Research on Low-Intensity Flash Technique Trauma Intervention by Prelicensed Student Clinicians

Military conflicts in the Middle East, Ethiopia, Somalia, and recently Ukraine, have displaced and traumatized untold millions of people, and there are simply not enough psychotherapists in the world to offer individual trauma intervention to all those who need it (Foa et al., 2013). Eye movement desensitization and reprocessing (EMDR) is a proven trauma treatment. There are EMDR-based group protocols with which one EMDR-trained therapist can, with the support of nonEMDR-trained licensed clinicians and trained support workers, provide EMDR therapy to many people (Smyth-Dent et al., 2020). However, EMDR requires substantial time and financial resources for training, which poses a barrier to mental health workers supporting those displaced and traumatized by military conflicts or those without access to conventional trauma interventions. On the other hand, the flash technique (FT) is an individual in-person protocol originally developed for the preparation phase of EMDR and only requires a few hours of training. A possible solution, therefore, may be low-intensity intervention with the FT based on highly scripted instructions in which participants can work on their issues independently, whether online or in person. Toward that end, our study aims to explore a set of scripted instructions for individual online trauma intervention, which can serve as a stepping stone toward the use of FT for low-intensity trauma interventions.

A low-intensity intervention is defined as a treatment with limited face-to-face contact with a mental health professional, such as group therapy, or treatment through self-help computer programs, books, or mental health apps (Maxfield, 2021). Maxfield also conceptualized “the EMDR group therapist as an instructor, providing scripted directions” with “the group participants working quietly and independently on their own materials” (Maxfield, 2021). Furthermore, Maxfield suggested that the same instructions could be provided (a) in a computerized format or (b) with task shifting, that is, by a nonspecialist. EMDR-based low-intensity treatments have been developed over the years to provide affordability and accessibility, and have played an important role in supporting the mental health of victims of natural and man-made disasters, such as refugees displaced by wars. However, while EMDR training is thorough, it is expensive; many mental health professionals working with vulnerable populations do not have the resources to be trained in EMDR—hence the need to find or develop lower-cost alternatives to traditional EMDR, such as low-intensity interventions.

EMDR and EMDR Groups

EMDR was first discovered by Francine Shapiro in the 1980s and was developed into an eight-phased protocol: history taking, preparation, assessment, desensitization, installation, body scan, closure, and re-evaluation (Shapiro, 2018). During EMDR, the client recalls the traumatic memory to be processed while doing bilateral stimulation such as eye movement or tapping, while being directed and supported by a trained EMDR therapist. Processing of the traumatic memory with EMDR tends to be faster than most other trauma modalities (Mavranezouli et al., 2020), and clients can even process their memories without disclosing the memories to their therapists (Blore et al., 2013). EMDR is a well-established trauma treatment modality with an extensive system of training for therapists, requiring many hours of training and practicum. Additional training may be required for additional protocols such as the Recent Traumatic Event Protocol (R-TEP) or the EMDR-Integrative Group Treatment Protocol (EMDR-IGTP).

EMDR started out as a high-intensity protocol for individual therapy but soon branched off into low-intensity work in response to natural and man-made disasters. EMDR groups were first developed by the Mexican Association for Mental Health Support in Crisis (AMAMECRISIS) team in response to an overwhelming need for mental health services after Hurricane Pauline in Mexico in 1997 (Jarero et al., 2006). This might be the first reported incidence of using EMDR as a low-intensity intervention for hundreds of children under the direction of a therapist, who was supported by a number of lay counselors and helpers. Since then, it has been formalized as EMDR-IGTP with scripted instructions (Artigas et al., 2009). Recently, EMDR-IGTP has been adapted to treat people with recent, present, or past prolonged adverse experiences, such as long-lasting or ongoing traumatic stress (e.g., patients with cancer; Jarero et al., 2016, 2018). This adaptation is known as the EMDR-Integrative Group Treatment Protocol-Ongoing Traumatic Stress (EMDR-IGTP-OTS). Jarero et al. (2013) have also developed the EMDR-PROPARA, an adaptation for paraprofessional use of the EMDR Protocol for Recent Critical Incidents (Jarero et al., 2011). EMDR-IGTP has a long history of supporting victims of natural disasters and refugees (Adúriz et al., 2009; Jarero & Artigas, 2012; Jarero et al., 2008; Karadag & Karadeniz, 2020; Trentini et al., 2018). Currently, it is being used to support people traumatized and displaced by violence and military conflict in Ethiopia (Abebe & Ashman, 2022).

Another proven low-intensity EMDR intervention is the Group-TEP (G-TEP) which is an adaptation of E. Shapiro’s Recent Traumatic Episode Protocol (R-TEP) (Shapiro & Laub, 2014). The G-TEP (Shapiro & Moench, 2018) is similar to the EMDR-IGTP in its use of drawings and scripted instructions but distinguishes itself with its extensive use of grounding and containment, as well as the use of a worksheet. The G-TEP has been used for trauma recovery for victims of man-made and natural disasters, such as refugees from the Middle East (Yurtsever et al., 2018) as well as victims of the Camp Fire in Northern California (Hignell, 2019).

Methods

In our study, we explored the use of the FT as a low-intensity trauma intervention administered by social work graduate students at California State University. Our goal was to explore two areas that are important for low-intensity FT intervention. We wanted to explore whether a scripted protocol can be used repeatedly and effectively for individuals with the Impact of Event Scale—Revised (IES-R) scores of 24 or more, which may indicate significant posttraumatic stress disorder (PTSD) symptoms. Secondly, we wanted to explore whether FT intervention can be delivered one-on-one online by student clinicians with minimal experience using the script, thus demonstrating effective task shifting.

Results

Discussion

According to the National Alliance on Mental Illness (NAMI), 3.6% of the U.S. population is affected by PTSD, which amounts to 9 million individuals (NAMI, 2017). Thus, the need for low-cost, low-intensity trauma intervention is needed both in the United States and globally (Kessler et al., 2017). For our study, we used the IES-R as the screening tool for PTSD symptoms. However, the IES-R was developed for the DSM-IV. It captures the PTSD symptoms of intrusion, avoidance, and hyperarousal but does not capture symptoms of negative cognition and alteration in mood, which are mentioned in the DSM-V. The PTSD Checklist for DSM-5 (PCL-5), which was developed for the DSM-V, would be a better choice for capturing changes in PTSD symptoms, and we recognize this drawback in our study. Nonetheless, changes in the IES-R score still track with the majority of the PTSD symptoms and provided us with information about the efficacy of our scripted protocol, as practiced by our student clinicians.

From our data, the ranges of IES-R scores dropped from a pretreatment range of 24–74 (mean of 45.97) to a posttreatment range of 3–59 (mean of 25.33), suggesting that even the clients with the highest scores in the group may have been helped by this scripted FT protocol, and resulted in improvements in their PTSD symptoms/scores. As an aside, a study from Japan (Kawamura et al., 2001) has shown that an IES-R score of 37 may result in suppression of the immune system’s function even 10 years after a traumatic event. Thus, a drop in the mean IES-R score for the group from 45.97 (pretreatment) to 25.33 (posttreatment) may result in substantial health benefits for the participants. This study on the suppression of the immune system’s functioning was based on a small group of 12 male workers with matching controls from a company in Japan and might be applicable to the general population. Moreover, we also note that for 14 participants, their IES-R score dropped to a level between 0–23, lower than the threshold for admission into the study program. Furthermore, with only 6 sessions of FT by this group of 9 prelicensed student clinicians, we have only 8 people in this group of 30 with an IES-R score of more than 33 at the conclusion of treatment, as compared to 23 people at the start of the program. However, these results must be interpreted with caution given the small sample size, lack of a control group, and other study limitations such as lack of follow-up after the end of treatment.

It should be reiterated that the goal of low-intensity intervention is not necessarily to reduce the emotional disturbance of a particular memory to zero. Rather, it is the reduction of PTSD symptoms, as self-reported in the pre- and postIES-R surveys. The protocol offered clients the opportunity to work on up to six different distressing memories with FT. With the assumption that clients were using their most distressing memories in the pre- and posttreatment surveys, it was possible that the most distressing memory at posttreatment would be different from the most distressing memory at pretreatment. Hopefully, the level of emotional disturbance of the most distressing pretreatment memory would be reduced during the six sessions of FT treatment. However, these are broad assumptions, more research into the memories participants choose to address via FT, and the reduction in their experienced distress from such memories is needed.

Furthermore, the results of this study suggest that scripted FT intervention was user-friendly enough that even inexperienced MSW student therapists could use it effectively with individuals with significant PTSD symptoms. These study results may, thus, pave the way to address the growing concern about the effects of traumatic experiences on mental health worldwide. However, there are significant barriers to mental health services, and trauma-informed treatments are not easily available to trauma survivors (Kazlauskas, 2017). The potential of alternative means of treatment delivery (including virtual) along with implementing task shifting with less experienced clinicians has been proposed as directions for future developments in the field of trauma treatment (Kazlauskas, 2017; Maxfield, 2021). Our study provides some initial results for both of these proposals. Larger scale studies, including RCTs and studies that explore whether or not the impacts of the intervention hold over time, are needed to explore the efficacy of the FT when delivered virtually by low-experience clinicians. Given our study results, future research should also explore these methods (low-intensity FT with task shifting) via a group modality delivered via both online and in-person locales.

It should be emphasized that our PEF—using slow breathing and body scan—is one of many PEFs that can be used in FT. This PEF does not use positive memories, videos, music, and so forth and can be used in situations where personal electronics are unavailable and for people with few good memories. Other PEFs—such as counting prime numbers or counting numbers forwards or backwards—may possibly be effective in such situations as well. Future research should assess the impact of FT with a variety of PEFs when delivered virtually and with task shifting.

We also want to emphasize that the protocol was meant for inexperienced student clinicians. Our protocol uses FT as the key component for the reduction of emotional disturbance. We then add other features, such as grounding exercises and negative cognitions, not typically done in FT, to make it easier for our student clinicians to practice and to maximize the benefits to the clients.

In our protocol, we chose the PEF (scripted slow breathing and body scan) instead of the client choosing PEFs individually for themselves since the student clinicians may not have the experience to help clients with identifying PEFs. We also chose a PEF that was modified from a group protocol used successfully with substance abusers in homeless shelters and which may work well with most clients (Wong, 2019).

We borrow from EMDR-based group protocols such as the EMDR-IGTP in the target identification and the G-TEP for the grounding exercises. The “running a video” for target identification was meant to give the inexperienced student clinicians the language to help clients to identify their targets. The grounding exercises were meant to give the student clinicians the tools to keep the clients grounded so as to minimize dissociation and other forms of abreaction.

Our protocol also includes the identification of negative cognition from EMDR which is not typically done in FT, in order to maximize the reduction in emotional disturbance. The student clinicians were not trained in EMDR and therefore not expected to continue with the various phases of EMDR or to work on any negative cognitions. We also perceived the negative cognitions as different aspects of the distressing memory and could become related targets. Since FT may be able to reduce the emotional disturbance of multiple targets at the same time (Zadurian, 2021) and based on our own practice with individual clients, we believe clients might be able to work on the negative cognitions as they work on the distressing memory with FT, and clients might be better able to reduce the emotional disturbance of the memory than otherwise. More research is needed to test this idea.

With all the added features, one may question whether this protocol is an EMDR-based instead of an FT-based protocol. However, it should be noted that EMDR and other techniques, such as mindful breathing and counting numbers, rely on dual attention on both the distressing memory and the activity—be it eye movement, mindfulness breathing, or counting numbers—and the reduction in emotionality and vividness of the distressing memory can be explained in the taxing of the working memory (Van den Hout et al., 2001, 2011). On the other hand, clients do not hold on to the distressing memory during FT but would hold only onto the PEF, be it a positive experience or a calming or grounding activity, such as slow breathing and body scan. The dual attention of bilateral stimulation and focus on the PEF may tax the working memory, but the distressing memory is not part of the dual attention in FT. This is the key difference between EMDR and FT. Even with the added features borrowed from EMDR and EMDR-based group protocols, the crux of our protocol is FT, and it should not be confused with EMDR-based protocols.

In terms of a theory for the mechanism of FT, Wong (2021) proposes that due to over-activation and enhanced connectivity in certain brain structures as a result of PTSD, the client may briefly and reflexively access the distressing memory during the blinking. During that brief access, the amygdala does not have time to react. It is the juxtaposition of a brief access to a distressing memory and the amygdala staying calm (i.e., no fear response) that leads to memory reconsolidation. Wong’s model was built from published functional Magnetic Resonance Imaging (fMRI) data from subjects with PTSD as well as well-accepted working memory research dated back to the 1970s. Readers are referred to his paper for details (Wong, 2021).

Our study had a high-dropout rate, similar to other trauma research studies (Kitchiner et al., 2019; Schnurr et al., 2022). Specifically, 52 people were eligible and consented to participate in the study, but only 31 completed the full 6 sessions, a 40% dropout rate. Our dropout rate is similar to Schnurr’s study for veterans with PTSD doing prolonged exposure therapy (55.8% dropout rate, initial n = 455 with mean attendance of 8.2 out of 12 sessions) and cognitive processing therapy (46.6% dropout initial rate, initial n = 461 with mean attendance of 9.1 out of 12 sessions). It should be noted that our study was done online in the 2021–2022 academic year, during the COVID-19 pandemic, while the Schnurr study was completed before the pandemic, by February 2019, and in person. The intention was for the MSW student clinicians to complete six sessions with up to six research participants. In the end, the MSW student clinicians completed six sessions with an average of 3.5 research participants. Furthermore, we also asked our clients for permission to record two online sessions, with the provison that they were not obligated to consent to the recording. The request for recording seemed to pose a barrier, and anecdotally, a number of clients balked at the request and dropped out without starting the program, even though consent to record was not a requirement for study participation. FT is a gentle protocol in which clients do not have to dwell on their disturbing memory, and it has been well-received by clients, see for example Brouwers et al. (2021). The high dropout rate of this study might not be due to the tolerability of FT itself but due to (a) the inexperience of the student clinicians, (b) the online delivery of the protocol during the COVID-19 pandemic, and (c) restrictions and requirements of the research methodology. Further research is needed to explore participant dropout.

Conclusion

This study aimed to explore whether or not a low-intensity FT intervention based on highly scripted instructions, in which participants can work on their issues individually, can be effectively delivered by MSW student clinicians. Furthermore, this study explored the possible impact of such an FT intervention on the traumatic and distressing symptoms of community-dwelling adults impacted by traumatic memories.

We have made significant progress in developing FT as a low-intensity trauma intervention. We have demonstrated that a script with a PEF based on slow breathing and body scan has the potential to be used reliably over at least six sessions. The script does not use positive memories or engaging videos as the PEF and thus may be useful for those with few positive memories, or folks unable to access positive memories untainted by their trauma, or in situations where personal electronics and/or the internet are not available. We were able to train a group of nine prelicensed master-level student clinicians on this script for trauma intervention. In turn, this group of student clinicians was able to demonstrate task shifting, that is, that trauma intervention can likely be provided by less-trained student clinicians in lieu of well-trained licensed therapists. Furthermore, using this scripted instruction, the student clinicians were able to help 30 clients reduce their PTSD symptoms with a large effect size. While the student clinicians in this study were not leading groups, we now have scripted instructions that could potentially be administered by student clinicians in low-intensity trauma intervention groups to bring FT to those who may not have the resources for individual trauma therapy.

Disclosure.

The authors have no relevant financial interest or affiliations with any commercial interests related to the subjects discussed within this article.

Acknowledgments.

We would like to thank Sophia Aguilera, Edgar De La Cruz, Gin Hansson, Mauna Minagar, Lena Ringstrom, Ana Ruiz Hernandez, Steph Stone, Andrea Sullivan, and Lainey Witt for their assistance with this research project and the provision of the flash technique. Special thanks to California State University, East Bay who supported this research with Faculty Support Grant funding.

Funding.

The authors received no specific grant or financial support for the research, authorship, or publication of this article.