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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 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).
DISORDERSESPECIALLY043$ BUTALSOPHOBIAS 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/REN3OLOMON ANDORSTIGMA their daily predicament and silent suffering, some-
attached to it may also influence the prevalence mea- times lasting for decades.
SUREMENT/NTOPOFTHAT THEYMAYBEDELIBERATELY s -OREVISIBLE 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 ONTHERISEINhDUETOUNUSUALLYLARGENUMBERS
043$STATISTICS!SATHOUGHTEXPERIMENT LETUSTAKE 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= 4HISSTATISTICISALMOSTCERTAINLY
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.
QUARRELABOUTWHETHERITISREASONABLETOASSUMETHAT s /NE
THIRDOFALLWOMENINTHEWORLDEXPERIENCE
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
EXPERIMENTGIVESUSAQUANTITATIVEORDEROFMAGNI- INTIMATEPARTNERSORNONINTIMATEPARTNERS7(/
tude about the global burden of trauma. C 'ENDER VIOLENCE AGAINST WOMEN WORLD-
)NTHEABSENCEOFGOODSTATISTICS ANOTHER INDIRECT WIDETAKESONMANYFORMS FOREXAMPLE INWARAND
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
MIGHTGIVEUSAROUGHSENSEABOUTTHEEXTENTAND &'- ANDTRAFlCKING)TISNOWONDERTHENTHAT
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 !CCIDENTSKILLOVERMILLIONPEOPLEAYEARAND
Exposure to Traumatic Events: INJUREANDDISABLETENSOFMILLIONSMORE7(/
“Four Violences ACCIDENTS ALTHOUGHNOTINTENDEDTOHARM
Perhaps the various types of violence—direct, natural, are a form of direct violence that traumatizes survi-
STRUCTURAL ANDCULTURAL'ALTUNG MAYOFFERA 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 )TCOMESINTHEFORMOFEARTHQUAKES TSUNAMIS mOODS
wildfires, volcanic eruptions, hurricanes and storms,
Acts of direct violence are intended to do harm to DROUGHT ANDEXTREMETEMPERATURESNOWOFTENSYMP-
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 .OLESSTHANBILLION PEOPLE CURRENTLY LIVE IN ADVERSECONSEQUENCESMAYLINGERFORYEARS
countries afflicted by political or criminal violence s 7ORLDWIDE ANANNUALAVERAGEOFMILLIONPEO-
ANDWAR4HE7ORLD"ANK 4HISSTATISTICIN- ple are affected by natural disasters (EM-DAT: The
cludes countries such as Syria, Congo, Afghanistan, )NTERNATIONAL$ISASTER$ATABASE .ATURALDI-
)RAQ ANDMANYOTHERS-ORESPECIlCALLY hABOUT sasters caused by climate change are becoming a
MILLIONPEOPLENOWLIVEAMIDSTVIOLENTINSE- recurring pattern and in the foreseeable future are
CURITYAROUNDTHEWORLDv,EANING'UBA
3APIR likely to affect even larger populations.
3INCE THE END OF 7ORLD 7AR )) MORE s ,OSS OF LOVED ONES SOMETHING EVERYONE EXPERI
THANWARSHAVEBEENFOUGHT9ANACOPULOS ENCES SEVERAL TIMES IN A LIFETIME FOR EXAMPLE
(ANLON INWHICHSOMEMILLIONPEOPLE 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 !CCORDINGTO4HE7ORLD"ANK WORLDWIDE of truly epidemic proportions.
SOMEBILLIONPEOPLELIVEDINEXTREMEPOVERTY Many of these categories of traumatic experiences
ONADAYININALL BILLIONLIVEDONLESS or events overlap, often adding insult to injury and
THANADAYTHATYEAR putting millions of people in double jeopardy by
s -OSTSUFFERFROMHUNGERORCHRONICUNDERNOURISH- causing multiple traumas. Of course, not all trau-
MENTMILLIONPEOPLE&OODAND!GRICULTURE matic experiences will lead to PTSD, although many
/RGANIZATIONOFTHE5NITED.ATIONS 3OME of those who spontaneously “recover” from trauma
MILLIONPERSONSWHOLIVEINABSOLUTEPOVERTY 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 SOMEMILLIONPEOPLEAREUNEMPLOYEDIN ( delayed onset).
)NTERNATIONAL ,ABOUR /RGANIZATION
MILLIONOFWHOMAREINTHEDEVELOPEDECONO- Challenges of Preventing and
MIES4HENUMBEROFCHILDLABORERSINIS 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 4HESEAREOBVIOUSLYTRAUMATIZINGCIRCUMSTANCES 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
)FYOUHAVEEVERWALKEDTHROUGHTHESLUMS 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
MAYLEADTOTRAUMA2ICHETAL h*USTvWARTHE- 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
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