EMDR FOR MINING AND RELATED TRAUMA: The Underground Trauma Protocol (UTP)
David Blore, UK Facilitator

Abtract: The author has now been providing EMDR to traumatised miners for almost seven years. As with other specialised client groups, the single trauma (STP) and recent trauma protocols (RTP), have required modifications. The author has collated the modifications made, and presented them here as 'The Underground Trauma Protocol (UTP)'. The UTP is intended to provide a rapid and effective method of conducting EMDR with traumatised miners and other similar, very specific, client groups. The author welcomes feedback on its use.


The UTP:

PRINCIPAL USE: traumatised MINERS (e.g.. coal, gold, nickel, gems etc. etc.)

OTHER USES:

traumatised TUNNELLERS (i.e.. excavation of tunnels both war and peace),
those traumatised in RAIL ACCIDENTS in tunnels (e.g.. fire in Channel Tunnel, Kings Cross tube fire),
those traumatised in UNDERGROUND LEISURE PURSUITS (e.g.. exploration of caves, 'pot holing'),
those traumatised by being TRAPPED (e.g.. in collapsed buildings as in Turkish earthquakes)

It is the author's recommendation that treatment of this client group only be undertaken by Level 2 trained clinicians 
who have experience of:
a) modifying protocols
b) existing clinical experience of using cognitive interweave

METHOD (based on traumatised miners):

IN ADDITION to Shapiro's instructions (Shapiro 1995 p89-215), cover the following points:

PHASE ONE
Did the traumatic event damage the 'integrity' of the underground environment? (i.e.. did the traumatic event damage a significant part of the underground environment such as a roof collapse or affect a component of the working environment that could affect the entire environment as in damage to ventilation/airflow?) Answer YES: Types of events: ROOF COLLAPSE/ CAVE-IN GAS BLOW-OUT (fractured pocket of gas under high compression) OIL IN-RUSH (fractured pocket of oil under high compression) EXPLOSION FIRE AIRFLOW/ MAJOR EQUIPMENT FAILURES some 'TRIPPING-OUT' INCIDENTS (e.g.. failure in situ of winding gear) Answer NO: Types of events: FATAL ACCIDENT (client in immediate proximity of fatal event) SERIOUS INJURY TO COLLEAGUE FIRST AID RESPONSIBILITIES TO COLLEAGUE (successful or otherwise) SERIOUS INJURY TO SELF DEHYDRATION WITNESS TO EXTREME ANXIETY OTHER 'PERSONAL' INCIDENTS (unless widespread such as in 'tripping out') If the answer to the above was YES then establish: How did the client become aware of the traumatic event ? (Look for increase in environmental temperature, reactions of colleagues, smells, changes in airflow etc. NOT JUST messages, Tannoy etc.) At the time, what was the client's perception of what happened ? (Distinguish between 'loss of visibility' and inability to recall events.) What was he doing at the time ? (Establish work instructions and who gave those instructions.) Where underground was the client ? (If possible obtain a sketch of the underground layout and identify the direction of airflow prior to the traumatic event. Then: Estimate how long the client had been underground and how much fluid the client consumed during the time underground. Note if the client lost track of time or was disorientated. Identify any image's) associated with 'heat'. If the answer to the above was NO then establish: Did the client personally know the individual's) involved ? What was the client's role at the time? (Issues of responsibility e.g.. first aider, safety officer etc.) What was he doing at the time ? (Establish work instructions and who gave those instructions. SPECIFICALLY were appropriate procedures being followed?) Identify the client's location underground (as in previous section). Estimate how long the client had been underground and how much fluid the client consumed during the time underground. Note if the client lost track of time or was disorientated. Identify any image's) associated with 'heat'.
PHASE TWO
FORMING A BOND WITH THE CLIENT: If at all possible familiarise yourself with the basics of mining jargon. Just as languages vary worldwide, so does jargon. If you don't understand a term, ask, - this is as much part of truth telling as what you would expect of your client.

Miners worldwide have a reputation for alcohol consumption. The author has encountered miners who consume well over 200+ units per week. They have built an enormous tolerance to alcohol. It is unrealistic in many cases to ask them to cut down on alcohol consumption prior to EMDR. However, this subject should be addressed as alcohol comes as a very natural method of 'blotting out' traumatic memories. Alcohol should not be consumed on the day of the EMDR session - I once had a miner who had convinced me he had not drunk any alcohol that day and who subsequently lost his balance whilst tracking eye movements and fell off the seat (fortunately without injury)!

NOTES ON CREATING A 'SAFE PLACE'

Safe places involving images relating to fishing, the family, open air, sunlight, gardening and holidays were the most popular amongst a group of 20+ miners treated. One miner picked being a mile underground at a colliery with a better safety record as his safe place image but this had to be replaced (!)
PHASE THREE
SELECTING A PICTURE When a picture is unavailable, Shapiro advises the clinician should invite the client to "think of the incident". An alternative and one that in the past I have used instead of locating any picture is:

"think of anything you remember about the accident that is hot (failing this substitute 'hot' with 'dark' or 'unusual size')",

(see phase one above, relating to memories associated with heat).
PHASES FOUR to SEVEN

Use Standard Trauma Protocol (STP) for all memories, OTHER THAN THOSE BELOW GROUND. For underground memories, TARGET HOTTEST MEMORIES FIRST or use Recent Trauma Protocol (RTP), STARTING WITH MEMORIES BELOW GROUND. FOR UNDERGROUND MEMORIES: Target memories of the 'actual event' in the order: associated HEAT associated DARKNESS associated DISORIENTATION / SIZE PROCESS NOTES: Some material can be gleaned from: Blore D.C., (1997). In addition the following should be useful: Memories associated with heat: Images specifically relating to damage to the integrity of the underground environment are frequently associated with a tactile sense of heat which can be very intense and distressing in itself to recall. Clinical experience seems to suggest that the heat sensation relates to increasing ambient temperature brought about by disruption to underground airflow management. This means that a major accident can, and is, communicated around the underground environment by means of methods other than direct verbal communication. In addition increase in heat can increase the risk of dehydration which can also bring about distortions to memories. Consequently miners who were underground at the time of the accident, yet who were neither in the direct vicinity of the accident nor were involved in the rescue, can easily have traumatic memories characterised by a sensation of heat. Exactly to what extent this was a problem at the time can be assessed by reviewing underground site plans which usually contain information about airflow. Memories associated with heat:

Memories associated with or consisting of smell: These can be particularly resistant memories and seem to play a large part in reactivating traumatic memories at a later date. Large quantities of disinfectant can be used (even pumped through airflow systems) to mask smells of decomposition, because rescue working conditions are already hampered by rapid decomposition because of increased temperatures and increased humidity. Unfortunately what helps to facilitate rescue working conditions at the time ends up being part of the traumatic memory repertoire that requires treatment.

Machismo, negative cognitions and cognitive interweave : Mining still has a huge machismo problem and it can hamper rapid treatment if the client feels he must identify perceived failings such as admission of certain negative cognitions. The following have been the negative cognitions most encountered clinically:

I am useless/worthless
I am weak (which is OK only if this relates to coping with emotions)
I should've coped (effectively 'I can't cope')
I should have known (effectively 'I should know')
I did.....wrong  (be careful this isn't ecological - check  whether safety
procedures were followed, in the UK information can be gleaned after
investigations via Her Majesty's Mines Inspectorate. Other countries
have equivalent systems.)
I should 'stand up' to superiors/managers
I should have done more (effectively 'I should do more')
I should have worked longer/harder (works best when in past tense)

More problematic still are the actual images themselves which can easily seem to produce evidence that the client didn't cope. Since miners are checked medically very regularly they are not going to be physically weak, but their pre-trauma beliefs are likely to be inaccurate. It is very common for miners to have given no thought whatsoever prior to an accident to the potential for disaster (e.g.. when there is a mile of rock above you) on the other hand most miners can expect injuries at some time in their working life, but generally not to the extent that they will realise their 'invulnerability' beliefs are being, or need to be, challenged.

'Anonymous' memories: Related to the previous comments is the issue of the client identifying memories which clash with perceived machismo. One way around this is to initially label memories A, B, C and so on. Although this may smack of covert avoidance to the Cognitive Behavioural amongst us, EMDR is the only psychotherapy that the author knows of that can be conducted blind to even the therapist! The author considers that it is a means to an end, if images can be readily and rapidly treated this way, there is no reason why later on some judicious cognitive therapy cannot be added to the EMDR to challenge belief structures. Shapiro frequently tells us that EMDR is not a stand alone treatment and that it should be part of an overall therapeutic programme.

Adapting SUD scales: There is no reason to stick with 'distress' as the posting to your SUD scales. Others may be more appropriate, try these:

0 = Cold memories or no sense of heat 10 = Hottest memories of all
0 = Light memories (e.g.. daylight) 10 = Very dark memories (i.e.. zero visibility)
0 = 'Normal size' and/or oriented content 10 = Very large and/or completely disorientated content

Future template:
In due course add a 'future template' relating to reassessment of RISK (this may trigger past assessment of risk) and 
REMEMBER BEING UNDERGROUND IS INHERENTLY VERY DANGEROUS, so: Successful treatment DOES NOT 
NECESSARILY mean 'successful' return to work underground. This can be a very important consideration when being 
asked (as in a medicolegal report) for an opinion as to subsequent suitability for work underground.

FINALLY
The above points have been collated from 'bitter experience' and are offered for use by appropriately trained and 
supervised clinicians. The author is willing to provide supervision for specific cases via email to any clinician 
in the world - the only request is that the language used is English!

Background


The UTP is the result of clinical experience gleaned over a period of almost seven years and has been collated by the clinician who provided those treatments. The UTP is still being modified in the light of experience. This version is dated 1.1.00. If anyone uses this protocol I would be very happy to collaborate in treatment. Please contact me on +44 7976 933096 or d.blore@virgin.net if you require further help, guidance or supervision all of which are provided to appropriately trained clinicians free of charge. Further updates to this protocol will available via either: The EMDR Practitioner: http://www.emdr-practitioner.net or EMDR Portal: http://www.emdrportal.com
References
Blore D.C., (1997) 'Reflections on "A Day when the Whole World seemed to be Darkened"', Changes International Journal of Psychology and Psychotherapy, 15(2):89-95.

Shapiro F., (1995). Eye Movement Desensitization and Reprocessing, basic principles, protocols, and procedures, New York: Guilford Press.
APPENDIX:
Reminders:
STP - 1 Memory or image of actual traumatic event
2  Flashback scene
3  Dream image or scene from most recurring nightmare,
4  Present stimuli that triggers disturbing memory.

RTP - 1  Obtain narrative history of event,
2  Target the most disturbing aspect of memory,
3  Target the remainder of narrative in chronological order,
4  Client visualises entire sequence, eyes closed, reprocess as disturbances arises,
continue (as 3) until whole sequence not distressing.
5  Repeat 4, with eyes open and install positive cognition,
6  Process present stimuli.
©2000 The EMDR Practitioner - All Rights Reserved Worldwide