of PTSD illness sever- during the duration of the study and had continual ex-
ity and global improvement; as well as a measure of posure to horrific stressors. All participants completed
somatic distress, stress coping, and work, family, and the follow-up assessments at 3 and 5 months. Their
social ­impairment. Each item is rated on a five-point attendance in treatment was voluntary and not man-
scale: not at all (0), a little bit (1), moderately (2), quite dated by their employer. There were no dropouts in
a lot (3), and very much (4). Scores between 18 and 32 the study.
correspond to marked or severe PTSD symptoms, 11
and 17 to moderate symptoms, 7 and 10 to mild symp-
Treatment
toms, scores of 6 or less indicated either no or minimal
symptoms. The SPRINT also contains two additional Members of immediate and waitlist/delayed treat-
items to measure global improvement according to ment groups were treated with one session of EMDR-
percentage change and by severity rating. This ques- PRECI. Each individual client session lasted between
tionnaire was translated from English to Spanish, back 90 and 120 min (Phases 1 and 2 lasted 30–35 min;
translated from Spanish to English, and reviewed and ­reprocessing phases lasted between 50 and 65 min).
authorized by one of its authors. SPRINT ­performs Only one treatment session was provided to each par-
similarly to the Clinician-Administered PTSD Scale ticipant. This limitation in treatment ­provision was
(CAPS) rating scale in the assessment of PTSD symp- a factor of the dangerous environment, as the clini-
toms clusters and total scores and can be used as a cians’ time on site was restricted because of safety
diagnostic instrument (Vaishnavi et al., 2006). In the concerns.

Journal of EMDR Practice and Research, Volume 6, Number 2, 2012 53

EMDR-PRECI Follow-Up Report of an Application in a Human Massacre Situation
 70

60

50

40 Immediate

30 Waitlist

Delayed
20

10

0
1 2 3 4 5 6
Assessment Times

FIGURE 1.  Mean IES scores at baseline, pretreatment, posttreatment, and two follow-up
assessments.

Results lower scores than the waitlist group. This finding

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

30

25

20

Immediate
15
Waitlist
10 Delayed

0
1 2 3 4 5 6
Assessment Times

FIGURE 2.  Mean SPRINT scores at baseline, pretreatment, posttreatment, and two follow-up
assessments.

54 Journal of EMDR Practice and Research, Volume 6, Number 2, 2012

Jarero and Uribe
Results of the Follow-Up Assessments the Time 5 IES ­measures ­indicated significant dif-
ferences across the ­multiple comparisons at p , .05
The present follow-up study reports on Phase 4 of (see Figures 1 and 2 and T­ ables 1 and 2).
the field research study, which included follow-up
­assessments with study participants conducted on Treatment Effect for Both Groups Between PreTreat-
September 30 and November 30, 2011. In the ­period ment and Follow-Up.  Researchers used paired sample
between the follow-up assessments, two more t tests to determine the differences on IES and SPRINT
­clandestine graves were discovered with another scores between pretreatment and the last follow-up
40 bodies, requiring forensic work by the participants. measurement for the immediate treatment group and
The participants also received renewed threats of vio- the waitlist/delayed treatment group. Results showed
lence from organized crime members and endured a significant decrease in scores for the immediate
the same extreme stressful circumstances in a horrific treatment group, for IES, t(17) 5 37.2, p , .001, and
work environment. SPRINT, t(17) 5 22.70, p , .00; and for the waitlist/
delayed treatment group, for IES, t(13) 5 27.88, p ,
Global Improvement.  The SPRINT contains two
.001, and SPRINT, t(13) 5 10.84, p , .001.
items to measure global improvement, one assess-
ing percentage change and the other rating severity. Comparison of Immediate Treatment and ­Waitlist/
Item 1: “How much better do you feel since beginning Delayed Groups.  t Tests for independent samples
treatment? As a percentage between 0 to 100.” Item 2: were used to compare the follow-up scores for the two
“How much has the above symptoms improved since treatment groups for both instruments to know the
starting treatment? 1 worse, 2 no change, 3 minimally, effect of the treatment for the two different groups,
4 much, 5 very much.” which had started treatment with significantly differ-
On Item 1, the mean response at follow-up for the ent scores on both measures. There were significant
immediate treatment group was 80% and for the wait- differences on the IES, t(30) 5 7.35 p , .001 (equal
list/delayed treatment group it was 88%. On Item 2, variances assumed, according to Levene’s test for
the mean response at follow-up for the immediate equality of variances), and the SPRINT, t(19) 5 5.19
treatment group was (4) much, and for the waitlist/ p , .001 (equal variances not assumed according
delayed treatment group it was (5) very much. Levene’s test). Mean scores at Phase 4 in both instru-
ments were significantly lower for the delayed treat-
Treatment Effect Across Time.  Comparisons be-
ment group than for the immediate treatment group
tween repeated measurements for both instruments
(see Figures 1 and 2).
(IES and SPRINT) and for both groups (­immediate
and delayed treatment) were done using analysis Maintenance of Treatment Effects.  A statistical
of variance (ANOVA). Results indicated a signifi- analysis compared the posttreatment results for each
cant main effect of the treatment across time for treatment group with their final follow-up scores to
the immediate treatment group, for IES scores: evaluate whether there was any change in reported
F(4, 65) 5 494.12, p , .001 and for SPRINT scores: symptoms between posttreatment and follow-up.
F(4, 85) 5 157.3, p , .001; and for the waitlist/de- t Tests for paired samples were used to compare the
layed treatment group, for IES scores: F(4, 65) 5 posttreatment scores with the last follow-up for the two
174, p ,. 001 and for  SPRINT scores: F(4, 65) 5 treatment groups. There were significant ­differences
27.07, p  ,  .001. ­Turkey post hoc comparisons of on the IES for both groups: for the ­immediate group,

TABLE 1.  Mean Scores and Standard Deviations

Baseline Pretreatment Posttreatment Follow-up 1 Follow up 2
N Time 1 Time 2 Time 3 Time 4 Time 5

Impact of Event Scale

  Immediate treatment 18 59.22 (5.41) 65.17 (5.90) 32.17 (4.41) 20.72 (2.16) 15.83 (1.82)
  Waitlist/delayed treatment 14 31.29 (4.58) 38.21 (3.49) 21.71 (2.27) 14.14 (3.15) 10.85 (2.17)
Short PTSD Rating Interview
  Immediate treatment 18 23.83 (3.73) 26.39 (3.45) 14.83 (1.86) 11.05 (1.73)   9.27 (1.12)
  Waitlist/delayed treatment 14 16.07 (3.83) 19.71 (6.58) 10.07 (3.95)   7.36 (3.10)   6.21 (1.96)

Journal of EMDR Practice and Research, Volume 6, Number 2, 2012 55

EMDR-PRECI Follow-Up Report of an Application in a Human Massacre Situation
TABLE 2.  Statistical Comparisons Between Scores at Pretreatment and Follow-Up for Each Group
Time Mean (SD) t df p

Impact of Event Scale

  Pretreatment versus follow-up
   Immediate treatment 65.17 (5.90)/15.83 (1.82) 37.27 17 p  .001
Time 2 vs. Time 5
   Waitlist/delayed treatment 38.21 (3.49)/10.85 (2.17) 27.88 13 p  .001
  Posttreatment versus follow-up
   Immediate treatment 32.17 (4.41)/15.83 (1.82) 18.37 17 p  .001
Time 3 vs. Time 5
   Waitlist/delayed 21.71 (2.27)/10.85 (2.17) 25.23 13 p  .001
Short PTSD Rating Interview
  Pretreatment versus follow-up
   Immediate treatment 26.39 (3.45)/9.27 (1.12) 22.70 17 p  .001
Time 2 vs. Time 5
   Waitlist/delayed 19.71 (6.58)/6.21 (1.96) 10.84 13 p  .001
  Posttreatment versus follow-up
   Immediate treatment 14.83 (1.86)/9.27 (1.12) 8.22 17 p  .001
Time 3 vs. Time 5
   Waitlist/delayed 10.07 (3.95)/6.21 (1.96) 6.32 13 p  .001

t(17) 5 18.37, p , .001 and for the delayed group, study (Jarero & Uribe, 2011) showed that the t­reatment
t(13) 5 25.23, p , .001. There were also significant produced a significant decrease in symptoms when
differences on the SPRINT for both groups: for the it was compared to waitlist and when pretreatment
immediate group, t (17) 5 18.22, p , .001 and for the scores were compared to posttreatment. Our current
delayed group, t(13) 5 6.32, p , .001. Mean scores study shows that treatment gains were evident at 3-
(see Table 1) confirmed that in both instruments and and 5-month follow-up, with a ­continuing significant
in both conditions (immediate and delayed), scores decrease in symptoms of posttraumatic stress. EMDR-
not only were maintained but continued to decrease PRECI appears to be an effective and efficient treat-
significantly by follow-up 2. (see Table 3). ment for PTSD symptoms, in situations of ongoing
extreme stress.
Before treatment started, there was a worsening
Discussion
of symptoms between baseline and pretreatment on
This study examined follow-up results with trauma- both the IES and SPRINT measures (see Figures  1
tized adults working under extreme stressors to whom and 2). This may be because of the continuum of
treatment was provided in a natural setting as a need- stressful events and the ongoing threats faced by the
focused intervention. These individuals were pro- participants in this study. This suggests that without
vided with EMDR-PRECI, in two groups: immediate treatment, there would not have been a natural or
treatment and waitlist/delayed treatment. Our earlier spontaneous improvement.

TABLE 3.  Statistical Comparisons Between Treatment Groups at Follow-Up

Time Mean (SD) t df p

Impact of Event Scale

Immediate treatment versus 15.83 (1.82)
waitlist/delayed treatment Time 5 vs. Time 5
10.85 (2.17) 7.35 30 p < .001
Short PTSD Rating Interview
Immediate treatment versus   9.27 (1.12) 5.19 19 p < .001
waitlist/delayed treatment Time 5 vs. Time 5
  6.21 (1.96)

56 Journal of EMDR Practice and Research, Volume 6, Number 2, 2012

Jarero and Uribe
Comparisons of the Immediate and Waitlist/ to the CAPS in the assessment of PTSD symptoms
Delayed Treatment Groups clusters and total scores; it can be used as a diagnos-
tic instrument and only takes an average of 5–10 min
The two treatment groups were created by placing to complete. In the SPRINT, a cutoff score of 14 or
those participants with lower scores into the waitlist/ higher was found to carry a 95% sensitivity to detect
delayed treatment group and those with more severe PTSD and 96% ­specificity for ruling out the diagnosis,
scores into the immediate treatment group. This was with an overall accuracy of correct assignment being
done for ethical reasons, to provide faster relief for 96% (Connor & Davidson, 2001).
those with more intense suffering. At the beginning of this study (Jarero & Uribe,
The study did not have the capacity to ­examine the 2011), baseline measures were administered to partici-
specific reasons why there was a differential response pants as a screening tool, and those participants whose
to the trauma, why some individuals experienced SPRINT scores met or exceeded the cutoff ­criteria
more severe symptoms than others. A number of fac- of 14 were assigned to treatment. Based on the 95%
tors could explain these differential responses. Perhaps sensitivity of the SPRINT, we can assume that at pre-
those with more intense symptoms had some preex- treatment, acute PTSD (duration of symptoms was
isting psychological problems, personality factors, or less than 3 months) was present for all participants in
other risk factors rendering them more vulnerable both groups. In the follow-up assessments, reported
to develop PTSD; perhaps they had more intense in this study, the SPRINT scores at Time 5 were 9.27
exposure to the trauma in the work setting, or were and 6.21, indicating that chronic PTSD (symptoms
more directly or personally impacted by the massa- last 3  months or longer) was not present in either
cre or by the threats to themselves and their families. group. Not one of the participants had a score over
Future research is needed to investigate these various 14, suggesting that none would meet diagnostic crite-
possibilities. ria for chronic PTSD. Statistical results and SPRINT
The differences between the two groups were ­sensitivity lead the authors to conclude that one
maintained throughout the study. Although treatment session of EMDR-PRECI helped to prevent the devel-
was very helpful to those with severe symptoms, their opment of chronic PTSD in this study population.
scores did not attain the lesser level of those who began Because this was a field study, it was not ethically
with less distress. The significant difference between possible to maintain an untreated control group for
the two groups was apparent at baseline, posttreat- the 6 months of the study. However, the comparison
ment, and at both follow-ups, with the delayed group of untreated waitlist group with the treated ­immediate
consistently showing less severe symptoms. Although treatment group provides a limited control for the
a second treatment session may have been beneficial ­effects of time. In this 1-month period, the symptoms
for those participants with more severe scores, the of the untreated waitlist group deteriorated and were
­clinicians’ time on site was restricted because of safety significantly worse than those of the treated partici-
concerns in the dangerous environment, and it was not pants who showed a significant improvement (Jarero &
possible to provide more than one treatment session Uribe, 2011).
to each participant. Also, it should be noted that the Although it has been shown that improvement in
finding that those with severe symptoms at baseline symptoms over time is the common course observed
had more severe symptoms at follow-up is consistent in longitudinal studies (Orcutt, Erickson, & Wolfe,
with research investigating individual predictors of 2004), in these circumstances, participants were
the longitudinal course of PTSD (e.g., Ehlers, Mayou, ­continually exposed to the horrors of human mas-
& Bryant, 1998; Marmar et al., 1999). sacre and were themselves often threatened by the
warring crime lords. Intensity and duration of expo-
EMDR-PRECI and the Prevention of Chronic
sure to trauma have been shown to play an important
Post-Traumatic Stress Disorder
role in symptom development (Norris et al., 2002).
Expeditious diagnostic assessment of PTSD is often It would be anticipated that these individuals would
very relevant in times of mass trauma (Vaishnavi have been likely to develop chronic PTSD, which is
et  al., 2006). Unfortunately, because of time limita- tenacious and disabling (Kessler, 2000). Developing
tions (structured interviews sometimes required as interventions to prevent PTSD is a pressing public
much as 45 min of a clinician’s time), the therapists health need (Institute of Medicine of the National
in this study were unable to administer a structured Academies, 2011).
interview such as CAPS to assess for the diagnosis of These results are relevant in comparison to pro-
PTSD. However, SPRINT has performed similarly longed exposure (PE) or cognitive therapy (CT).

Journal of EMDR Practice and Research, Volume 6, Number 2, 2012 57

EMDR-PRECI Follow-Up Report of an Application in a Human Massacre Situation
Table 4.  Comparisons Between Shalev et al., 2011 and the Current Study
Prolonged Exposure (PE) Cognitive Therapy (CT) EMDR-PRECI

Statistical analysis ANOVA ANOVA ANOVA

Follow-up 2 months 2 months 3 and 5 months
posttreatment posttreatment posttreatment
Number of sessions 12 weekly 12 weekly 1 session
Session duration 90 minutes 90 minutes 90–120 minutes
Ongoing stressful events NO NO YES
postincident
In vivo exposure or home work YES YES NO
PTSD after traumatic event and 21.6% 20.0% 0%
treatment
Dropouts 44.4% 40% 0%

A recent study by Shalev et al. (2011) was conducted themselves from the trauma, having access to more
in a hospital setting with survivors of traumatic events adaptive information, negative affect reduction,
who met PTSD diagnostic criteria. The participants ­reduction in ratings of subjective disturbance, and an
were not engaged in further stressful events. They increase in validity of positive cognitions. Examples
­received 12 weekly 1.5 hr sessions of CT or PE (with of positive cognitions mentioned by clients during the
prolonged imaginal exposure to traumatic memories EMDR-PRECI global installation phase were, “I can,”
and in vivo exposure to avoided situations). Results “I do the best I can,” “I can choose whom to trust,”
showed that the proportion of participants who con- “I’m strong,” “I learned from it,” “I deserve to live,”
tinued to meet diagnostic criteria for PTSD 5 months “I deserve good things,” “I’m a good person,” “I now
after the traumatic event (and 2 months posttreat- have choices,” “I’m now in control,” “I can make my
ment) was 21.6% for PE and 20.0% for CT. Partial or need known,” “I’m intelligent,” “I can be trusted,”
noncompleters proportion (dropouts) was 44.4% for “I deserve to be happy,” “I’m honorable.” It appears
PE and 40% for CT. Shalev et al. concluded that PE that this confidence in self-mastery and self-efficacy
and CT ­effectively prevented chronic PTSD in recent continued for months after the treatment ended,
survivors. We compare that to the results in this study even though they continued to work on site under
where one session of therapy significantly ­reduced new organized crime threats, new clandestine graves
symptoms at 3- and 5-month ­follow-up, where there with more bodies, and the same extreme stressful
were no dropouts, and where the SPRINT scores of ­circumstances in a horrific work environment.
all participants were far below PTSD cutoff levels Although resilience was not measured directly,
(see Table 4). Researchers have viewed EMDR as more statistical results indicate that ongoing exposure to a
effective than exposure-based CBT, both in vivo and traumatic work environment and subsequent similar
imaginal, in improving the PTSD symptoms because incidents no longer elicited the same distressing symp-
of its rapid effects, low drop-out rates, and lower rat- toms after EMDR treatment but, in turn, ­created less
ings of distress following treatment (Fleming, 2012). distress for the participants. Based on these results,
we can conclude that participants appeared to have
­developed psychological and emotional resilience.
EMDR-PRECI and the Possible Development
These results also provide some preliminary sup-
of Resilience
port for hypotheses deriving from Shapiro’s (2001,
Before treatment, the participants expressed that they 2006) AIP model: Adaptive resolution of disturb-
were very overwhelmed by their work with the muti- ing memories should lead to a shift in symptoms,
lated decomposing bodies and by the ongoing dangers ­personal characteristics, and the sense of self; and ef-
in the workplace. By the end of the EMDR-PRECI fective EMDR treatment should give the individual
treatment session, clinicians observed important in- access to a wider range of memory and experience
dicators of change in the clients such as distancing and the potential for resilience in situations of ongoing

58 Journal of EMDR Practice and Research, Volume 6, Number 2, 2012

Jarero and Uribe
t­ rauma. According to this model, when the dys- aftermath for months or years to come as they cope
functional stored memories have been processed with the reminders of the destruction (Jordan, 2010).
and ­assimilated into adaptive memory networks, The possibility of utilizing EMDR-PRECI as one
the learning that has taken place becomes the func- component of a comprehensive system to prevent
tional basis for interpretation and response to any psychopathology in those at risk, to develop ­resilience,
newly encountered situation. The application of this and break the suffering cycle has important global
model is indicated in this study: It appears that when implications. Some of the protocol benefits include
the treated participants coped effectively with simi- transportability and its ease of use for both new and
lar incidents, the information was connected with experienced EMDR practitioners. It is time effective—
adaptive networks, expanding them, increasing the only one session was needed to achieve resolution
learning and the positive resources; therefore, in each of posttraumatic symptoms (Jarero & Uribe, 2011).
new similar event, participants responded with more There is no need for homework, thus facilitating a
and more ­resources and a sense of resourcefulness short duration of work in the field. It is likely that
and resilience. These hypotheses need to be tested EMDR-PRECI will also have that same cross-cultural
more directly. effectiveness as the standard EMDR therapy protocol
for PTSD (Maxfield, 2008, 2009).
These study results lend support to the view that
EMDR-PRECI as an Intervention in an Ongoing
the EMDR-PRECI can be used effectively as an early
Trauma Situation
intervention in a natural setting of a human massacre
Ongoing traumatic situations such as the urban situation to a group of traumatized adults working
­disasters in this study—war, ethno-political violence, under extreme stressors when there is no ­posttrauma
and natural or human-provoked disasters—can cause period of safety for memory consolidation by reduc-
deleterious ­effects. War-related traumas tend to in- ing self-report measures of posttraumatic stress and
clude repeated exposures. Their negative impact on PTSD symptoms, helping to prevent the develop-
health may be more persistent and pervasive in the ment of chronic PTSD, and developing mechanisms
long term, with the development of lasting ­symptoms of psychological and emotional resilience.
and suffering over decades. Identifying traumatized The authors recommend future research on the
individuals in the early aftermath and providing EMDR-PRECI to better understand the early phases
­access to mental health care if suffering persists may of trauma where there seems to be lack of memory
prevent long-term effects (­Holgersen, Klöckner, Boe, ­consolidation due to the lack of a posttrauma safe-
­Weisaeth, & Holen, 2011). ty period that prevents the consolidation of the
Disasters are collectively experienced ­traumatic ­original critical incident in memory or in long-last-
events with a severe impact, which affect large num- ing unresolved events (e.g., traumatic bereavement
bers of people. Following a disaster, survivors may on prolonged grief reactions, posttraumatic stress
start to suffer from mental health disturbance, such ­symptoms, and general mental health).
as PTSD, depressive disorders, substance abuse, and
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Jarero and Uribe
Tofani, L. R., & Wheeler, K. (2011). The recent-traumatic Acknowledgment.  The authors give Jose Antonio Fernán-
episode protocol: Outcome evaluation and analysis of dez, Alaide Miranda, and Martha Givaudan thanks for their
three case studies. Journal of EMDR Practice and Research, work in this humanitarian project.
5(3), 95–110.
Vaishnavi, S., Payne, V., Connor, K., & Davidson, J. R. Correspondence regarding this article should be directed to
(2006). A comparison of the SPRINT and CAPS assess- Igancio Jarero and Susana Uribe, Boulevar de la Luz 771,
ment scales for posttraumatic stress disorder. Depression ­Jardines del Pedregal, l Álvaro Obregón, Mexico City, 01900.
and Anxiety, 23(7), 437–440. E-mail: [email protected]

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EMDR-PRECI Follow-Up Report of an Application in a Human Massacre Situation