jagomart
digital resources
picture1_Emdr Pdf 109079 | Emdr Scaling Up 2014


 133x       Filetype PDF       File size 0.22 MB       Source: www.trauma-aid.nl


File: Emdr Pdf 109079 | Emdr Scaling Up 2014
scaling up what works using emdr to help confront the worlds burden of traumatic stress rolf c carriere unitar fellow unicef country director in asia ret global estimates of trauma ...

icon picture PDF Filetype PDF | Posted on 27 Sep 2022 | 3 years ago
Partial capture of text on file.
                                                      Scaling Up What Works:  
                                             Using EMDR to Help Confront the 
                                           Worlds Burden of Traumatic Stress
                                                                     Rolf C. Carriere
                                                  UNITAR Fellow, UNICEF Country Director in Asia (ret.)
                           Global estimates of trauma exposure, classified under the heading “Four Violences,” demonstrate that 
                           the world faces a mental health crisis of truly epidemic proportions. Given the extent, severity, and con-
                           sequences of trauma-based disorders (including posttraumatic stress disorder) worldwide for individuals, 
                           communities, and societies, the current minimal global public health response needs to be addressed. 
                           An important part of the response should involve the implementation of timely treatment both during 
                           and after a crisis. Eye movement desensitization and reprocessing (EMDR) therapy offers a potentially 
                           scalable intervention that combines effectiveness, efficiency, affordability, and acceptability—essential 
                           preconditions—for launching an ambitious global trauma therapy plan. An overview of both challenges 
                           and solutions to effective scaling up and global implementation is provided, including the areas of policy, 
                           funding, and ethics. This article concludes with a list of activities (including research) that should be 
                           initiated without delay as part of starting up a global trauma therapy plan.
                           Keywords: global trauma prevalence; EMDR scalability; task shifting; paraprofessionals; dilemmas; 
                            action plan
                         he profound importance of addressing the                   affect both mental and physical health, as well as 
                  Tglobal problem of trauma can hardly be over-                     the ability to learn, and the quality of personal 
                         estimated—for human and world develop-                     and work relationships. (F. Shapiro, 2014, p. 183)
                  ment and even for world peace. The contribution                   Moreover, effective treatment could help break the 
                  large-scale trauma healing could make to enhance so-           causal chains of violence begetting violence and abuse 
                  cial, economic, and cultural productivity, as well as in-      begetting more abuse transmitted from generation to 
                  dividual educability, creativity, and well-being, could        generation.
                  well be historic. Effective trauma treatment could 
                  stop immense and insidious silent inner suffering,             Scale of the Problem
                  which includes posttraumatic stress disorder (PTSD) 
                  but goes well beyond that:                                     Statistics on the worldwide extent of current accu-
                     As indicated by the adaptive information pro-               mulated untreated trauma are incomplete. Many 
                     cessing (AIP) model (F. Shapiro, 1995, 2001,                countries have barely begun to measure trauma oc-
                     2014; Solomon & Shapiro, 2008) that guides                  currence, and the World Health Organization (WHO) 
                     EMDR therapy’s clinical applications, the recog-            only began to collect prevalence data in the late 1990s. 
                     nition that unprocessed memories are the basis              PTSD lifetime prevalence rates range from a low of 
                     of a wide range of pathology highlights the ur-             0.3% in China to 6.1% in New Zealand and between 
                     gency of treating victims of trauma and other               6.8% and 7.8% in the United States (Gradus, 2011). 
                     adverse experience because of debilitating ef-              These sometimes surprising variations may be ex-
                     fects that range far beyond that of simple PTSD.            plained by the use of different definitions, population 
                     These unprocessed memories of adverse events                subgroups, or methodologies, making these statistics 
                  Journal of EMDR Practice and Research, Volume 8, Number 4, 2014                                                      187
                  © 2014 EMDR International Association  http://dx.doi.org/10.1891/1933-3196.8.4.187
                     hard to compare. Lack of awareness of trauma-based               were killed until the year 2000 (Leitenberg, 2006). 
                     DISORDERSˆESPECIALLY฀043$฀BUT฀ALSO฀PHOBIAS฀ANXIETY฀            Survivors of these atrocities live on with lifelong 
                     and panic  disorders, chronic and phantom limb pain,             disability, sorrow, anger, guilt, and trauma. They 
                     pedophilia, complicated mourning, and other health               number in the millions. Most of us rarely consider 
                     PROBLEMS฀/REN฀฀3OLOMON฀	ˆANDOR฀STIGMA฀                   their daily  predicament and silent suffering, some-
                     attached to it may also influence the prevalence mea-             times lasting for decades.
                     SUREMENT฀/N฀TOP฀OF฀THAT฀THEY฀MAY฀BE฀DELIBERATELY฀           s฀ -ORE฀VISIBLE฀ PERHAPS฀ AT฀ THE฀ END฀ OF฀ ฀ SOME฀
                     underreported or overestimated for political or other            45.2 million people were “forced displaced” (refu-
                     purposes.                                                        gees and internally displaced people). That figure is 
                        The United States arguably has the most accurate              ON฀THE฀RISE฀IN฀฀hDUE฀TO฀UNUSUALLY฀LARGE฀NUMBERS฀
                     043$฀STATISTICS฀!S฀A฀THOUGHT฀EXPERIMENT฀LET฀US฀TAKE฀           of new refugees and internally displaced people” 
                     its lifetime prevalence rate (say, 7%) of the general            seen by the United Nations (UN) refugee agency 
                     adult population. Then project this prevalence onto              (United Nations High Commissioner for Refugees 
                     the world’s population of 7 billion. That would yield            ;5.(#2=฀	฀4HIS฀STATISTIC฀IS฀ALMOST฀CERTAINLY฀
                     a figure of some 500 million people with PTSD. That               part of the earlier cited statistics on political and 
                     may not be sophisticated epidemiology and one could              criminal violence.
                     QUARREL฀ABOUT฀WHETHER฀IT฀IS฀REASONABLE฀TO฀ASSUME฀THAT฀        s฀ /NE
THIRD฀OF฀ALL฀WOMEN฀IN฀THE฀WORLD฀EXPERIENCE฀
                     the world as a whole (including the populous devel-              SEXUAL฀ PHYSICAL฀ OR฀ OTHER฀ ABUSE฀ IN฀ THEIR฀ LIFETIME฀
                     oping world) reaches that U.S. level, or a lower level,          !DVOCATES฀ FOR฀ (UMAN฀ 2IGHTS฀ 	฀ -UCH฀ OF฀
                     or even a higher level of prevalence. But this thought           this happens in the form of domestic violence by 
                     EXPERIMENT฀GIVES฀US฀A฀QUANTITATIVE฀ORDER฀OF฀MAGNI-               INTIMATE฀PARTNERS฀OR฀NONINTIMATE฀PARTNERS฀7(/฀
                     tude about the global burden of trauma.                          C	฀ 'ENDER฀ VIOLENCE฀ AGAINST฀ WOMEN฀ WORLD-
                        )N฀THE฀ABSENCE฀OF฀GOOD฀STATISTICS฀ANOTHER฀INDIRECT฀         WIDE฀TAKES฀ON฀MANY฀FORMS฀FOR฀EXAMPLE฀IN฀WAR฀AND฀
                     approach is to estimate how many people are exposed              armed conflict, in the name of “honor,” against girl 
                     to traumatic circumstances and events. This, too,                children, dowry-related, female genital mutilation 
                     MIGHT฀GIVE฀US฀A฀ROUGH฀SENSE฀ABOUT฀THE฀EXTENT฀AND฀                &'-	฀AND฀TRAFlCKING฀)T฀IS฀NO฀WONDER฀THEN฀THAT฀
                     severity of trauma, PTSD, and other trauma-based                 women are more than twice as likely as men to suf-
                     disorders worldwide.                                             fer from PTSD and other trauma-based disorders.
                                                                                   s฀ !CCIDENTS฀KILL฀OVER฀฀MILLION฀PEOPLE฀A฀YEAR฀AND฀
                     Exposure to Traumatic Events:                                    INJURE฀AND฀DISABLE฀TENS฀OF฀MILLIONS฀MORE฀7(/฀
                     “Four ViolencesŽ                                                 	฀ACCIDENTS฀ALTHOUGH฀NOT฀INTENDED฀TO฀HARM฀
                     Perhaps the various types of violence—direct, natural,           are a form of direct violence that traumatizes survi-
                     STRUCTURAL฀AND฀CULTURAL฀'ALTUNG฀	ˆMAY฀OFFER฀A฀            vors, relatives, and first responders.
                     helpful prism through which to consider the potential 
                     magnitude of the problem and to bring into focus the          Natural Violence
                     various categories of traumatized victims.                    Natural violence is both unintended and unavoidable. 
                     Direct Violence                                               )T฀COMES฀IN฀THE฀FORM฀OF฀EARTHQUAKES฀TSUNAMIS฀mOODS฀
                                                                                   wildfires, volcanic eruptions, hurricanes and storms, 
                     Acts of direct violence are intended to do harm to            DROUGHT฀AND฀EXTREME฀TEMPERATURES฀NOW฀OFTEN฀SYMP-
                     human beings. They take on many forms and are                 toms of man-made climate change) and usually gets 
                     widespread:                                                   only momentary attention and relief aid, although its 
                     s฀ .O฀LESS฀THAN฀฀BILLION฀ PEOPLE฀ CURRENTLY฀ LIVE฀ IN฀     ADVERSE฀CONSEQUENCES฀MAY฀LINGER฀FOR฀YEARS
                        countries afflicted by political or criminal violence       s฀ 7ORLDWIDE฀AN฀ANNUAL฀AVERAGE฀OF฀฀MILLION฀PEO-
                        AND฀WAR฀4HE฀7ORLD฀"ANK฀	฀4HIS฀STATISTIC฀IN-            ple are affected by natural disasters (EM-DAT: The 
                        cludes countries such as Syria, Congo, Afghanistan,           )NTERNATIONAL฀$ISASTER฀$ATABASE฀	฀.ATURAL฀DI-
                        )RAQ฀AND฀MANY฀OTHERS฀-ORE฀SPECIlCALLY฀hABOUT฀              sasters caused by climate change are becoming a 
                        ฀MILLION฀PEOPLE฀NOW฀LIVE฀AMIDST฀VIOLENT฀INSE-              recurring pattern and in the foreseeable future are 
                        CURITY฀AROUND฀THE฀WORLDv฀,EANING฀฀'UBA
3APIR฀              likely to affect even larger populations.
                        	฀ 3INCE฀ THE฀ END฀ OF฀ 7ORLD฀ 7AR฀ ))฀ MORE฀        s฀ ,OSS฀ OF฀ LOVED฀ ONES฀ SOMETHING฀ EVERYONE฀ EXPERI

                        THAN฀฀WARS฀HAVE฀BEEN฀FOUGHT฀9ANACOPULOS฀฀                ENCES฀ SEVERAL฀ TIMES฀ IN฀ A฀ LIFETIME฀ FOR฀ EXAMPLE฀
                        (ANLON฀	฀IN฀WHICH฀SOME฀฀MILLION฀PEOPLE฀                IN฀ ฀ AN฀ ESTIMATED฀ ฀ MILLION฀ PEOPLE฀ DIED฀
                     188                                                         Journal of EMDR Practice and Research, Volume 8, Number 4, 2014
                                                                                                                                      Carriere
                      worldwide (WHO, n.d.). Mortality leaves count-                  that justify violence. Although cultural violence per se 
                      less millions bereaved each year.                               may not traumatize in large numbers, it leads to struc-
                                                                                      tural and/or direct violence; therefore, it must still be 
                   Structural Violence                                                confronted at a deeper level to bring about more ef-
                                                                                      fective primary prevention of trauma altogether by 
                   Structural violence occurs when a social structure                 eliminating or mitigating its sources. Although com-
                   harms people and prevents them from meeting                        mon and widespread, no statistics are available to 
                   their basic needs. Although we do not usually think                quantify the extent and severity of this type of chronic 
                   of  poverty as a form of violence, it, too, harms and              adversity.
                   hurts—indirectly and largely—unintentionally. But                     This quantification of the four violences, we may 
                   structural violence is not inevitable because ultimately           conclude, lends credence to the assertion that global 
                   it is caused by human agency. Built into the structure             statistics on PTSD and other trauma-based disorders 
                   of the world sociopolitical–economic system, it adds               are probably considerably underestimated. In any 
                   another dimension to the genesis of trauma.                        case, it is clear that the world faces a trauma problem 
                   s฀ !CCORDING฀TO฀4HE฀7ORLD฀"ANK฀	฀WORLDWIDE฀                 of truly epidemic proportions.
                      SOME฀฀BILLION฀PEOPLE฀LIVED฀IN฀EXTREME฀POVERTY฀                 Many of these categories of traumatic experiences 
                      ON฀฀A฀DAY฀IN฀฀IN฀ALL฀฀BILLION฀LIVED฀ON฀LESS฀      or events overlap, often adding insult to injury and 
                      THAN฀฀A฀DAY฀THAT฀YEAR                                        putting millions of people in double jeopardy by 
                   s฀ -OST฀SUFFER฀FROM฀HUNGER฀OR฀CHRONIC฀UNDERNOURISH-                causing multiple traumas. Of course, not all trau-
                      MENT฀฀MILLION฀PEOPLE฀&OOD฀AND฀!GRICULTURE฀                 matic experiences will lead to PTSD, although many 
                      /RGANIZATION฀OF฀THE฀5NITED฀.ATIONS฀	฀3OME฀                of those who spontaneously “recover” from trauma 
                      ฀MILLION฀PERSONS฀WHO฀LIVE฀IN฀ABSOLUTE฀POVERTY฀               continue to live with some residual scarring show-
                      ARE฀ DISABLED฀ -C#LAIN
.HLAPO฀ 	฀ 7ORLD-                 ing up soon after the event or sometimes much later 
                      WIDE฀SOME฀฀MILLION฀PEOPLE฀ARE฀UNEMPLOYED฀IN฀                ( delayed  onset).
                      ฀ )NTERNATIONAL฀ ,ABOUR฀ /RGANIZATION฀ 	฀
                      ฀MILLION฀OF฀WHOM฀ARE฀IN฀THE฀DEVELOPED฀ECONO-                  Challenges of Preventing and  
                      MIES฀4HE฀NUMBER฀OF฀CHILD฀LABORERS฀IN฀฀IS฀฀              Treating Trauma
                      MILLION฀)NTERNATIONAL฀,ABOUR฀/RGANIZATION
)NTER-
                      national Programme on the Elimination of Child                  The magnitude of this challenge may, by itself, cause 
                      ,ABOUR฀	                                                  a sense of being overwhelmed among those charged 
                   s฀ 4HESE฀ARE฀OBVIOUSLY฀TRAUMATIZING฀CIRCUMSTANCES฀                with the responsibility to mobilize responses. But 
                      Poverty as a pervasive and insidious social-global              need it be?
                      reality constitutes a traumatic condition of chronic               Ideally, traumas would be prevented altogether, 
                      adversity with devastating consequences for mental              and in fact, many different policies and actions are al-
                      health (Desjarlais, Eisenberg, Good, & Kleinman,                ready under implementation to prevent or mitigate 
                      	฀)F฀YOU฀HAVE฀EVER฀WALKED฀THROUGH฀THE฀SLUMS฀               traumatizing conditions. These include disaster pre-
                      of Dhaka or the favela in Rio, the risk of lifelong             paredness, initiatives against domestic and collective 
                      trauma to the local inhabitants will be instantly               violence, zero-tolerance codes (e.g., against bullying, 
                      clear.                                                          sexual harassment), strengthening resilience, pro-
                                                                                      moting a culture of peace and nonviolence, poverty 
                   Cultural Violence                                                  alleviation, protection of human rights and civil lib-
                                                                                      erties, disease prevention, disarmament, and many 
                   Cultural violence often lies at the root of direct and             others. But given the fact that many traumatizing cir-
                   structural violence. It manifests in prevailing attitudes          cumstances are often beyond direct control of those 
                   and beliefs about power and “necessity” of violence—               (potentially) affected, it would only be realistic to ex-
                   ideas taught since childhood and surrounding every-                pect that the number of new cases of trauma, PTSD, 
                   one in daily life. It comes in many forms: apartheid,              and other trauma-based disorders in the world each 
                   discrimination, oppression, colonialism, exploitation,             year will remain high and may even increase. This 
                   and racism—each of which exerts a chronic stress that              means that the prevalence of trauma and serious 
                   MAY฀LEAD฀TO฀TRAUMA฀2ICH฀ET฀AL฀	฀h*USTv฀WAR฀THE-            disorders such as PTSD will only come down if the 
                   ory, ideas about honor killings or the need for capital            world succeeds in effectively treating its victims on a 
                   punishment, are some examples of the cultural beliefs              large scale.
                   Journal of EMDR Practice and Research, Volume 8, Number 4, 2014                                                             189
                   Scaling Up What Works
                        Meanwhile, for most of the world—and especially             we can neither prevent nor effectively treat it—or the 
                     for low-income countries—the huge individual and               belief that no effective, recognized trauma therapies 
                     global burden of trauma and traumatic stress has               are available that are also affordable and scalable. 
                     remained largely hidden: It is undiagnosed, unrecog-           These beliefs may well explain why the worldwide 
                     nized, and therefore untreated. The unmet need for             action response to trauma up until now has been so 
                     trauma treatment of people living with PTSD world-             lukewarm. And they may also clarify the lack of good 
                     wide remains enormous.                                         statistics (“why bother collecting baseline prevalence 
                        It may therefore seem surprising that trauma ther-          rates if no large-scale interventions are planned or 
                     apy as a topic was not included in the UN Millennium           possible?”).
                     Development Goals (MDGs) for 2015. In fact, until                 Although these beliefs may have been valid un-
                     more recently, mental health altogether (including             til recently, today, they are no longer. The time has 
                     trauma and PTSD) has not been an explicit global               therefore come worldwide to stop neglecting trau-
                     policy priority despite its high disability-adjusted life      matic stress (and/or being fatalistic about it) and start 
                     year score. Mental disorders account for about 160             acknowledging that there are treatments that work. 
                     million lost years of healthy life per year (WHO,              This is where eye movement desensitization and 
                     2001)—a huge economic burden. In practical terms,               reprocessing (EMDR) therapy comes in.
                     worldwide mental health receives around 2.8% of 
                     health budgets; for high-income countries, it is 5.1%,         To Scale With EMDR Therapy
                     but low-income countries allocate much less: under 
                     0.5% of already small health budgets (WHO, 2011).              In 2013, the WHO conferred to EMDR formal recog-
                     What may be left for trauma therapy is absolutely              nition as an effective evidence-based therapy, putting 
                     not in proportion to the extent and severity of the            it on par with trauma-focused cognitive behavioral 
                     problem.                                                       therapy (CBT), noting that “Like CBT-T, EMDR 
                        Opinions differ regarding the reasons why such a            aims to reduce subjective distress and strengthen 
                     massive world problem has not come into sharper fo-            adaptive beliefs related to the traumatic event. Un-
                     cus and moved higher on the world agenda. Perhaps              like CBT-T, EMDR does not involve (a) detailed 
                     financial and human resources are not allocated be-             descriptions of the event, (b) direct challenging of 
                     cause of (a) a lack of understanding among policy              beliefs, (c) extended exposure or (d) homework” 
                     makers and donors. Indeed, other “pressing” health             (WHO, 2013a).
                     concerns get higher priority, such as HIV/AIDS,                   With EMDR, the world now has a new efficient 
                     immunizations, and infectious or chronic physical              and effective therapy against the damaging effects of 
                     diseases. One exception is the budgets for military            traumatic stress, one proven to be quick, low-cost, 
                     veterans of some countries, and there are some en-             and widely applicable in a range of crisis settings and 
                     couraging signs that increasingly include trauma               cultural milieus.
                     therapy in (short-term) donor aid for disaster and hu-            The comparative strengths of EMDR therapy bode 
                     manitarian relief.                                             well for treatment on a very large scale. Here I would 
                        But lack of proper appreciation is only one factor.         highlight three of EMDR’s special characteristics that 
                     There are several other obstacles: (b) social stigma           are a sine qua non for going to scale.
                     or people’s sense of fatalism, resulting in failure to            First, its rapid positive results and treatment effec-
                     seek trauma treatment; (c) difficulties with diagnosis,         tiveness: EMDR requires only minimal contact time 
                     measurement, and recognition, especially in differ-            to be effective, measured in hours and (consecutive) 
                     ent cultural settings; and (d) poor coordination and           days, not weeks and months. Moreover, the use of 
                     limited integration of mental health into public health        group protocols (Artegas, Jarero, Alcala, & Lopez 
                     services, which may prevent trauma victims from                Cano, 2009) currently receiving research validation 
                     getting proper treatment. All these reasons are un-            will make it possible to reach larger numbers in a 
                     doubtedly important and play a role.                           shorter period of time. These offer a huge operational 
                        That said, perhaps the most pertinent reason for            advantage in resource-poor conflict and disaster 
                     not addressing trauma, PTSD, and other trauma-                 settings.
                     based disorders on a scale commensurate with its                  Second, its acceptability: EMDR is minimally in-
                     extent, severity, and significance is a general belief          trusive and minimally dependent on verbalization 
                     that there is not much we can do about trauma—that             of the trauma experience—two more plusses—that 
                     190                                                          Journal of EMDR Practice and Research, Volume 8, Number 4, 2014
                                                                                                                                       Carriere
The words contained in this file might help you see if this file matches what you are looking for:

...Scaling up what works using emdr to help confront the worlds burden of traumatic stress rolf c carriere unitar fellow unicef country director in asia ret global estimates trauma exposure classied under heading four violences demonstrate that world faces a mental health crisis truly epidemic proportions given extent severity and con sequences based disorders including posttraumatic disorder worldwide for individuals communities societies current minimal public response needs be addressed an important part should involve implementation timely treatment both during after eye movement desensitization reprocessing therapy offers potentially scalable intervention combines effectiveness efciency affordability acceptability essential preconditions launching ambitious plan overview challenges solutions effective is provided areas policy funding ethics this article concludes with list activities research initiated without delay as starting keywords prevalence scalability task shifting paraprofes...

no reviews yet
Please Login to review.