SVS EMDR Group Protocol: A Collaborative Approach to Trauma Therapy

Introduction

It is well documented that eye movement desensitisation and reprocessing (EMDR) therapy is increasingly recognised as a gold standard treatment for posttraumatic stress disorder (PTSD) and a treatment for survivors of sexual violence (SVS) (Edmond, 2004; Jaberghaderi et al., 2004; Schwarz et al., 2019). In Aotearoa New Zealand we are fortunate to have access to government funding infrastructure to provide treatment for SVS via the Accident Compensation Corporation (ACC). With a substantial population of SVS in Aotearoa New Zealand (Fanslow et al., 2007), there are extensive waiting lists for ACC-funded treatment and a shortage of EMDR trained therapists. Therefore, providing EMDR group therapy for this population began as a means to increase accessibility to this treatment and accelerate survivors’ recovery. In this article, the authors discuss the development of the SVS protocol and the benefits they have observed, with the aim of encouraging clinicians to consider integrating SVS EMDR group therapy into their treatment planning as an adjunct to individual therapy. In addition, they hope this article inspires EMDR-trained clinicians to extend their individual clinical practice to working with groups, and encourages further research and adaptations to extend the benefits of group EMDR into broader contexts, populations and cultures.

Development of the SVS Group Protocol

There are multiple group based EMDR approaches that are predominantly based on early intervention for recent trauma events (Morrow Robinson & Kemal Kaptan, 2023). All EMDR groups use the adaptive information processing model to inform their clinical practice, which was developed by Francine Shapiro, the originator of EMDR (F. Shapiro, 2018). Two of the most widely used EMDR groups are the group traumatic episode protocol (G-TEP) and EMDR integrative group treatment protocol (EMDR-IGTP) (Morrow Robinson & Kemal Kaptan, 2023). As EMDR group-based, early-intervention models, G-TEP (E. Shapiro, 2013) and EMDR-IGTP (Jarero et al., 2008) were initially designed to treat recent trauma survivors and respond to the devastating impacts of global man-made and natural disasters (Lehnung et al., 2017; E. Shapiro et al., 2018; E. Shapiro & Laub, 2008, 2014, 2015; Yurtsever et al., 2018). With the growing international body of EMDR clinicians developing and working with EMDR in group format (Morrow Robinson & Kemal Kaptan, 2023) and after completing the G-TEP training, the present authors identified the potential for G-TEP to be adapted as an effective treatment for SVS, which was their main scope of individual clinical practice. The authors were drawn to the group format of the G-TEP, which is designed to be a brief intervention. In these groups, the facilitator guides participants through a worksheet, which features stabilisation, resourcing, followed by EMDR of a trauma event.

The SVS protocol is intended as a means to enhance a survivors’ trauma recovery by sitting within a broader treatment plan, such as those developed for a client accessing ACC Sensitive Claims. The protocol is adapted to treat acute disturbance over a potentially broad span of time so participants may be reprocessing recent or historic sexual violence events (Robinson et al., 2023). Like G-TEP, the SVS group protocol is also worksheet based, but it recognises the complex needs SVS often present with as a population, and provides additional stabilisation, resourcing and more focused future templating. As an early intervention model, the G-TEP to reduce or to prevent symptoms of PTSD (Flint & Elkins, 2021), whereas the SVS group protocol aims to relieve the acute distress of existing or ongoing PTSD symptoms, and support trauma recovery where participants may have been suffering from the impacts for a significant span of time, often years.

While the G-TEP was initially developed as a standalone single-session intervention including stabilisation and reprocessing (E. Shapiro, 2023; F. Shapiro, 2018), the SVS group protocol is a six-session programme over two parts. Part One of the programme consists of three sessions. Session One is focused on welcoming and orienting participants to the therapy space, other group participants and facilitators, thereby promoting a foundation of safety and therapeutic relationships. This session includes stabilisation and resourcing, initial triaging of participants’ capacity to make use of the EMDR group intervention and preparation for the rest of the programme. Sessions Two and Three include stabilisation and trauma reprocessing. Part Two of the programme begins with two trauma reprocessing sessions, then finishes with a future-focused resourcing session and the opportunity for participants to reflect on their journey in the group. Participants choose whether to engage in subsequent groups, with approximately half of all participants returning for multiple groups (Robinson et al., 2023).

This future-focused session is distinct to the SVS protocol because it includes an additional worksheet that is solely focused on installing future templates and resourcing participants for the future (Robinson et al., 2023). These future templates include participants handling life challenges or triggers more effectively, identifying and strengthening their existing resources and identifying and letting go of maladaptive coping strategies, while also drawing on the positive resources of other group members. Similar to individual EMDR therapy, this session recognises that individuals have developed coping strategies that have helped them survive during and post trauma, but that once they have reprocessed the trauma, new adaptive, more ‘healthy’ coping strategies can be developed. The authors noticed that there were additional benefits to participants engaging in this future planning process in a group setting. Connecting with and being inspired by others who have also experienced trauma appeared to assist in helping participants achieve autonomy from the trauma; for example, recognition that ‘the trauma is not who I am’ (Robinson et al., 2023). The authors observed that this session was often filled with hopefulness and positivity while simultaneously providing a collective opportunity of shared grief.

Reflections on the Benefits of the SVS Group Protocol

Over the last 3 years of running SVS groups, through reflective clinical practice and collection of qualitative and quantitative data, the authors have observed a raft of benefits beyond their initial aim of reducing waiting lists for ACC clients to access EMDR therapy.

Trauma Desensitisation

As with individual EMDR therapy, one of the main aims is to reduce acute disturbance from a trauma event. Because of the specific challenges experienced by SVS, including heightened propensity for dissociation, particularly in group settings requiring some level of interpersonal emotional intimacy (Robinson et al., 2023), the authors were initially cautious around their expectation of participants reducing their disturbance levels or subjective units of disturbance (SUDs). Being the first to provide an adaptation of G-TEP for this population in Aotearoa New Zealand and with limited international research available for EMDR group work with this population, the authors hypothesised that participants would reduce their disturbance levels by one or two SUDs after one group session (Robinson et al., 2023). However, as the evidence suggests individual EMDR therapy for this population (Edmond, 2004; Schwarz et al., 2019), the authors were excited to observe that group participants frequently reprocessed sexual violence trauma events to 0 SUDs (no disturbance) and were often able to reprocess more than one event across one or more groups. These results were a key indicator of the efficacy of EMDR group therapy for this population.

A Gentle Way to Work With Shame

The whakamā or shame associated with sexual violence can be a trauma itself (Matos & Pinto-Gouveia, 2010) and is often deeply isolating and difficult to put into words, even in the most trusted therapeutic relationship. The authors observed that SVS EMDR group therapy provided a safe context for participants to gently approach and begin to shift this shame (Robinson et al., 2023). Because a key aspect of SVS groups is not sharing trauma event details, the authors observed that participants could individually and confidentially reprocess trauma events safely within a group setting. The authors hypothesised that the power to gently begin to shift shame lay in the dual process of collective healing as a group from the shared experience of trauma, while giving each participant individual confidentiality at the same time; visibility as a survivor and privacy from the details of the trauma. One participant shared, 'The lack of needing to speak out loud in depth about my story was a great benefit. Mostly the processing is an inside job’ (Robinson et al., 2023).

Safety in Sharing

Reciprocity and safe sharing was an observed benefit of the group, whereby participants identify connections and similarities; learning from and sharing with others. Each SVS group is clearly contracted, structured and predictable, providing the therapeutic frame for safe sharing. This emerged as an integral component of the overall programme, with the script adapted to ensure facilitators have a clear structure to follow. This provides containment and clear timeframes for specific components of each session, particularly the more process-oriented future-focused session. The authors observed that sharing as a facilitated and time-structured process could help prevent retraumatising information being shared and encouraged positive resourcing among participants. One participant noted, ‘I enjoyed the opportunity to share positive experiences with the others in the room, and felt the shared humanness of us all by doing so, when listening to everyone else’ (Robinson et al., 2023).

Measurable Recovery

From the outset of developing the SVS groups, the authors set out to collect data, such as the PTSD Checklist for DSM-5 for PTSD symptoms before and 3-months post-group programme. They collected participants’ SUDs before and after each reprocessing session and measured their validity of cognition, or how believable their positive cognition about the ‘self’ changed over the course of each future-focused session. However, from their clinical perspective, it soon became apparent that the richest data were in the qualitative outcomes and feedback from questionnaires post-group, some of which are woven throughout this article.

Parallel to the clinicians measuring and collecting recovery data, participants also engaged in this process via the worksheets. The worksheets provided a visual journal and qualitative evidence for participants to notice their reduction in SUDs, and provided a resource to keep and take into their individual therapy sessions, if they chose to. This process aided integration of the group work as an adjunct to individual therapy. A participant shared, 'I like the structure of the worksheets, both working with them on the day and to keep as a visual diary of my journey. The drawings likewise, had a coherence to them that somehow made my memories more accessible to work with and they acted as a kind of confirmation of my story’ (Robinson et al., 2023).

The authors have continued to collect qualitative and quantitative data to inform their clinical practice and ongoing development of the SVS protocol. As more G-TEP groups have been established in Aotearoa New Zealand over the last year, the authors strongly encourage other EMDR group therapy clinicians to engage in further research to grow this expertise and increase the resource of evidence-based practice.

The Power of Connectivity

Over the course of running the SVS groups, the authors were struck by the power of connectivity in the group process. Witnessing the interactions between group participants, and from the feedback participants shared with facilitators and each other, the authors discovered that each session not only strengthened a participant’s individual resources, but became a shared exercise in connectivity with the other group participants. Together they shared in the strengths of being survivors, shifting and shedding the shame and isolation of being a victim of sexual violence. As one participant noted, 'I’ve realised I am not alone in my struggles—abuse can be very isolating in its effects, and had been for me, until recently’ (Robinson et al., 2023). More than one participant has used the term ‘trauma midwives’ to describe their experience of the facilitators helping them to breathe and move through their trauma reprocessing together, alongside their experience of co-regulating with other participants, often moving in synchronicity with their pacing of eye-movement timing, sharing in breathing, processing their trauma privately yet together.

Benefits for Individual Therapists

Feedback from ACC lead providers (the individual therapists contracting to provide ACC therapy) indicated that the SVS groups had a range of benefits for their clients, including bringing a multidisciplinary component to a population that frequently presents as complex (Robinson et al., 2023). One lead provider shared, ‘As a therapist I feel ok that I cannot be “all things to all people” and that having additional help from other professionals (when dealing with trauma) is positive in that it can give the client an opportunity to explore alternatives outside of “talking therapy”’.

Individual therapists have reported that another benefit of an SVS EMDR therapy group lay within the middle stages of long-term therapy, where the therapy can become ‘stuck’ or side tracked by responding to crisis or everyday life stressors. For example, one shared, ‘The group has been helpful in a sense that my client can focus on one aspect of their trauma, do the work, gain insight that may not have otherwise come from individual therapy and then bring their experience back into the room for us to explore and process further’. Another shared, ‘I feel the option of the group is a valuable tool for both myself and the client’.

Integrating EMDR Group Therapy into a Treatment Plan

SVS EMDR group therapy is based on the ethos that the therapeutic relationship is an essential component of trauma recovery, and recognises secure attachment as a source of co-regulation of emotions, behaviour and physiology (Maté, 2019; Parnell, 2013; Wallin, 2007) and that a participant’s individual therapy provides a secure relational foundation from which to launch safely into group-based trauma reprocessing (Robinson et al., 2023). The authors proposed that for survivors with historical, chronic impacts of trauma, SVS EMDR group therapy is most beneficially integrated into a client’s treatment once they are on the path of learning to develop trust and security within their therapeutic relationship, which is a reparative experience of relationship (Parnell, 2013). This capacity to begin learning to trust again can provide an indicator that clients can also feel safe enough to remain in their window of tolerance and make use of the group as a relationally reparative therapeutic intervention (Robinson et al., 2023). The timing of each referral is therefore an important consideration, which is guided by the client and their individual therapist’s clinical assessment of their capacity to engage in both their individual and group-based therapy. The authors’ screening process was a risk and safety questionnaire integrated into the registration form, and the first session in Part One of the programme simultaneously functions as a triage session.

Early Stage of Trauma Therapy

Survivors who have experienced a recent single trauma event and have a therapist not trained in EMDR may find that attending EMDR group therapy early on in their treatment can assist in reprocessing this trauma, thereby reducing the amount of time they require in treatment. Desensitising the trauma in a contained, titrated manner using the group setting may serve to increase confidence in their capacity to process trauma, and help to accelerate their individual work. This may also increase the therapist’s availability for new clients.

Middle Stage of Trauma Therapy

From the authors’ clinical experience in working with longer-term clients who have experienced complex trauma, therapists and clients can at times feel stuck, held hostage by the daily or weekly crisis that can take over therapy sessions. Naturally at this stage of trauma therapy, with the survivor’s attachment system fully activated within the therapeutic relationship, treatment planning and trauma processing can also become put aside, as the relational reparation, attachment trauma work unfolds (Parnell, 2013). EMDR group therapy can provide a solution to these middle-stage impasses. First, it provides opportunity for a structured focus on trauma reprocessing and second, it offers the therapist space to work with the therapeutic focus on attachment trauma and daily life challenges, while the treatment for the sexual violence trauma event continues.

Later Stage of Trauma Therapy

The authors observed that a referral to an SVS EMDR group at a later therapy stage can be beneficial when the survivor is ready to take a step beyond individual trauma therapy towards new ways of relating to themselves and others; perhaps getting ready to begin life without therapy. Trauma therapy is a unique recovery pathway, which can be a lonely, deeply personal process. Participating in an SVS EMDR group can provide an opportunity for survivors to begin to see themselves in relation to others, beyond their trauma experiences. Group work can increase a survivor’s confidence in relating with others and to embark on their next stage of life without therapy, having experienced a collective sense of belonging and survivorship. As one participant noted, 'Changing my attitudes and core beliefs somehow became possible during this period of my life in a way I hadn’t been able to achieve before. Losing the victim script has made the most profound difference’ (Robinson et al., 2023).

As is well documented in group therapy literature, participants at the later stage of treatment can experience a measurable sense of how far they have come in their recovery and offer inspiration for participants who are at an earlier stage of their trauma treatment (Robinson & Pond, 2019). Having participants at a range of therapeutic stages provides evidence and hope of recovery for participants who may feel disheartened, or hopeless about their capacity to heal from the overwhelming and often insidious impacts of trauma.

Cultural Considerations and Implications

The authors recognise that for group work to be safe, clinical practice requires mindfulness that interpersonal relationships, group culture and group context is a microsystem that sits within a broader system, ‘influenced by the state of race relations in the larger society’ (Sue et al., 1992, p. 479). The authors are mindful of Aotearoa New Zealand’s traumatic violent colonial history and the devastating impacts of colonisation which continue to privilege Pākehā (Addy, 2008; Ngata, 2019). Providing trauma treatment within a system and broader context that continues to traumatise Māori requires careful navigation (Ngata, 2019). The authors’ positioning as Pākehā (Addy, 2008) has several implications for their clinical practice with SVS groups in Aotearoa New Zealand. This includes making a commitment to an ongoing, unfolding process of vulnerability, challenge and growth, while maintaining authenticity, equity and efficacy within the bicultural therapeutic relationship (Addy, 2008; Crocket, 2010). The foundation for safe bicultural practice in an SVS group begins with facilitators having the capacity to sit with discomfort, work with impasse, engage in difficult conversations and remain in relationships with each participant and the group as an entity.

When developing the SVS protocol, the authors realised that many of the elements can be referenced to Māori values. For example, the notion of groups working collaboratively to thrive means that one person’s recovery positively affects the whānau, and therefore the wider system as a whole (Durie, 2003; Mead, 2016). The Māori value of whakawhanaungatanga, or strengthening ties, is embodied within the benefits of sharing within the group, the careful way relationships are negotiated and developed, (Drury, 2007; Durie, 2007) alongside shared resources and reciprocity (Thomas, 2020).

More recently, the authors have engaged in a process of seeking consultation to collaboratively translate the SVS EMDR group therapy worksheets into te reo Māori (Māori language). This evolved in response to participants who are proficient in speaking te reo Māori, and the authors observing that facilitators and participants often spontaneously wove Māori kupu (words) into group conversations. Although the authors are motivated by a desire to normalise te reo Māori in public spaces as the Indigenous, ancestral language of Aotearoa New Zealand (Te Huia, 2022) they also recognise that use of te reo Māori also sits in the realm of the colonial practices of traumatising violent oppression of te reo Māori (Te Huia, 2022) and requires respectful reflection of the varied meaning this may have for Māori participants.

The authors’ aim is to create a foundation of safety for all SVS group participants to sit within their window of tolerance to engage in trauma reprocessing. They reflect that each participant’s journey in a SVS group will be distinctly different, and assumptions create unsafe practice. The complexity of intersecting vulnerabilities (Te Wiata & Crocket, 2011) is always present, and the authors recognise that each group creates a subculture of their own. Fresh attention is required from the facilitators for each new SVS group to the intersecting vulnerabilities of each participant, whether that falls under the umbrella of bicultural, multicultural, neurodiversity or another intersecting vulnerability, to create the safe foundations for each group.

Further Research Recommendations

The authors identify a shortage of EMDR research in Aotearoa New Zealand. From a clinician’s perspective, the authors hypothesised that with the overwhelming demand for EMDR as an already evidence-based trauma therapy, clinical practice takes precedence. The authors also note that clinicians who are registered as ACC providers are predominantly working in private practice, and while the trauma treatment is funded, research or writing about clinical practice is not. This highlights a gap in funding for EMDR research, particularly for further exploration and research regarding EMDR group therapy for this population and much needed indigenisation of EMDR in Aotearoa New Zealand. The authors are hopeful that their reflections on their clinical practice with the SVS protocol contributes to this growing body of research and encourages further research on EMDR group therapy in an Aotearoa New Zealand context.

Conclusion

The pathway to recovery for SVS is not linear, nor is it a one person job. It often requires more than one practitioner, intervention and approach. In the authors’ clinical experience, SVS EMDR groups can offer benefits for sexual violence survivors at the beginning, middle and later stage of their recovery. From the authors’ experience of developing and facilitating SVS EMDR group therapy, they have observed that both SVS and clinicians can benefit from integrating group based EMDR trauma therapy into their individual treatment plan, as a multidisciplinary component and collaborative approach to trauma treatment.

Authors

Emma Sanderson and Ceit Robinson are accredited EMDR therapists, EMDR case consultants in training and co-directors of EMDR Group Therapy Aotearoa. As experienced trauma therapists passionate about trauma recovery and inspired by the positive outcomes of EMDR therapy for their clients, Emma and Ceit co-founded the Kāpiti EMDR & Therapy Centre in 2019. After training in G-TEP and motivated by their shared love of group work, Emma and Ceit began running EMDR therapy groups after securing a contract with ACC Sensitive Claims. In 2020 they co-developed the SVS EMDR group therapy protocol. Their chapter on EMDR group therapy with SVS entitled, ‘You Are Not Alone: Sexual Violence Survivors EMDR Group Protocol’, appears in EMDR Group Therapy: Emerging Principles and Protocols to Treat Trauma and Beyond, published by Springer in 2023.