European Centers for refugee mental health are increasingly using

EMDR with this population

Experience-based EMDR Practices and Research (EMDR Italy Association network) with Refugees and Asylum Seekers in Italy Italian EMDR clinicians, treat regularly with EMDR,refugeesandasylumseekerswithin migrantcentersandmentalhealthfacili:es

Refugeesandasylumseekers,comingfromwartorn,mainly sub-Saharan Africa and the Middle East, arerese=led in Italy in governmental and NGO camps,andmany seek treatment or are referred tomentalhealthservicesfortrauma-relateddisorders.

EMDR in the field: Working in the hot spots of refugees arrivals

• InterveningintheacutephaseoftraumaFzaFonrelatedtocriFcalincidents,duringtheflight

• ReducingriskfactorsformentalandemoFonaldisorders(domesFcviolence,intergeneraFonaleffectslikeinadequatebonding,withdrawal,etc.)

• OrganizinggroupintervenFonsinordertoenhanceresourcesandprotecFonfactors

• Interveningwithpersonnelthathasbeenexposedtohighlevelsofstressrelatedtotheirhumanitarianwork

• Providinghelpinrehearsingfortheasyluminterview.ConstrucFngaconsistentnarraFvethroughtheuseofbilateralsFmulaFonwiththeRecentTraumaFcEpisodeProtocol(Shapiro,E.;&Brurit,2012).

• PreparingrefugeestohavefurtherpsychologicalsupportinEuropeancountries,throughEMDREuropenetwork(17.000EMDRcliniciansin24Europeancountries)

Refugees, Asylum Seekers and Psychosocial Factors All EMDR treated individuals haveexperiencedextremely traumaFc events such as torture,rape, loss,havebeenexploitedandabandoned,and most of them have come by sea aZer ahorrifyinganddangerousjourney.

ThegreatestissuesforthesepopulaFonsistheirrole loss, idenFty loss, as well as loss frommulFpledeaths.

Their belief system completely embracesfatalism and animism, to which they surrendertheir ability to make choices and personalstrategicplanning.

Symptoms Themostcommonpsychologicalsymptomsamongall treated individuals with EMDR, are complexPTSD, dissocia:ve states, depression andsoma:za:on. Usually people coming fromdeveloping countries, mainly Africa, tend toexpressemoFonaldistressthroughtheirbody. Infact, somaFc disorders are frequently brought totheclinician’sa=enFon,andmayoZenbeasignofunreferredpos=raumaFcsymptomatology.Mentalhealth issues are usually misdiagnosed intransculturalmedicalse^ngs(Onofrietal.,2014).Frequent disorders include gastri:s, derma::s,difficul:esinconcentra:ng,nightmares,difficul:esinlearning(e.g.Italian),andsleepingdisorders.

Their core traumaFc feeling is an u=er sense ofpowerlessnesstheyperceiveasinscribedintheirbody:to overcome this, clinicians noted that theseindividuals sFll need to realize that they’ve survived.Furthermore, social exclusion experienced in hosFngcountr ies can lead to worsening of PTSDsymptomatology.IntervenFons go from dealing with the mostcompellingneedsandobjecFves,aswellasaddressinganyrecentandpast traumaFcepisodes.Theyneedtoput into words their life experiences and create anarraFve.

The therapeutic intervention must be done in their native language, “the language of the heart”

EMDRtreatmentiseasilyimplementedwiththehelpofa translator, it has been widely used already withtranslators in European countries in the last 15 years,without difficulFes regarding different languages andcultures. EMDR clinicians can treat refugees in groupse^ngs,inordertobeFmeeffecFve.Inthiswaymorepeople can receive specialized evidence based traumaprevenFonandtreatment,intheacuteaswellasinthechronicphaseoftrauma.

• The most basic element of communicaFonbetween clinician and paFentsmust be a verysimpleand"unshaming"language.Onaone-to-onebasis,paFentsneedtohearthatwhattheyare going through is a “normal” response toextremelyadverselifeevents,andthattheyarenot“crazy”orill.• EMDR clinicians usually avoid introducingthemselvesaspsychiatristsorpsychotherapists,but simply explain that they are doctors whohave been providing help to strong and bravepeople who have been able to surviveextremelydifficultcircumstances.

• TreaFng refugees not as vicFms, but as acFveagentsof their lives in the faceofadversity. It isessenFaltodevelopadeepsenseofappreciaFonand admiraFon toward these people, for havingbeen able to endure and withstand such harshexperiences.• The greatest challenges against sFgma are notmetwithwartrauma,butwithpeoplewhohavebeen traumaFzed by sexual and domesFcviolencepriortothewar.

The Issue of Stigma EMDRclinicianshavelistedaseriesofacFonstotacklesFgma:•  DeliverpsychoeducaFonontrauma•  Raiseawarenesswithinthecampsaboutthebenefitsofpsychologicalcounselingsubsequenttotrauma.

•  Askhowwouldsymptomsbedealtwithintheircountryoforiginandcreatealinkwiththecultureofthehostcountry.

•  InviteallrefugeeslivinginthecamptoparFcipateandtakepartatgroupmeeFngs,mainstreamingresilienceandposiFvesharing.Groupsmayleadsubsequentlytoone-to-onetreatmentwithclinician.

• Clinicians have to be sensiFve toward culturalpa=erns, they have to ask permission fortouching the paFent. Opposite-sex cliniciansand interpreters shouldbeavoided, aswell asmaintainingappropriatedistance.• Past and recent trauma are not easilyreprocessed, due to refugees’ ongoingtraumaFzaFon, caused by their current livingcondiFons. IniFally, clinicians should helppaFent focus only on the present: it is nearlyimpossibleforthemtoconcentrateonthepastdue to cultural barriers, as well as being toopainful

• When applying EMDR, clinicians reported theneedtobeveryflexible,shiZingconstantlyfrompast to present, reprocessing many large Ttraumas from the past, along with very severeongoing current trauma. Once current livingcondiFons in termsofsafetyandstabilitywithinthe camps had been ensured, clinicians usuallybegan with history taking which could takeseveral sessions, due to the presence of manypastandrecenttrauma.

SPECIAL POPULATION WITH SPECIAL NEEDS

• Whenconstantlyplaguedbyrecurrentnightmaresandflashbacks,thatiswhentheyunderstandtheyneedhelp.• WeexplainEMDR’sfuncFon,intermsoftakingthepainaway,notthememories,sincethispopulaFonoZenfearstolosethememoriesoftheirrelaFveseveniftheyaredead,sincememoriesisalltheyhave.• AlthoughcreaFngaSafePlacehasproventobedifficult,insomecasesMuslimswereabletoselecttheconclusionoftheRamadanasaveryjoyousmoment.• SincereprocessingtheirnumerouslargeTtraumamaybefartoooverwhelming,cliniciansrecommendtosafelytargetthetraumaFceventwithJimKnipe’sCIPOSmethod(TheMethodofConstantInstallaFonofPresentOrientaFonandSafety).

Adaptations of EMDR Procedures SomereportsnotedthatassessingorinstallingrespecFvelythenegaFvecogniFon(NC)andposiFvecogniFon(PC),andinsomecasestheSafePlace,wasalmostimpossible,sincepaFentsdidnotseemtounderstandtheseconcepts,butratherexperiencedtheiremoFonsintheirbodyand“heart”.Thisdifficultymaylieintheirli=lementalizingabiliFesordifferentculturalconcepts,notalwayshavingtheabilitytocreatealinkbetweentheiremoFonalandcogniFvestates.Drawingsofthemapoftheirjourney,pictures,songsandtheuseofamoresimplifiedlanguagearealsousedforeffecFveEMDRreprocessing.

EMDR: new frontier of treatment with refugees •  Decrease in anxiety, depression,nightmares, ruminaFon, and subjecFvewellbeing(SUDoftraumaFcmemoriesgotozero)

•  Efficacy in addressing traumaFc eventsand building resilience and hope insituaFonsofongoingtrauma.

•  EMDR treatment intervenFon with refugees and asylum centerdisplaced in refugee camps in Rome (Onofri et al., 2014). The coreteam provided a one-to-one treatment to 3 Refugees. TheintervenFonplanned15sessionsforeachpaFent.•  Results: paFentsweremorelikelytofeelstable,andfelttheycouldtrusttheclinician,sensingthattheirstoryandmostincumbentneedsweretakenseriously.•  ThemainfocuswasthesomaFccomponentofpaFents’psychologicaldistress linked to the traumaFc experience. An iniFal bo=om-upreprocessing addressed the body, moved on to the emoFonalcomponent of the distress, and finally accessed cogniFons, enablingrecall,reprocessingandintegraFonofthetraumaFcexperiences.•  PaFents seemed reluctant toward reprocessing their extremelypainful past, whilst struggling with their current difficult andsomeFmesthreateninglivingcondiFons.

3 Case Reports of EMDR therapy with adults within a phase centered intervention plan

(Onofri, A., Gattinara Castelli, P., Ciolfi, A., Lepore, M.,Ventriglia, S., 2014)

•  TheefficacyofEyeMovementDesensiFzaFonandReprocessingforPTSDanddepressionamongSyrianrefugees:ResultsofaRandomizedControlledTrialCerenAcarturk,EmreKonuk,MustafaCeFnkaya,IbrahimSenay,MaritSijbrandij,BirgGalen,PimCuijpers

GAZIANTEP ORPHANAGE FOR SYRIAN CHILDREN (June 2016-July 2016)

The Orphanage requested for these children EMDRtreatmenttoprovidereliefandatherapeuFctreatmentfortheir trauma. EMDR helped to heal their war wounds,whilepromoFngadaptaFonandintegraFonprocesswithinthe new society and community of their host country(Turkey).The fear, depression, anxiety, anger, and pain from theirunprocessed trauma experiences, in fact, can havedebilitaFng effects on the individual that can derail anyhopeofahappyandproduc:velife.

•  OrasR.,CanceladeEzpeletaS.,AhmadA.(2004).TreatmentoftraumaFzedrefugeechildrenwithEyeMovementDesensiFzaFonandReprocessinginapsychodynamiccontext.NordJournalPsychiatry.58:199-203.

•  Smith,TimothyB.andGriner,D.(2006).CulturallyAdaptedMentalHealthIntervenFons:AMeta-AnalyFcReview.AllFacultyPublica:ons,Paper279.CabralR.R.,SmithTB.(2011).Racial/ethnicmatchingofclientsandtherapistsinmentalhealthservices:ameta-analyFcreviewofpreferences,percepFons,andoutcomes.JournalofCounselingPsychology,58(4):537-54.

•  TerHeide,F.,Mooren,T.M.,Knipscheer,J.W.,Kleber,R.J.(2014).EMDRWithTraumaFzedRefugees:FromExperience-BasedtoEvidence-BasedPracFce.JournalofEMDRPrac:ceandResearch.Volume8,Number3,147.

•  Zaghrout-Hodali,M.(2014).HumanitarianWorkUsingEMDRinPalesFneandtheArabWorld.JournalofEMDRPrac:ceandResearch.Volume8,Number4.

•  Onofri,A.,Ga^naraCastelli,P.,Ciolfi,A.,Lepore,M.,Ventriglia,S.(2014).L’ApproccioEMDRinunServiziodiAiutoPsicologicoperRifugiaFerichiedenFAsiloaRoma.PsicobieNvo.Vol.24.

•  TheUNRefugeeAgency.RetrievedJanuary22nd,2016,fromh=p//www.unrefugees.org/what-is-a-refugee.

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