Download 2001 Allocation of DETYA Research Infrastructure Block Grants (RIBG)

Ramsay Health Care – Allied Health Research Awards 2014
APPLICANT
Name:
Qualifications:
Mailing Address:
Telephone:
E-mail:
Julia Kwiet
Masters of Social Work
Royal North Shore Hospital, Severe Burns Injury Unit, Douglas Building,
Level 6
Pacific Highway, St Leonards, NSW 2065
9462 9477
0419773 970
[email protected]
SUPERVISOR
Principal and Research
Name:
Qualifications:
Mailing Address:
Telephone:
E-mail:
Loyola McLean
BA MBBS (Hons) FRANZCP PhD Dip Psych Psychotherapy Cert ATP
Consultation-Liaison Psychiatry, Level 3, Clinical Services Building, RNSH
0405539 625
[email protected]
APPLICATION TITLE:
A randomized-control trial (RCT) of Eye Movement Desensitisation and Reprocessing (EMDR) for
post-traumatic stress symptoms in burns patients.
Research Project
This study seeks to explore the effects of brief EMDR interventions on intrusive post-traumatic
symptoms and evaluate the efficacy of early EMDR interventions following burns trauma. The proposed
research seeks to establish whether EMDR is a safe, effective and appropriate intervention for patients
exhibiting high levels of post traumatic disturbance in an acute care setting, beyond treatment as usual
(TAU). Burns patients are at increased risk of developing PTSD. Early intervention is potentially
important for this vulnerable and marginalized client group, before new trauma becomes chronic and
disabling and interferes with recovery.
Research questions:
1. Is early EMDR a safe and effective treatment for post-traumatic symptoms in severe burn injury
patients in an acute care setting with opportunity for out-patient follow-up?
2. How effective is the Acute-Traumatic Incident Procedure (A-TIP), a specific EMDR protocol, in
reducing intrusive symptoms and reducing the rate of PTSD and other mental health disorders in burns
patients, when compared with Treatment as Usual (TAU), that includes basic counselling, and
psychological “first-aid”, but does not include the specific EMDR intervention.
Background
Severe burn injuries are associated with considerable psychological trauma (2, 3, 4, 5, 6, 7, 9). EMDR is
an effective evidence based treatment for psychological trauma (10, 11, 12, 13, 14) as it is a
psychotherapy that facilitates resolution of traumatic memories. It has been well researched; to date
there are 21 randomized clinical trials demonstrating its efficacy in reducing and eliminating PTSD
symptoms (13) and is recommended as an effective treatment for trauma (15, 16). The World Health
Organization (WHO)’s new guidelines for mental health care after trauma recommend EDMR as an
effective treatment method along with trauma-focused CBT. These guidelines specifically call for more
research with acute trauma.
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To date, there are few studies on early EMDR intervention following trauma and many researchers and
clinicians have identified this as an important area requiring further investigation (17). It is believed that
early EMDR intervention may help patients integrate traumatic memories preventing the development of
chronic pathology (11, 12, 13, 14, 17) and may influence adaptive integration, promote positive coping
and contribute to the development of resilience (17, 18, 19 ). Recent research on early EMDR
intervention in acute care settings have shown very promising results (11, 12, 19). There are, however
surprisingly few publications addressing early EMDR intervention (13) although this is starting to
emerge (11, 12, 20). There are several case studies reporting positive outcomes after acute stress with
early EMDR intervention (11, 19, 22) More recent studies from Mexico and Israel have supported other
anecdotal reports on the rapid effects of brief EMDR interventions on intrusive symptoms in early
posttraumatic cases (11, 23) and claim “that treatment may have helped prevent the development of
chronic PTSD and facilitated greater resilience and coping. Luber et al’s (12) randomized control study
with a waitlist/delayed treatment control group of earthquake survivors found that one session of early
EMDR produced significant improvement on symptoms of posttraumatic stress, with results maintained
at 12 week follow up (12). They also demonstrated symptom improvement within the delayed treatment
group post intervention. These researchers suggest that EMDR may be the key brief early intervention
modality after traumatic events (12).
The question of the timing of early EMDR and whether it can thereby reduce the incidence of PTSD and
other disorders that can follow trauma are among the general challenges that need to be studied
empirically (17, 18). However within burns, which is a particularly challenging treatment context, the
basis safety and efficacy, over and above normal psychological “first aid” and the effect of the
therapeutic alliance needs demonstrating.
This research then aims to explore the effects of early EMDR interventions on burn patients’ mental
health outcomes with a primary focus on posttraumatic symptoms but also track mood and coping,
which often suffer during rehabilitation. This project has the support of the Burns Psychosocial Research
Group (McLean, Kwiet, Kornhaber, Streimer, Vandevord and affiliates), which has been researching
burns patients mental health recovery and rehabilitation for several years (24). This project would
represent the next collaborative project for the team who has been struck by the severe psychopathology
that is present in burn survivors. The opportunity to promptly intervene with simple and effective
psychological treatment to avoid sequelae in those who were previously well warrants investigation and
sits with clinical observation that even good psychological “first aid” with Consultation-Liaison support
appears to be insufficient to support best recovery. This project pulls together the different kinds of
expertise to deliver a collaborative project aiming to improve the treatment of sufferers of burns and will
be supported by a planned QA, screening all severe burns patients admitted to the Severe Burns Injury
Unit at Royal North Shore Hospital to gather complete data for a cohort on which to base future
treatment, policy and advocacy and a targeted study on early intervention for PTSD.
The hypothesis that early EMDR intervention/treatment has a positive effect on burns patients’ mental
health outcomes, in terms of reduction in PTS, PTSD and depression will be tested. Patients will be
randomly assigned to ensure groups are similar and therefore help control for extraneous variables. The
proposed project will utilize a quantitative approach that will examine the pre- and post-measures on
PTSD scales and coping measures both in those patients who receive a specific EMDR intervention and
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those who receive stabilization, stress management strategies and supportive counselling. Data will then
be compared and it is hypothesized that outcomes may match other research findings (11, 12, 20, 22, 23)
that show significantly reduced prevalence of PTSD and lower PTS scores in patients that have received
early EMDR treatment. As depression is a longer term outcome of traumatic symptoms, it is
hypothesized that this will also be less in the EMDR treated group at follow-up. Patients will also be
invited to participate in qualitative interviews in an associated project on recovery from Burns
undertaken by the affiliated post-doctoral researcher Dr Rachel Kornhaber and qualitative data on the
EMDR and the supportive counselling experience will be sought.
Data collection will necessarily involve both interviews and questionnaires. Baseline psychosocial
screening has been undertaken for some time in burns and is being upgraded with universal
questionnaires and tracking of recovery in the first year as part of quality assurance. Patients who score
high on the IES (25) will be considered for the trial. However as exclusions for EMDR are those whose
trauma symptoms are too chronic and complex, a screening interview will be conducted based on the
Adult Attachment Interview (21) that has been modified for Burns patients (26) and trialed over the last
few years on the burns ward. This will be used to identify those patients with chronic complex trauma
that may be unsuitable for early EMDR. These patients will be referred instead to the ConsultationLiaison Psychiatry Team who have an ongoing close liaison with the Burns team and who’s Director, Dr
Streimer has been a part of the joint research endeavors over the last years.
Significance
Interventions that reduce post-traumatic symptoms early in the recovery and rehabilitation are likely to
enhance patients’ outcomes, resilience and coping. Effective early intervention may prevent
development of chronic pathology, potentially reduce length of hospital admission, and positively
influence rehabilitation and psychosocial reintegration. This would not only have a positive impact on
patient’s health outcome but would be resource and cost effective for the health system in the long run.
Knowledge gained from the proposed research can be utilized to inform and further develop more
effective early trauma interventions. Early EMDR interventions may facilitate improved psychosocial
recovery of burns patients and this first step towards full evaluation is necessary to establish basic proof
of concept that early EMDR intervention is safe, useful and valuable in this acute and medically
complex setting. There is consensus in the literature that more controlled research to evaluate further the
efficacy of early EMDR intervention is warranted
The Acute-Traumatic Incident Procedures (A-TIP) is a modified EMDR Protocol recommended for
patients in an acute care setting, where trauma is recent and often ongoing (1). It has increased measures
for safety and containment, stabilization and consists of a comprehensive three session protocol aimed to
1) Facilitate adaptive processing of traumatic memories, 2) Prevent accumulation of negative associated
links and 3) reduce suffering and later complications. It is also believed to preempt avoidance, however
to date this protocol has not been validated by research and this will be a first formal randomized-control
pilot.
Research Methods and Design
The intervention design is 2 stepped:
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1) A Randomized-Control Trial of early EMDR, using the Acute –Traumatic Incident Procedure (ATIP), where this novel treatment will be compared with an early intervention of supportive counselling
that includes basic stabilization and stress management strategies and a supportive psychotherapeutic
relationship, constituting “Treatment as Usual” (TAU). The rationale for this control treatment is that
some early positive effects of treatment might occur through psychophysiological stabilization and
dearousal, brought about by the powerful effects of social soothing in a therapeutic relationship and/or
via simple instruction and/or encouragement to engage in stress management strategies. Comparison of
the proposed “active” component of EMDR with an “active”, albeit supportive, with provision of basic
stress and affect management skill and a supportive therapy frame diminishes the risk of overlooking the
therapeutic effect of good psychosocial care.
2) A partial waitlist/delayed EMDR treatment group where those in the TAU group who are
symptomatic at the end of the 3-session intervention (IES ≥26) will be offered a course of 3 sessions of
EMDR, and analysed as a treatment-delay subgroup, and compared with the group who are initially
treated with EMDR and to their own prior progress This treatment after TAU is offered out of ethical
concerns that the literature to date suggests that the EMDR may be a more effective intervention than
supportive counselling, and remained effective in a waitlist control group (12, 23). It will also offer
further documentation of any time delay effects of EMDR which are very likely in a “real-world” burns
care setting.
Sample
This will include those willing participants admitted to the Severe Burn Injury Unit (SBIU), Royal North
Shore Hospital (RNSH) with moderate-severe posttraumatic symptoms established at baseline screening
who do not have exclusion criteria.
Inclusions
Burn patients admitted to the SBIU, RNSH, who have moderate to high levels of uncomplicated posttraumatic stress symptoms at 2-4 weeks post injury will be offered participation in this study, defined as
an Impact of Event Scale (IES) score ≥ 26. Patients with known psychiatric disorders, previous
substance abuse histories, and suicidal ideation may still be included, provided they have been screened
by C-L psychiatry, and assessed for dissociation and are subsequently deemed safe and appropriate
participants. The window within which posttraumatic symptoms might begin to settle with natural
coping is 2-4 weeks post injury. The aim is to tap participants who may not be settling within that time
frame, but to study a group with some variability, not simply those who have an established PTSD
diagnosis at 4 weeks post event.
Exclusions
Patients younger than 18 years of age.
Estimated IQ below 70.
Patients with a delirium, psychosis, dementia or other cognitive impairment.
Current and ongoing severe substance abuse, impairing cognition
Patients with high levels of dissociation (DES score >40)
Patients suffering from acute grief reactions
Patients at risk of self-harm who cannot assure their safety.
Patients who remain in an unsafe environment/current abusive relationship.
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Patients with complex chronic trauma histories that are unresolved (discernible signs of ongoing
traumatic disorganization of reasoning, discourse and behaviour).
Protocol Stages:
Stage 1- Screening for posttraumatic symptoms.
All patients admitted to the SBIU, RNSH will be screened within the first two-four weeks following
injury (or the first 2 weeks following discharge from Intensive Care), using the Impact of Event Scale
(IES). This will be a part of universal screening on the unit. Patients whose baseline scores indicate
moderate-to-severe posttraumatic stress symptoms will be considered for recruitment into this study
(IES score ≥26).
Stage 2_- Clinical assessment to identify exclusions and pre-treatment variables.
The subgroup of patients with elevated IES scores will be evaluated further via a full psychiatric
assessment by the Consultation-Liaison Psychiatry team to determine clinical exclusions and Ms Kwiet
will also perform a fuller psychosocial research assessment, including evaluation of dissociative
symptoms (via interview and the Dissociative Experiences Scale (DES) (27), past trauma history as well
as other risk and resilience factors, such as past psychiatric illnesses, family history, medications,
premorbid personality and functioning and levels of social support. This will be obtained via a semistructured interview incorporating these clinical domains, the Adult Attachment Interview (Burns
Modified with Social Support probes) (26) and the CAPS (the gold standard interview measure of
PTSD) (28). Patients identified as having unresolved complex chronic trauma and high levels of
dissociation will not be considered for inclusion in the RCT, as they are likely to require a prolonged
period of stabilization within a longer term therapeutic relationship. They will be referred to the
Consultation-Liaison (C-L) Psychiatry Team for advice re management and follow-up and while on the
ward will receive the appropriate support and follow-up from C-L and Social Work.
Other potentially relevant biopsychosocial variables such as 1) coping style (COPE) (29), 2)
peritraumatic responses and psychological sequelae (PCL-C (30), DASS (31)) will be assessed via
questionnaire and 3) information re burn depth, size and location will also be obtained (collected
routinely in all burns patients) as well as 4) current medications and pain relief. As time since injury is
central to the process of development of traumatic symptoms and their consolidation, this will be
tracked. This data will be available for consideration in analyses of covariance.
Stage 3: Randomized treatment
Patients with (uncomplicated) moderate to severe posttraumatic stress symptoms will be recruited and
randomly allocated into two groups. One group will receive 3 hours of EMDR as per the Acute –
Traumatic Incident Procedure (A-TIP) (see table 1) and the other group will receive 3 hours of
supportive psychotherapy, which will include basic psychological stabilization and stress management,
considered as psychological “first aid”, as well as a supportive psychotherapeutic relationship (see table
2). All interventions will be provided my Ms Kwiet, who will establish rapport and a therapeutic alliance
with each patients of both groups and has worked with burns patients in this acute care setting for 10
years. All treatment sessions will be taped to foster close supervision and to allow a review of adherence
to protocol by other members of the research team. At commencement and completion of each session
of treatment the IES will be repeated to track any change in the interval between screening and treatment
and any interval changes.
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Stage 4: Residual symptoms and crossover to EMDR.
Those patients in the Supportive Therapy (TAU) group whose IES scores remain elevated at the end of 3
sessions will be offered the EMDR treatment. All participants who remain symptomatic at the end of the
period of intervention will be referred to the Consultation-Liaison Psychiatry Team for review and
advice on a management plan and follow-up.
Stage 5: Outcome and Follow-up assessments
The IES (24) will be administered to all patients following each treatment intervention and again at 3, 6
and 12 months following the intervention so that levels of symptoms can be measured and tracked.
At 6 months follow-up the Clinician-Administered PTSD Scale (CAPS) (28) the gold standard for PTSD
symptoms will be administered to all participants from both groups. At 12 month follow up Ms Kwiet
will perform a Burns Modified Adult Attachment follow up Interview (26) and a CAPS (28) to all
participants from both groups. The COPE (29), DASS (31) and DES (27) will also be re-administered to
each patient at each follow up. Although the 12 month and some of the six month measures will fall
outside the time-line of the fellowship, they will be part of Ms Kwiet’s MPhil/PhD work, which will
continue beyond the fellowship.
Summary of the Interventions:
The Intervention protocols
An explanation of both the EMDR and supportive counselling will be provided at the time of obtaining
informed consent. This involves describing the nature of treatments to patients as well as giving a brief
demonstration of the bilateral eye stimulation along with a disclaimer that “the intervention may or may
not help the distress”.
Table1.
EMDR/A-TIP Intervention:
The Acute –Traumatic Incident Procedure (A-TIP) is a simplified version of the Recent-Traumatic
Events Protocol (R-TEP), which was modified from the standard eight phase EMDR protocol for early
intervention following traumatic exposure (1). It consists of 3 one hour sessions.
Session One: Introduction & Stabilisation
1) The A-TIP is administered within 3 sessions and ‘processing’ is confined to the recent event.
These limitations are explained clearly and form part of the therapeutic contract before work
commences.
2) The patient is asked to give a brief chronological narrative of the whole traumatic experience and
then asked to rate their level of disturbance (SUD, 0 being no disturbance and 10 maximum
disturbance). The patient’s negative cognition associated with the event as well as their
positive/adaptive belief is elicited and rated using the VoC scale (validity of cognition, 1 being
totally false and 7 being totally true).
3) Patients are taught some basic relaxation and self-soothing strategies, to assure safety and
containment as well as adequately assess patients’ readiness for processing. Patients must have
the ability to both tolerate their disturbance and regulate their responses. If this is not the case,
more stabilisation work may need to be done before bilateral stimulation is introduced. Safe/calm
place, container and breathing exercises will be used for this.
4) Patients are then asked to ‘walk through’ the story with continuous BLS (bilateral stimulation)
5) Debrief & closure. Options for next session are discussed and if necessary affect management
skills for stabilisation
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Session Two: Processing the disturbance
1) The ‘worst part of the incident’ is assessed, including image that represents the event, sensory
component, negative and positive belief, VoC: 1-7, emotions, SUD (0-10) and body location of
disturbance. This is then processed using BLS until SUD is as low as possible. This is followed
by the installation of the positive belief until the VoC is as high as possible. This is repeated for
other disturbing aspects/fragments of the trauma, either in chronological or by level of
disturbance.
2) Debrief and closure. Affect management skills if required.
Session Three: Reevaluation& Future Action Planning
1) Patients are re-evaluated, both globally in terms of any changes, dreams, startle responses and
triggers that may have arisen and specifically to the previous ‘targets’ processed. Any new or
remaining disturbances are processed as in session two.
2) Patients are asked to imagine potential future aspects similar to the traumatic event and asked to
hold their positive belief with that situation. The VoC is checked and then BLS is applied until
the VoC moves to an adaptive level.
3) Exit interview and closure
Table2.
Supportive Counselling Intervention:
Session One:
1) Explanation of 3 session contact for supportive counselling.
2) Provide psycho-education re PTS and normal trauma reactions/what to expect
3) Explore patients concerns, coping and social supports.
4) Patients are taught some basic relaxation and self-soothing strategies, to help them manage their
current post traumatic symptoms, assure safety and containment. Safe/calm place, container and
breathing exercises will be used for this.
Session Two:
1 Exploration of patients’ ongoing concerns, allowing patients to reflect on how they have coped
and made meaning of traumatic experiences.
2 More affect/stress management skills as required.
Session Three:
3 Exploration of patients’ ongoing concerns, allowing patients to reflect on how they have coped
and made meaning of traumatic experiences.
4 More affect/stress management skills as required.
5 Debrief and closure
Time of Intervention
It is important to state that initial acute stress symptoms should be viewed as normal reactions to an
overwhelming experience. These immediate responses will not be pathologised, but viewed as
potentially adaptive attempts to restore equilibrium after traumatic exposure (11). Both types of
intervention will only be offered when complaints, symptoms or distress has not does not decreased to
below moderate levels within 2-4 weeks of traumatic exposure. Research nevertheless suggests that high
levels of PTS symptoms experienced at 2 weeks correlate with PTSD and this was found to be the most
reliable predictor for PTSD (32). Due to the physical impediments to screening and psychological
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resolution in Burns care, such as intense early (and traumatic) treatment and ICU admissions for many,
this window for early treatment is extended to cover the 2-4 week window between the event and the
time for diagnosis of PTSD at one month post injury. Interventions have been time sensitive in the small
number of studies to date and time from injury will be closely monitored as a variable.
Sample size and Data analysis
The effect size of EMDR has been shown to be substantial in many studies with a moderate to strong
effect found of a Cohen’s d of 0.7 or more, and comparable early use studies demonstrating an even
stronger effect (12, 23). Although the burns group is an unwell and extreme population, it is reasonable
on the published data to anticipate that adequate power of 0.8 may be achieved with a sample size of 20
in each initial group, for a repeated measures analysis of within-subject changes and between group
differences between the initial EMDR and TAU groups. However in order to obtain larger numbers for
the sub-analysis with the crossover group, and to allow for dropouts, and some analysis of covariates,
the study will aim to recruit n>40 in each group, over around a 2 year period. Sufficient numbers and
power are likely for an early analysis of n=20 in each group at the end of the fellowship year. The SBIU
sees over 200 patients a year and with most studies showing a prevalence of 20-25% of PTSD,
(including local unpublished data, McLean et al. 2013). We anticipate sufficient numbers as this project
will treat those with significant symptoms rather than simply a formal PTSD diagnosis. If recruitment is
unexpectedly slow the project will still continue to completion as it is the basis of the first part of Ms
Kwiet’s part-time MPhil/PhD. Analysis will proceed via a repeated measures ANCOVA model. Logistic
regression will also be used to identify the risk factors for at risk subgroups (eg PTSD or major
depression on final measures). Ms Kwiet will be supported and guided in this task of analysis by Dr
McLean who is familiar with multivariate repeated measures analyses.
Recruitment and ethics:
As all patients will receive screening there will be no initial coercive influence from clinicians as
researchers on identifying potential participants. Potential participants identified as patients with high
posttraumatic symptom scores (IES ≥ 26) will be further screened as described above. No other aspect of
treatment will be affected by refusal/agreement to participate. It is planned that intervention will start
during or after week 2-4 in order to allow for natural recovery, but still within a time frame where
chronicity might be avoided. Patients’ consent to participate in this study will be obtained after the
nature of both possible interventions is explained and a disclaimer that “the intervention may or may not
help the distress” is provided.
Research Tools and Measures
1. Impact of Event Scale (IES): This is a 15-item widely used self-report questionnaire. It is a reliable
measure of subjective posttraumatic stress to a traumatic or stressful life event (25).
2. PTSD Checklist-Civilian (PCL-C): This is a validated and reliable screen for post-traumatic
symptoms. It is included here to gauge its correlation with the IES and CAPS as a future screening
tool in this population (30).
3. The Depression Anxiety and Stress Schedule (DASS) (31) is a valid and reliable self-report measure
for symptoms of depression, anxiety and stress. As depression is often a sequel of trauma and post4. traumatic symptoms, we wish to track these symptoms in our cohort as well as anxiety and a
measure of subjective stress.
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5. The COPE (29) is a valid and reliable self-report measure of coping style. As coping style impacts
on recovery from burns (26) and avoidant strategies markedly impact on recovery (6), we wish to
track this and other coping strategies that may impact on the recovery of our cohort.
6. Burns modified Adult Attachment Interview ( 26) is modified from the Adult Attachment Interview (
21) which is a gold standard for assessing unresolved loss and trauma and attachment state of mind
7. CAPS (Clinician-Administered PTSD Scale) a semi-structured interview that is the gold standard for
PTSD symptoms (28).
1.7 Anticipated outcomes:
It is anticipated that this research may match other studies that have shown early EMDR interventions to
have a significant impact on the rate of PTSD (12). Most burns patients are still receiving burns care up
to 18 months post injury as this is the timeframe for scar maturation, so follow up is not expected to be
problematic. If, as predicted, EMDR proves safe, usable and effective, then it is possible that a better
psychosocial outcome can be established for Burns survivors. This would allow the evidence on which
to seek funding for a larger randomized-control trial of this potentially important treatment and test its
inclusion within a continuum of care. The Burns Psychosocial Research Group believes developing
interventions that prevent PTSD is a pressing public health need and research in this area is required
(23).
Budget justifications:
The grant would provide salary support to Ms Kwiet. Her salary represents the main budgetary cost. The
formal transcription and scoring of the AAIs will be pursued as a sub-project, but the clinical
use of them for the purpose of assessment does not require this and so Ms Kwiet’s project can proceed
without that aspect being funded.
Ethical implications and a statement regarding the status of Ethics Committee approval from the
relevant institutions:
Instituting research within an active treatment program is always ethically challenging. However the
Burns psychosocial research group supporting this research are closely and collaboratively involved
with the treatment program and understand the duty of care. EMDR is known in other settings to be
effective and this trial is a first step in demonstrating its safety and feasibility in a Burns cohort. Ethics
approval will be sought in the latter part of 2013. However the ability to continue treatment as usual,
with no overt pressure brought to bear on participants minimizes the ethical challenges for the
participants. Those who are excluded will be referred as per established clinical practice to social work
as well as the C-L Psychiatry Team. Early and ongoing analysis of data will be undertaken, overseen by
the supervisor Dr McLean, albeit with initially small numbers, to check that no comparative harm is
being experienced by either treatment group.
Key references:
1. The Acute-Traumatic Incident Procedure Protocol (A-TIP) , Roy Kiessling, LISW, ACSW as
modified from the Recent-Traumatic Episode Protocol (R-TEP), Elan Shapiro & Bruit Laub,
2008
2. Fauerbach, J.A. et al (2005). Burden of Burn: A Norm-Based Inquiry into the influence of Burn
size and Distress on recovery of Physical and Psychological Function Journal of Burns Care and
Rehabilitation, 26, 21-32
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3. Pruzinsky, T. (2005). Celebrating progress in psychosocial rehabilitation: Empirically validating
the efficacy of social skills training and body image assessment for burn survivors Journal of
Burn Care and Rehabilitation, 26 (6), 543-545
4. Philips, C., et al (2007). Considerations for psychosocial support following burn injury: A family
perspective Burns (doi:10.1016/j.burns.2007.01.010)
5. Fauerbach, J.A., Pruzinsky, T. & Saxe, G.N. (2007). Psychological health and function after burn
injury: Setting research priorities. Journal of Burns Care and Research, 28 (4), 587-592
6. Kildal, M et al (2005). Coping strategies, injury characteristics and long term outcome after Burn
Injury International Journal of the Care of the Injured, 36, 511-518
7. Tedstone, J. E., et al (1998) An investigation of the factors associated with an increased risk of
psychological morbidity in burn injured patients Burns 24, 407 - 415
8. Wisely, J. A. (2007) Where to start? Attempting to meet the psychological needs of burned
patients Burns (doi:10.101016/j.burns.206.10.379)
9. Wallis, H. et al (2006). Emotional Distress and psychosocial resources in Patients Recovering
from Severe Burn Injury Journal of Burn Care and Rehabilitation, 27 (4), 734-741)
10. Korn, D.L. (2209). EMDR and the Treatment of Complex PTSD: A Review Journal of EMDR
Practice and Research, Vol. 3, No.4
11. Kutz, I. et al (2008) The effect of Single-Session Modified EMDR on Acute Stress Syndromes
Journal od EMDR Practice and Research, Vol. 2, No. 3
12. Luber, M et al (2011). The EMDR Protocol for Recent Critical Incidents: Application in a
Disaster Mental Health Continuum of Care Context Journal of EMDR Practice and Research,
Vol. 5, No.3
13. Shapiro, E. (2009). EMDR Treatment of Recent Trauma Journal of EMDR Practice and
Research, Vol. 3, No.3
14. Shapiro, F (2001). 2nd edition Eye Movement Desensitization and Reprocessing Guilford Press,
New York
15. American Psychiatric Association (2004). Practice Guidelines for the Treatment of Patients with
Acute Stress Disorder and Posttraumatic Stress Disorder Arlington, VA: American Psychiatric
Association Practice Guidelines
16. Department of Veterans Affairs & Department of Defense (2004). VA/DoD Clinical Practice
Guidelines for the Management of Post-Traumatic Stress. Washington, DC: Veterans Health
Administration, Department oof Veterans Affairs and Health Affairs, Department of Defense.
Office of Quality and Performance publication 10Q-CPG/PTSD-04
17. Shapiro, E. & Laub, B. (2010). The Recent-Traumatic Episode Protocol (R-TEP): An Integrative
Protocol for Early EMDR Intervention (EEI) in Luber, M. Eye Movement Desensitization and
Reprocessing (EMDR) Scripted Protocols Springer Publishing Company, New York
18. Shapiro, E Laub, B. (2009). Early EMDR Intervention (EEI): A summary, a Theoretical Model,
and the Recent Traumatic Episode Protocol (R-TEP)
19. McCann, D. (1992). Post-Traumatic Stress Disorder Due to Devastating Burns Overcome by a
Single Session of Eye Movement Desesitization J. Behav. Ther. & Exp. Psychiat. Vol. 23, No. 4
pp. 319-323
20. Maxfield L, ‘EMDR Treatment of Recent Events and Community Disasters’ Journal of EMDR
Practice and Research, Volume 2, Number2. 2008
21. George C, Kaplan N and Main M. (1996). Adult Attachment Interview, 3rd edition, 1996
Unpublished manuscript, Department of Psychology, University of California at Berkeley
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22. Tofani, L. & Wheeler, K. “The Recent-Traumatic Episode Protocol: Outcome Evaluation and
Analysis of Three Case Studies”, Journal of EMDR Practice and Research, Volume 5, Number
3, 20011
23. Jarero, I & Uribe, S ‘The EMDR Protocol for Recent Critical Incidents: Follow-Up Report of an
Application in a Human Massacre Situation’ Journal of EMDR Practice and Research, Volume
6, Number 2, 2012
24. Kornhaber R, Wilson A, Abu-Qamar MZ, McLean L, Adult burn SSurvivors personal
experiences of
rehabilitation: An integrative review Burns 2013
25. In Wilson, J.P. & Keane, T.M. (eds), Assessing psychological trauma and PTSD: A
Practitioner’s Handbook. New York: Guildford, Chapter 15: The Impact of Event Scale by
Weiss, D & Marmar, C.
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