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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. 1 Ramsay Health Care – Allied Health Research Awards 2014 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 2 Ramsay Health Care – Allied Health Research Awards 2014 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: 3 Ramsay Health Care – Allied Health Research Awards 2014 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. 4 Ramsay Health Care – Allied Health Research Awards 2014 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. 5 Ramsay Health Care – Allied Health Research Awards 2014 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 6 Ramsay Health Care – Allied Health Research Awards 2014 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 7 Ramsay Health Care – Allied Health Research Awards 2014 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. 8 Ramsay Health Care – Allied Health Research Awards 2014 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 9 Ramsay Health Care – Allied Health Research Awards 2014 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 10 Ramsay Health Care – Allied Health Research Awards 2014 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. 26. McLean L, Proctor M-T, Rogers V, Shaw J, Kwiet J, Streimer J, Vandervord J, Kozlowska K 27. (2013)Secure attachment to God and a secure/comfortable attachment organization may both promote healthy recovery from severe burns injury. In John L. Hochheimer & Jane FernandezGoldborough (Eds). Spirituality in the 21st Century: Conversations Inter-Disciplinary Press: Oxford, UK 28. Eve Bernstein Carlson & Frank W. Putman, Dissociation Experience Scale (DES) 29. Dudley, D. Blake, Frank,W.Weathers, Linda M. Nagy, Danny G. Kaloupek, Dennis S. Charney, & Terence M. Keane, (1998) Clinician-Administered PTSD Scale (CAPS) for DSM-IV, National Center for PTSD 30. Carver, C.S., Sceier, M. F. & Weintraub, J.K. (1989), Assessing coping strategies: A theoreticaically based approach. Journal of Personality and Social Psychology, 56, 267-283 31. Blanchard, E. B., Jones-Alexander, J., & Forneris, C.A. (1996). Psychometric properties of the PTSD checklist (PCL). Behavioral Research & Therapy, 34: 669-673 32. Lovibond, S. H. & Lovibond, P. F. (1995) Manual for the Depression Anxiety Stress Scales (DASS). Sydney: The Psychology Foundation of Australia Inc 11