Frontliners narratives: qualitative insights into EMDR group therapy during COVID-19

ABSTRACT

Background: The COVID-19 pandemic raised unprecedented challenges for frontline healthcare workers and emergency volunteers, leading to significant psychological distress. To address these issues, EMDR-IGTP (Eye Movement Desensitization and Reprocessing-Integrative Group Treatment Protocol) was proposed as a trauma-focused group intervention. Although its efficacy is widely documented, little is known, from a qualitative perspective, about the experiences of frontliners who underwent this treatment during the pandemic.

Objective: This study aimed to investigate the experiences of frontline professionals and volunteers who underwent EMDR-IGTP during the first wave of the pandemic, to improve psychotherapists’ knowledge and skills in managing the psychological processes activated during treatment. Method: A qualitative study was conducted within the Emergency Psychology Programme of a northern Italian Health Authority. Semi-structured interviews were performed with 20 frontline workers who had attended EMDR-IGTP sessions. Reflexive thematic analysis was employed to identify patterns and insights from participants’ narratives.

Results: Two overarching themes: (1) the participants’ experiential journey through EMDR-IGTP, encompassing dealing with an unfamiliar treatment and with multifaceted reactions to adverse bodily sensations, be wondered of floating between the present and the past, achieving relief after going through complex reactions and searching for meanings for the lack of benefit; and (2) insights into intervention components, namely psychoeducation, the ‘butterfly hugging’ technique, and the group as both a safe container and a challenging context.

Conclusions: Our findings offer insights for psychotherapists conducting group EMDR in emergency contexts. Psychoeducation and linking EMDR techniques to their theoretical underpinnings can help recipients fully benefit from the intervention. Adequate time should be reserved to create a safe environment and to evaluate how single receivers ‘inhabit’ the group. Future research should address the longer-term impact of group EMDR through longitudinal follow-up of recipients, as well as participant characteristics that shape engagement with EMDR in the group setting.

HIGHLIGHTS

• EMDR-IGTP facilitated emotional relief and trauma processing in frontline healthcare workers.

• Psychoeducation on trauma and EMDR mechanisms was crucial for treatment acceptance.

• Participants appreciated the group as a safe space, despite individual differences.

• Challenges included initial skepticism, emotional resistance, and difficulty interacting with others in the group.

• Insights underscore the need for personalised approaches and the importance of assessing who can benefit from this type of intervention.

1. Introduction

As the pandemic unfolded rapidly, frontline workers in healthcare found themselves thrust into immediate action. Despite having a limited understanding of the intricacies and contagion of the pandemic, these frontline workers faced significant challenges while simultaneously managing their health risks and navigating a profound sense of uncertainty (Das et al., 2021). Confronting and grappling with the unfamiliar triggered their psychological, social, and emotional turmoil (Xu et al., 2021). This shaped their fear of being infected and, in turn, infecting others (Ramanathan et al., 2020). Also, frontline workers faced sudden changes in their responsibilities and workload; this was compounded by the stress of working in proximity to the risk of mortality (Billings et al., 2021). As reported in the literature, the experiences they went through were so traumatic that professionals felt they were ‘working in a war zone’ (Baldwin & George, 2021). Being continually exposed to the trauma of others has increased frontliners’ risk of developing vicarious trauma, a psychological and emotional phenomenon resulting from repeated and prolonged exposure to distressing narratives or images of trauma survivors. Symptoms of vicarious trauma may include intrusive thoughts, emotional numbing, increased arousal, and a shift in fundamental beliefs about safety, trust, and the world (McCann & Pearlman, 1990). Many frontliners began manifesting intrusive thoughts, avoidance, increased arousal, and, more generally, an impairment of the individual’s functioning, as typically observed after traumatic experiences in post-traumatic stress disorder (Figley, 1995; Foli et al., 2021).

As the stressogenic framework due to the pandemic increased the risk of developing medium- and long-term psychological distress in frontliners, some healthcare organisations developed support programmes aimed at both preventing and managing traumatic stress, anxiety, and depression symptoms and post-traumatic stress disorder (PTSD) in this population (Du et al., 2020; Laï et al., 2020).

Within the realm of trauma-focused psychological support grounded in empirical evidence, an example of such an approach is Eye Movement Desensitization and Reprocessing (EMDR) (Solomon & Shapiro, 1997). EMDR stands as a firmly established psychotherapeutic method for reinstating emotional regulation in cases of trauma-related psychological symptoms (Chen et al., 2018; Novo Navarro et al., 2018). It employs alternating bilateral stimulation, like horizontal saccadic eye movements or other left/right alternating stimulation, to address symptoms stemming from traumatic experiences (Pagani et al., 2012). Although its use is well established with PTSD patients, its potential value as a preventative intervention for individuals exposed to trauma but not formally diagnosed with PTSD has only recently been documented. Belvedere et al. (2023) reported that early group EMDR interventions with healthcare workers during the COVID-19 emergency helped reduce acute stress symptoms and maintained positive effects over time, potentially mitigating the risk of developing chronic PTSD (Belvedere et al., 2023). Similarly, Sanz et al. (2024) emphasised the importance of integrating group interventions, including EMDR, into institutional prevention and well-being programmes for healthcare workers to reduce psychological distress and prevent the onset of long-term mental health conditions in a recent systematic review (Sanz et al., 2024).

Amid emergency scenarios wherein the requirement for psychological aid from the public escalated incessantly, the idea of accommodating the needs of several individuals concurrently emerged as a necessity. This led to the conception of the EMDR  – Integrative Group Treatment Protocol (EMDR-IGTP) (Jarero & Artigas, 2014), a variation of EMDR therapy aimed explicitly at victims and frontliners. Evidence from the literature shows that EMDR-IGTP is an effective practice, both in traditional in-person and online (Jarero & Artigas, 2014) settings.

Research on the employment of EMDR group therapy with healthcare frontliners during the pandemic is poor. It includes only observational studies with before-and-after evaluations.

Fogliato and colleagues’ study assesses the usefulness of EMDR-IGTP, conducted face-to-face, on healthcare professionals who worked in hospitals during the first and second waves of the pandemic (Fogliato et al., 2022). The study observes positive changes over time despite prolonged exposure to emergencies and the potential for re-traumatization during subsequent waves. The study by Faretta and colleagues, conducted in a nursing home in Italy, shows the feasibility of an adapted version of group EMDR for online use and the effect of the online group intervention on the perceived symptoms of PTSD in participants (Faretta et al., 2022). Overall, evidence concerning EMDR group therapy is summarised in the systematic review of Kaptan and colleagues, which explores the existing literature on group protocols, including EMDR-IGTP, EMDR Group Traumatic Episode Protocol (GTEP), EMDR Integrative Group Treatment Protocol for Ongoing Traumatic Stress, and EMDR Group Protocol with Children (Kaptan et al., 2021). Findings from this review, which utilises standardised outcome measures and quantitative data, suggest that group EMDR protocols may be effective in improving a wide range of mental health outcomes, including PTSD, depression, and anxiety.

As far as we know, no qualitative study has been published exploring the lived experience of healthcare frontliners treated with EMDR group therapy during the pandemic. Capturing the narratives and reflections of this population could shed light on a crucial yet underexplored area within the broader context of psychotherapeutic interventions during the challenging times of the COVID-19 pandemic.

This study aimed to explore the personal experience of frontline healthcare professionals and emergency volunteers who received the EMDR-IGTP intervention during the initial wave of the pandemic.

Looking into this aspect through the participants’ perspective can provide both psychotherapists and stakeholders with information about what happens when participants receive treatment at its various steps. It can also enhance our understanding of participants’ perspectives on the mechanisms of action underlying the efficacy of EMDR-IGTP interventions. Furthermore, a deep understanding of the meanings emerging from the experience of receiving EMDR can increase psychotherapists’ awareness of the specific psychological processes activated during treatment, making them more confident in proposing and conducting EMDR group interventions.

2. Methods

2.1. Study design and research question

We conducted a qualitative study through semi-structured interviews (Pope, 2000) stemming from the following research question: ‘What is the experience of frontline healthcare professionals and emergency volunteers joining EMDR-IGTP sessions during the first pandemic wave?’. The qualitative design of this study enabled us to capture distinctive, first-hand viewpoints that cannot be discerned through standardised questionnaires and scales. We reported this study according to the COnsolidated criteria for REporting Qualitative research (COREQ) (Tong et al., 2007).

2.2. Research setting

The study was conducted within the Emergency Psychology Programme of the provincial health authority in Reggio Emilia, northern Italy, which comprises a central hub and five satellite hospitals. This permanent Programme was initially established in 2017 to help patients, families, and healthcare professionals deal with the psychological consequences of sudden and unexpected traumatic events through EMDR. The Programme is carried out by staff comprising five psychotherapists with advanced training in EMDR (IG, ER, GR, SDL, SF), coordinated by a psychotherapist expert in both EMDR and Emergency Psychology (LT).

Since the onset of the COVID-19 pandemic, the Programme has continuously prioritised supporting all stakeholders involved in delivering and receiving care. This includes individuals severely affected by COVID-19, their families, healthcare professionals, and volunteers to address the psychological impact of this unprecedented and unforeseen emergency. To achieve this, two distinct projects were implemented. The first project involved the provision of online individual EMDR sessions to patients and relatives experiencing significant psychological distress related to COVID-19. Patients received these interventions either during their hospital admission or after discharge, while relatives were also eligible for treatment during the bereavement phase. Healthcare professionals made referrals to the staff psychotherapists from teams operating across the six hospitals within the local health authority. The second project focused on delivering EMDR sessions in group formats to frontline workers. These sessions targeted staff from different wards or specific healthcare teams. The modality of these sessions, whether online or in person, was determined by the preferences of the participants and the availability of adequately spacious and well-ventilated venues. Based on their psychological needs, as assessed by the psychotherapists administering the IGTP treatment, participants could also receive individual EMDR sessions. Information about this project was disseminated to department heads and published on the provincial health authority's website.

2.3. The EMDR-IGTP intervention

LT and IG delivered the intervention in person to frontliners engaged in pandemic care after the end of the first lockdown, between June and September 2020, in three distinct hospital facilities of the provincial Health Authority.

EMDR-IGPT consisted of four weekly sessions attended by 8–12 participants. The first session comprised the delivery of the Critical Incident Stress Orientation (CISO), a structured approach developed to address the psychological impact of traumatic events (Maslovaric, 2020). A symptom framework was provided to participants, showing typical and common reactions to post-traumatic stress; moreover, the psychotherapists equipped participants with advice and suggestions on emotional self-protection strategies and explained the EMDR-IGTP treatment in detail. At the beginning of the second session, participants were invited to create a ‘Safe Place’ by envisioning a location or experience that induced feelings of peace, safety or pleasantness. This session, as well as the following ones, was focused on the processing of traumatic memories from the pandemic according to a structured schedule closely used by the psychotherapists as a guide. The steps involved in processing such traumatic memories are outlined in Table 1.

Table 1.

Steps shaping the processing of traumatic memories within the EMDR-IGTP protocol (sessions 2–4).

1. Recollection of a traumatic memory image
Participants were guided by the psychotherapist to focus individually on their traumatic memory without sharing it with others. The psychotherapist helped participants to recall the most distressing image associated with the selected memory. Participants were then asked to use graphic representation to express their emotions and physical sensations on paper, and to rate their subjective discomfort level on a 0–10 point scale.
2. Bilateral stimulation
Focusing on what they had represented on paper, participants were invited to apply the self-administered bilateral stimulation named ‘butterfly hugging’. This technique consists of crossing the arms over the chest and tapping the hands alternately on the upper arms or shoulders, imitating the flapping of butterfly wings. Then, they were asked to recall the initial traumatic memory, to re-create it again on paper and to rate their discomfort level referred to the current representation on a 0–10 point scale. This step was repeated three or four times, depending on the psychotherapist’s judgement.
3. Assessment of the experience
The psychotherapist asked about the desire of each participant to bring their own experience to the group, and provided the group with comments and input on what had been disclosed.
4. Closing of the session
Participants were invited to represent on paper their safe place or any positive input that emerged during the abovementioned steps.

2.4. Sampling and data collection

We performed a purposive sampling of the total population (Morse, 1991, 1995; Patton, 1990; Trotter, 2012), including participants we considered as key informants, meeting the following criteria: (i) being healthcare professionals or emergency volunteers; (ii) working in frontline COVID-19 services during the initial wave of the pandemic period; (iii) having participated in at least three EMDR-IGTP sessions and (iv) having provided the researchers with their informed consent to participate in the study. During the protocol phase, we intended to reach out to all participants in the programme (24 at the time of the study). Two EMDR psychotherapists from the research group (LT and IG) contacted potential eligible participants by phone, explaining the study’s objectives and procedures, the approximate time needed to complete the interview, risks and benefits related to participation, and requesting voluntary consent. Frontliners who agreed to participate in the study were contacted by another research group member (MEDC) to organise the interviews.

MEDC conducted all interviews in the presence of an independent observer (either EZ, a psychologist, or LR, a psychology student), who documented non-verbal communication. This approach enabled a more nuanced interpretation of the interview transcripts. Both the interviewer and the observer had no prior knowledge of the participants. MEDC followed a flexible pre-planned semi-structured interview topic guide, with open-ended questions developed by the researchers (Table 2). At the end of the interview, socio-demographic information was collected. Interviews were performed between June 2020 and January 2021.

Table 2.

Semi-structured interview guide.

Interview sections	Guiding questions
Opening	• Thanks for being here. Do you have any questions or doubts about the aims of the study? • Could you tell me what your thoughts were when you were asked to participate in this study?
Topic area 1: experience with the pandemic	• Could you tell me how you experienced the pandemic as a healthcare professional/volunteer? • Could you tell me about the events that you found most significant?/I would like you tell me about the events you found most significant. • How did you feel? • What were your thoughts following these events? • How did you find out about the support from the Emergency Psychology Programme addressed to frontline workers? • Can you tell me when you decided/chose to contact them? • What did you think? • How did you feel?
Topic area 2: experience with the EMDR-IGTP Intervention	• I would like you to tell me how the sessions went … • How did you feel? • Could you tell me what impressed you most?
Topic area 3: feedback relating to intervention characteristics	• What do you think now about the reasons that led you to participate in the EMDR support programme? • How did you feel afterwards? • What aspects did you like the most? • Which aspects did you like the least? • Could you provide an example? • Would you recommend the programme to others? To whom specifically?
Closing	• Thanks again for taking part in this interview. Are there any further thoughts, examples or comments you want to share? • Is there anything else you would like to tell me at the end of this interview? • May we contact you again if we need further information?

Following each interview, the interviewer and observers participated in debriefing sessions to discuss the interviewees’ key points and the interaction’s overall dynamics. Shortly thereafter, all interviews were transcribed verbatim.

2.5. Data analysis

Interviews were analyzed using Braun and Clarke’s (2020, 2021a) reflexive thematic data analysis. Initially, LT, EZ, ER, LG, SDL and MEDC independently read and re-read all interview transcripts to become thoroughly familiar with the collected data. Subsequently, LT, EZ, ER, and MEDC generated initial codes and organised relevant data extracts under each potential theme. Comparisons were made across transcripts to identify patterns, resulting in the preliminary reporting of the data’s content and the development of initial themes and sub-themes. LG, SDL, and ER then reviewed the proposed themes and sub-themes, refining them to ensure internal consistency, coherence, and clear distinctions between categories. All researchers collaboratively examined the themes, reaching a consensus on their ability to reflect the data accurately. Finally, SDL and ER prepared the final report.

2.6. Rigour and reflexivity

The 15-point Checklist of Criteria for Good Thematic Analysis suggested by Braun and Clarke (2006) guided the researchers in conducting the study. At least two researchers conducted every step of the data collection and analysis.

This study was conducted by a multidisciplinary team composed of professionals with different levels of familiarity and involvement with the EMDR-IGTP intervention. LT, who coordinated the Programme, was vested in evaluating the intervention's outcomes due to her direct responsibility for its implementation. This positionality, explicitly disclosed in the participant information sheet, was made known to all participants, who were thus informed of the PI’s dual role as programme lead and researcher. Given the potential for perceived pressure due to the dual role of LT, several measures were implemented to minimise any sense of obligation or social desirability in participants’ responses. Although initial contact to assess eligibility was made by LT and IG, formal recruitment and interview organisation were handled exclusively by researchers external to the therapeutic programme, specifically MEDC, EZ, and LR. These researchers were not involved in EMDR delivery, had no prior relationship with the participants, and clarified that participation was entirely voluntary and would not affect their relationship with their employer or access to psychological services. Furthermore, all interviews were conducted by MEDC, accompanied by either EZ or LR as independent observers.

Regarding the analysis, LT insider position allowed for deep contextual understanding while presenting potential interpretive biases, which the research team mitigated through collaborative and reflexive strategies. IG, SF, ER, GR, and SDL, all trained psychotherapists with expertise in EMDR, contributed with their clinical perspective to the design and interpretation of the study. Their experience enriched the understanding of the process and participants’ emotional trajectories. However, their embeddedness within the therapeutic context could also predispose them to interpret data in ways that align with their clinical expectations. To ensure analytical rigour and maintain proximity to participants’ voices, the research process integrated perspectives from team members external to the EMDR programme, such as MEDC, EZ, and LG. These researchers did not have previous experience with EMDR and were not involved in the programme’s delivery, enabling a degree of epistemological distancing. They played a key role in conducting the interviews and validating the analysis. LG, a senior qualitative researcher, supervised all methodological phases of the study, guaranteeing transparency and fostering reflexive discussions within the team. Regular debriefings and iterative coding sessions were employed to surface positional assumptions and address potential confirmation biases. This reflective and collaborative method allowed the team to analyze findings with contextual sensitivity and analytical rigour.

2.7. Ethical considerations

The AVEN Ethics Committee approved the study (in-house prot. n. 806/2020/OSS/IRCCSRE). All participants signed an informed consent form containing transparent and standardised information about the study aims, procedures, and their rights, including the voluntary nature of participation and confidentiality of the data collected. Free access to additional psychological support was offered to ensure participants’ psychological well-being, especially considering the emotional depth of the interviews. Any participant who experienced distress or wished to further elaborate on emotional content that emerged during the interview had the opportunity to schedule follow-up meetings with psychotherapists from the Emergency Psychology Programme, at no cost and voluntarily.

3. Results

3.1. Study population

Overall, 24 eligible participants were contacted, of whom 20 agreed to participate in the study. Reasons for refusal of those who declined participation include lack of time or work-related issues. Their socio-demographic and professional characteristics are reported in Table 3. Most participants were female (16/20), married (19/20), cohabiting with a partner (19/20), and aged between 24 and 68 years (mean: 48.55); 13 of them were involved in the management of the pandemic as healthcare professionals and seven as volunteers. Most participants had an educational background ranging from a high school diploma to above. Only three participants contracted COVID-19 during the first wave of the pandemic. The interviews lasted between 17 and 63 min.

Table 3.

Participants’ characteristics.

Participant	Sex	Age	Job	Education level
1	F	33	Nurse	Bachelor's degree
2	F	33	Nurse	Master's degree
3	F	50	Physiotherapist	Bachelor's degree
4	M	62	Volunteer	Middle School Diploma
5	F	68	Volunteer	High School Diploma
6	M	61	Volunteer	Middle School Diploma
7	F	36	Volunteer (Coordinator)	University Diploma
8	F	24	Volunteer	Master's degree
9	M	61	Volunteer	High School Diploma
10	F	59	Speech Therapist	Bachelor's degree
11	M	50	Volunteer (President)	Middle School Diploma
12	F	28	Physiotherapist	Bachelor's degree
13	F	56	Nursing assistant	High School Diploma
14	F	56	Nurse	Bachelor's degree
15	F	52	Nurse (Coordinator)	Master's degree
16	F	44	Social worker	Master's degree
17	F	45	Nurse	University Diploma
18	F	45	Physician	Master's degree
19	F	56	Physician	Postgraduate Specialization
20	F	52	Case manager	Master's degree

3.2. Characteristics of the traumatic events processed during the EMDR-IGTP intervention

During the interviews, some participants disclosed specific memories from the pandemic during which they worked during the IGTP sessions. These vivid images evoked feelings of loneliness and helplessness, referring to themselves and their patients. Another feeling often disclosed was their perceived vulnerability due to the risk of virus contagion. Table 4 reports some examples of participants’ narratives.

Table 4.

Examples of participants’ narratives delivered during the interviews.

‘My worst experience was the loss of an elderly couple who were rescued during COVID: the couple stopped and looked at their house before getting into the ambulance. Later we heard that they both had died’ (04)

‘One memory that really disturbed me was seeing a patient die in intensive care due to cardiac arrest. The healthcare professionals failed to intervene in time due to the long dressing time.’ (12)

‘I remember a patient with advanced Alzheimer's (so she couldn't understand the situation she was in). She could not respect the “rules”: so, for example, she was always getting out of bed and putting herself in danger. And in the initial chaos of that period, we couldn't, in my opinion, manage her as she needed to be managed. We didn't have the time to be with her constantly, we couldn't go into the room as often as we should have. This lady passed away in a way that affected me very much.’ (02)

‘The most painful memory I have is of an elderly patient who, during a video call, even though he was really ill, wanted to reassure his family by saying that he was quite well, when he knew very well that he would never see them again, that he would not survive.’ (15)

‘An image of a door with stretchers passing through. The hospital entrance, this long hallway, reminded me of the entrance to Auschwitz with the railway tracks. The silence, no one around, I had the feeling of being in a concentration camp. People came in and couldn't make contact, they were locked in the room … ’ (18)

‘An image resonates loudly within me: a red door and a line on the ground dividing the clean from the infected (trolleys, gowns, gloves, masks, footwear, headwear).’ (16)

‘I remember one of the first rescues, the ugliest and most difficult that ever happened to me. It caused a blockage that I had to work on with the psychologist for the first two sessions: I had to work alone in a complex situation, with an unconscious person having great difficulty breathing. I had a strong feeling of loneliness and powerlessness, because I couldn't do anything on my own and no one could help me.’ (08)

‘When I was working in the highest risk wards, without protection, I asked to have a mask, to have glasses, to have some protection, to be warned if a patient had a fever. I also asked to avoid going to certain wards, where there were already COVID patients and we did not yet know what prevention measures to take with them; and in any case we did not have masks and gloves to go in. Instead, they told me: “you cannot refuse to go to that ward”;  …  I will check that you have gone; because you are compelled, you must go, it is your job and you cannot refuse to go!’ (03)

3.3. Qualitative findings

Participants’ depiction of the comprehensive EMDR-IGTP could be categorised into two main themes: the participants’ journey throughout the EMDR-IGTP sessions and insights into the treatment’s components. A graphical representation of themes and subthemes is provided in Figure 1. In the following paragraphs, these themes and the related sub-themes are described in detail, representative quotations from participants are also reported.

Figure 1.

Qualitative findings. Main themes.

3.3.1. Theme 1: the participants’ journey throughout the EMDR-IGTP sessions

Participant feedback covered a broad spectrum of thoughts, emotions, and physical sensations experienced during treatment sessions. These focused on how initial difficulties evolved over time, the emotional commitment and the opportunity related to the re-emergence of traumatic events from the past and the reactions to the bodily sensations experienced during treatment. Participants also extensively highlighted the benefits they perceived from the sessions, the emotional demands required by the EMDR-IGTP, and factors related to the perceived lack of benefit from the treatment.

3.3.1.1. Dealing with the unfamiliar

When discussing their reactions to the EMDR-IGTP treatment, participants referred to the difficulties they experienced during the first stages and how these reactions evolved throughout the sessions. In some cases initial anxiety or skepticism towards a therapeutic approach they were not familiar with had given way to feelings of calm, ease and lightness: ‘The first time, I felt a little bit nervous […]  – told us a participant  – Afterwards not so much, perhaps because afterwards we did repetitive things, so I experienced them more lightly’ (04). Others, depicted difficulties in terms of initial discomfort or reticence in ‘letting things be/happen’ and in trusting both the process and the EMDR techniques to fully benefit from treatment, ‘My first approach to this technique was not entirely  …  how to say, spontaneous and automatic, and therefore I struggled a bit to be able to welcome it, and make the most of it’ (16).

Participants’ journey throughout EMDR sessions was also described, emphasising the fluctuating, intense emotional reactions they experienced from time to time, in the context of a ‘strange’ and unfamiliar therapy.

In the first session, I didn't feel many sensations. However, during the second meeting, I experienced an episode of anxiety, with a rapid heartbeat and somatic sensations which, ultimately, led me to experience a greater feeling of well-being and tranquility. (14)

3.3.1.2. Processing the present and repairing the past

EMDR therapy relies on the human brain's innate ability to create interconnections between neural networks in order to process traumatic events. During bilateral stimulation, emerging associative chains can span different periods and experiences, allowing for the desensitisation of traumatic memories and their integration into memory networks. Thus, it happened that during treatment some participants focused not only on distressing episodes related to the pandemic but also on previous childhood life events, as reported by this nurse:

I also had the feeling of wandering over time, of going and bringing up episodes of my life when I was a boy. […] This brought me back to experiencing those bad, dramatic moments, but also the good things … […] Let's say I took a look and in that moment I became emotional. (11)

In other situations, emotions regarding a pandemic-related event recalled previous events where that same emotion had been experienced, a phenomenon frequently encountered during EMDR therapy: ‘In addition to crying and feeling bad and reliving the emotions, there was also anger […] Some fears are also linked to my way of being, to my personal experience … ’ (03). In the above-mentioned cases, the EMDR adaptive information process appears to have involved both recent pandemic-related memories and other past memories, subliminally linked to each other. Bringing to the surface and adaptively rearranging these minds’ contents arouse positive feelings of peace, calm and relief, as exemplified by the metaphorical narrative of this participant:

This kind of therapy can effectively on the one hand open Pandora's box, on the other try to arrange the various pieces of the ‘mosaic’, little by little …  (12)

3.3.1.3. Perceiving kaleidoscopic reactions to adverse bodily sensations

EMDR processing involves not only cognitive but also sensory input. Participants reported a range of body sensations they experienced during and after the sessions, such as tiredness, headache, muscle tension, and a lump in the throat. In some cases, these sensations were experienced with surprise, dismay and hostility, ‘I noticed a strong physical presence of my body in response to intense and deep emotions […] I was surprised by the physical effects over the next few days … headaches and fatigue’ (16). In other cases, body sensations were addressed and overcome by adopting a welcoming and accepting attitude, which then allowed participants to gradually let them go, as suggested by the therapists, leaving room for a feeling of well-being:

So as soon as I had the first chat, the drawing, the number, I suddenly relived the muscular tensions, the headache, the lump in my throat, the physical things I had felt … […] I took home some incredible sensations […] I already knew that it was normal and that maybe it was even positive […]. Going through suffering and letting it go helped me a lot […] Then these tensions that I wouldn't even have released with a massage went away on their own, so I finally felt myself breathing, I felt better …  (03)

3.3.1.4. Achieving relief after going through difficult reactions

Some participants described their journey with EMDR therapy mainly highlighting the benefits and relief from suffering achieved at the end or at specific treatment points. In their stories, relief from distressing memories involved passing through a swing of intense sensations, feelings and sensory fragments until reaching a calm or neutral mental state.

Usually at the end of the session I had a feeling of emptiness, but a positive one, not empty of energy but a feeling of being well, I had purified myself. Maybe at the beginning there were many rumours or memories chasing each other, both of the hospital but also of life outside with family […] Afterwards, some thoughts that were nagging or disturbing became lighter (12)

The disturbing event has always become from 10, 2, 1, 0 … […] Afterwards, however, I was a bit  …  I was not very well […] So I immediately felt relieved […], but then in the following days I still dreamed of cleaning the whole hospital. Then over time this sense of anguish, this sense of inner heaviness faded …  (17)

Sometimes the transition from a state of discomfort to a state of relief and well-being has been explicitly attributed to the specific techniques used in EMDR therapy:

I realized that the eye movements and the alternating movements of the arms and hands were really able to free my brain from bad things or focus on the good ones […] maybe I could free myself from burdens from that day that perhaps I would have carried with me for much longer …  (20)

In other cases, participants disclosed that group sessions were not enough for them, and that achieving relief required some further EMDR individual sessions.

3.3.1.5. Searching for a meaning for the lack of benefit

Some participants reported that they did not particularly benefit from the treatment, or that they felt bothered by some aspect of the treatment. In some cases, they attributed this to tiredness and lack of concentration due to overwork during the pandemic. In other cases, they spoke about their personality-related difficulty in becoming aware of unpleasant emotions or disclosing them in the group context, a topic that need to be better explored by the scientific literature.

Well, initially bringing back memories that have caused a lot of discomfort and suffering is very challenging. […] You feel that your body is very involved, there are those who cry and those who cannot … […] It is not so obvious that you can be available in that moment. […] In other words, the slightly more immediate approach is to say “it's over, I don't think about it anymore”. (16)

All those things, sensations that my colleagues felt and that I didn't feel  …  I couldn't feel this transport that they said they felt, and so I remained quite distant. […] I don't know, I find it hard to let go …  (05)

Other reasons mentioned by participants were the lack of familiarity with drawing and writing compared to talking, and the perceived brevity of the treatment. Referring to the first, a participant reported:

I struggle to write about my experience, even to draw it. Instead, when I talk about it, something more comes out. […] We spoke with L. [the psychotherapist] but no one got rid of the ‘brick’ we had inside, and I don't believe those who say that everything is fine. (06)

3.7.2. Theme 2: insights into the treatment’s components

Participants offered valuable insights into their experience with the EMDR-IGPT intervention, referring to its main components. Such insights concerned psychoeducation delivered by facilitators throughout the sessions, the employment of the ‘butterfly hugging’ technique, and the opportunity to process painful memories within a structured pathway. Moreover, the group’s dual role as a safe place for processing individual experiences and as a context of commonality and sharing was identified.

3.7.2.1. Feeling enlightened by trauma psychoeducation

The theoretical input delivered by psychotherapists who conducted the sessions were reported in detail by participants, which highlighted the importance of being provided with scientific information on how the human brain reacts to trauma and what the potential mechanisms of action of EMDR therapy are: ‘First, there was a traditional two-hour lesson on what happens to the psyche during a traumatic event (such as an emergency)  …  An introductory lesson, beautiful because it explained […] where the trauma comes from’ (01).

Some participants emphasised the intrinsic therapeutic value of these explanations, as if they laid the cognitive and emotional foundations for the processing of traumatic memories:

First, they had a two-hour meeting, where they explained what an emergency is and what happens psychologically during an emergency. […] Even just hearing these things explained in a very rational way was absolutely enlightening for me […] Being a very rational person, I needed to rationalize what happened to the brain … […]. Then they explained well what the EMDR technique is, how it came about and how it aims to help the processing of stressful memories. (18)

Others focused on how the sessions were conducted and which instructions were delivered by the psychotherapists, including what was to be expected at the end of the processing of a traumatic memory:

[The psychotherapist] guided us to think about a bad memory without giving specific meanings, perhaps we started with a type of memory and then the mind moved on to other things; then the other part consisted of drawing it, in representing it figuratively […] The aim was not to remove the memory but, let's say, to give it an emotional connotation that was less disturbing, therefore to look at it with a less painful emotion. (14)

3.7.2.2. Approaching the novelty of ‘butterfly hugging’

Participants referred to the butterfly hugging technique used during the sessions, emphasising its novelty with various nuances. Some expressed curiosity and surprise at how it works and its effects, together with the need for further improving their knowledge about its mechanism of action:

It took very little time, but I realized that the eye movements and the alternating movements of the arms and hands got me to free my brain of the bad things, or focus on the good ones. After that, I read this thing a bit, because it was very new to me and therefore clearly I also wanted to understand what it was. (20)

Others dwelled on the strangeness of this technique: ‘It's something a bit special, it seems a bit strange, but it works. When it's done individually, it's much, much better. In any case, even done in a group session, it helps’ (02)

3.7.2.3. Processing memories in a structured pathway

According to EMDR underpinnings, the processing of painful memories can only take place within a protected and safe environment, where the psychotherapist’s awareness and mastery in using this approach play a crucial role. In their accounts of the EMDR sessions, participants described the effects of processing disturbing memories noting the extent to which they were able, along the way, to experience these memories as progressively less painful or to better cope with similar situations:

It helped me to review some events in particular – […] try to process them and put them into a box that had a beginning and an end, that is, rethink them […] not only with my thoughts but in a guided path. (13)

Referring also to the psychotherapist’s competence, a participant stated:

At the beginning of the meeting, I usually started with a high score when I thought about that episode, but at the end of the meeting, I always had very low scores […]. L. [the psychotherapist] didn't give us any medication, so maybe it was something my head needed to get out. (09)

As they follow a structured pathway, participants can safely choose their own personal ways of living and coping with the challenges of processing traumatic memories. Thus, some felt safe dealing with one memory at a time, thereby fragmenting and managing difficult emotions:

You bring home […] this strategy of fragmenting the anguish or even the negative experiences into many pictures, into many moments and then addressing them perhaps one at a time […] This helps to break it down […], it doesn't become an all-encompassing anguish but becomes a worry, a pain of something ending. We talk about death, about a painful experience. But you can deal with it better. (19)

3.7.2.4. Staying connected with one’s individuality within the group

Although the EMDR treatment was delivered in the group setting, participants pointed out that the processing of painful memories occurred on an individual level and that they felt free, throughout the process, to share or not share their inner experiences with the other group members. In their accounts, the focus on the intimate and personal nature of reflection and self-work seemed to emerge in a close relation to a deep sense of interpersonal connection.

[The psychotherapist] made us focus on a memory that …  we carried inside …  focus on a point in the body where it accumulated …  I had a throat; I was short of breath here …  some had a stomach …  some had a headache …  (17)

We stood there in a semicircle, guided by the professional, and everyone worked on their own. We didn't share the thing we worked on, unless we wanted to in the end […]. Strange, interesting things happened every time …  (07)

3.7.2.5. Feeling themselves to be part of the group

The meanings and value of interpersonal connection were made explicit in the narratives of many participants, who underlined the benefits of feeling part of a group. Some reported feeling understood, also through the reassurance that came with realising other colleagues had experienced similar emotions: ‘Unlike others who said “I became anxious”, I felt very good because I perceived that other people had experienced situations similar to mine and therefore  …  you feel understood!’ (15).

Others were positively impressed by the bond created between the group members or noted the strengthening of pre-existing bonds, as disclosed by this participant:

I was impressed by the strong bond with a group of colleagues who had participated in the EMDR sessions. All of us were young individuals of similar ages, which led to the creation of a subgroup within the larger group. This subgroup cohesion has also proven beneficial in our work environment. (12)

The benefits which come from allowing oneself to share one’s experiences and feelings within the group, rather than keeping them private, was highlighted by some participants, for whom the group EMDR pathway seems to have represented a means to experiment with this opportunity: ‘It helped me a lot to talk and share with others, I got emotional and tears came out, I felt I could express my discomfort even in front of my colleagues’ (03).

4. Discussion

4.1. Summary of findings

To our knowledge, this is the first qualitative study on EMDR group therapy delivered to frontliners involved in the COVID pandemic. Our focus was on acquiring new knowledge to promote the confidence of EMDR psychotherapists in introducing and conducting the EMDR group intervention; moreover, we aimed to improve their awareness of both the psychological processes activated within the intervention and the mechanisms of action underlying its efficacy, a topic that is widely documented in the literature (Landin-Romero et al., 2018; Oren & Solomon, 2012).

The meanings derived from the experiences of EMDR-IGTP recipients highlight three key areas that could inform and enhance the work of psychotherapists, thereby optimising the effectiveness of EMDR treatment. These areas are explored in detail in the following paragraphs.

4.2. Sustaining the emotional effort of processing traumatic memories: a matter of knowledge and attitude

Participants in our study reported detailed explanations provided by the psychotherapist on how the brain reacts to traumatic events and the hypothesised mechanism of action involved in EMDR therapy. Their narratives bring to light how the theoretical input they received about the EMDR approach nurtured their willingness to bear the burden of both difficult emotions and disturbing physical sensations during the processing of traumatic memories. Participants’ bodily reactions, avoidance behaviours, and emotional changes can be meaningfully understood through trauma models like polyvagal theory (Porges, 2011), which explains responses such as dissociation, hypervigilance, or shutdown as adaptive ways the autonomic nervous system reacts to perceived threat. Rather than seeing these as mere symptoms, this perspective frames them as survival strategies. Recognising such patterns helps make sense of participants’ experiences in a trauma-informed way. Creating a sense of physiological safety is also key to therapeutic work, as highlighted by Dana (2018), and supports engagement by responding to shifts in the nervous system (Dana, 2018).

EMDR psychotherapists should pay attention to trauma psychoeducation, a core component of EMDR treatment both in the initial phases and throughout the therapeutic process, as highlighted by recent research within and outside the emergency field. In the study on HPs working in Nephrology and Dialysis during the COVID-19 emergency (Belvedere et al., 2023), both psychoeducation and resource installation represented a significant part of the EMDR group intervention, as well as the employment of stabilisation techniques, such as grounding. Mazzoni et al, exploring the acceptability and the effect of group EMDR in patients with recurrent interpersonal traumatic episodes, reserved two of the ten group sessions to psychoeducation on the function of the trauma and EMDR therapy, and to a training on stabilisation including the search of positive autobiographical memories in addition to the safe place or the memory of a pleasant feeling. Qualitative findings highlighted a high acceptance and personal satisfaction from participants for the overall research-intervention programme.

In our study, psychoeducation seems to emerge as a set of cognitive inputs precisely informed by the psychotherapists’ attitude to support participants in the emotional commitment required for processing traumatic memories. An attitude that entails being present, legitimising, and normalising what happens during the sessions, reassuring participants and instilling trust in the process. These aspects are part of what Hase et al. conceived as the ‘sensitivity’ that psychotherapists should cultivate to deliver EMDR appropriately (Hase, 2021). As the psychotherapy process activates the attachment system due to the nature of therapeutic relationship, sensitivity involves delivering cognitions and tailoring verbal support according to situations, keeping eye contact without being intrusive, calibrating the rhythm and timing of bilateral stimulations, monitoring the group climate, refraining from comments during the processing of traumatic memories, connecting patients’ signals to their needs and being emotional available to respond to them.

4.3. Addressing the scientific rationale of EMDR techniques while embracing their impact on the receivers

Participants refer to the techniques employed during the treatment (e.g. butterfly hugging, graphic representation, the freedom to share or not share one’s experience in the group), emphasising their novelty and particularity. Sometimes, they express amazement, surprise, perplexity and curiosity toward these techniques. At the same time, they look at the EMDR treatment as a sort of safe container for addressing recent and past painful memories through a rigorous scientific approach and under the guidance of a professional expert in the field. Our findings highlight the importance of EMDR psychotherapists being able to both welcome participants’ particular feelings toward the distinctive features of this approach and repeatedly connect them with its theoretical underpinnings. This is particularly important, considering that none of the neurophysiological mechanisms underlying EMDR, i.e. working memory taxation (van den Hout & Engelhard, 2012), orienting responses (Bergmann, 2010) and changes in neural activity patterns during memory processing, (Pagani et al., 2017) have been conclusively proven.

The consequences of the lack of a clear understanding of EMDR are reported in the study by Mardsen and colleagues where group participants showed difficulty with the rationale of the treatment and with specific aspects of the method (Marsden et al., 2018); in this study, participants also reflected positively and favourably on the employment of preparation techniques like the ‘safe place’ and grounding. Processing memories within the context of EMDR can sometimes lead to some degree of emotional distress and dysregulation. Moreover, participants with a low education level or who have difficulty expressing themselves through writing or drawing require specific attention. Depending on the context and the participant's condition, the psychotherapist's ability to appropriately manage these scenarios involves applying variations to the original protocols to meet the participant's needs. In the study performed by Vignaud et al. on migrants with PTSD and major depression (Vignaud et al., 2023), two of the six sessions of the group EMDR protocol were devoted to training participants on the protocol framework and on stabilisation exercises, which were further reiterated in the last session. Moreover, the intervention sessions were performed by three practitioners. In using group EMDR with women who were sexually assaulted in Congo, Allon made some adaptations to the intervention protocol (Allon, 2015), introducing a research assistant who wrote down on paper what participants were describing and measuring the SUD using descriptive words instead of numbers.

Beyond techniques, the value of the therapeutic relationship, as well as the psychotherapist’s intuition and flexibility, are also highlighted in qualitative studies on the experience of delivering and receiving EMDR therapy in different healthcare settings (Marich, 2010, 2012; Marich et al., 2020; Wise & Marich, 2016).

4.4. Looking at the group setting through the eyes of different receivers

The group setting is experienced from three perspectives, depending on the participants. Some view the group as a facilitator and catalyst for processing painful memories, explaining the benefits linked to the possibility of sharing their internal experiences in this setting. The role of the group as a supportive environment which helps to normalise reactions to traumatic events through shared narratives and mutual validation is widely documented in literature. Burlingame et al., in their meta-analysis on the impact of group cohesion on patients’ outcomes, found that groups with greater trust, bonding and sense of unity tend to have better patient improvement regardless of the kind of therapy (Burlingame et al., 2018). Lo Coco et al., in their meta-analysis on the value of therapeutic alliance in group therapy, highlighted that the relational climate among participants encompassing trust, mutual understanding and engagement is a crucial aspect for recovery in group settings (Lo Coco et al., 2022). The group EMDR approach was specifically developed to help people deal with the impact of collective trauma, such as significant events and natural disasters. In these situations, the group setting can create a supportive and empowering environment where participants can share their experiences and learn coping strategies from each other. At the same time, every participant is free to interact or not with the others, and during the processing phase, everyone works independently on their material (Jarero et al., 2006). This is a distinctive characteristic of EMDR, where the psychotherapists should be consider themselves experts of the structure of the therapy, but not of the content: i.e. they are primarily responsible for activating patients’ intrinsic information processing system and keeping it in a dynamic form, and has to refrain themselves from injecting anything in the process (Hase, 2021).

However, the group may also introduce challenges. Some participants in our study, although recognising and appreciating the value of the group and the benefit received from the EMDR treatment, pointed out their difficulty in disclosing themselves to others. The third perspective is that of participants who, unlike other group members, feel unable to enjoy both the benefits of the treatment and the advantages associated with the group setting. Since these participants tend to judge themselves negatively when comparing themselves to others, EMDR psychotherapists should pay particular attention to them, promptly detecting their reactions and possibly addressing them through individual sessions, with the aim of better understanding their psychological functioning and their specific needs for support to deal with traumatic memories. This strategy can also be helpful for individuals who perceive themselves as unequipped to become confident with their emotional states, a further aspect emerging from our findings. As emphasised in the literature, two preventive measures that could be adopted to address this issue are to reserve a meeting exclusively for training participants on techniques for fostering emotional stabilisation and to employ pre-treatment assessments to identify participants’ specific needs and mental health conditions promptly. Recent research offers some interesting insights into these aspects. In the feasibility study on migrants diagnosed with PTSD or major depression performed by Vignaud et al., participants were screened through a psychiatric interview to exclude other comorbid conditions (Vignaud et al., 2023). In the pilot study conducted by Vock et al. on chronic pain patients, candidates to group EMDR were screened through a phone call and a preliminary individual therapy session to exclude those with severe dissociation or psychosis, active suicidal ideation or severe self-harming behaviour, active substance dependence and insufficient social stability (Vock et al., 2024); moreover, other exclusion criteria were the participants’ inability to tolerate the group setting and a lack of motivation and commitment with the group therapy. In the above mentioned study performed by Belvedere et al. during COVID-19 (Belvedere et al., 2023), healthcare workers to be included in the group EMDR were firstly administered with a socio-demographic questionnaire asking for information potentially valuable for guide psychotherapists in conducting EMDR sessions, i.e. participants’ employment in ‘dirty’ or ‘clean’ work area, household composition, isolation or not during emergency, the presence of minor children and whether they had contracted the virus; beside, the composition of the groups was established according to the objective of giving value to the teams as a resource on a personal and working level. Overall, the criteria reported in the literature for referring people to EMDR group sessions are not uniform and vary according to the setting and the psychological condition being treated. This is in line with several authors arguing that best practices require not only an adherence to the fidelity of the protocols employed, but also a willingness to adapt them to meet the needs of different populations (Hase, 2021; Monteiro, 2017).

5. Strengths and limitations

At the protocol stage, we planned to contact all the HPS and emergency volunteers participating in the EMDR-IGTP programme during the study period (N = 24). This decision was based on the study's exploratory nature and our aim to capture the full diversity of perspectives within this finite population. Ultimately, 20 individuals agreed to participate in the study. Given the relatively small number of potential participants and the richness of the interview material, we did not define a predetermined sample size based on conventional saturation thresholds. In line with recent methodological reflections (Braun & Clarke, 2021b; Tight, 2024), we chose not to adopt the ‘data saturation’ concept as a strict benchmark. Saturation, often associated with a more positivist logic of redundancy and completeness, may not be congruent with reflexive thematic analysis and other approaches grounded in qualitative interpretivism. Instead, we adopted a strategy that focused on the complexity and meaning-making within the accounts, rather than the repetition of codes across participants. This position aligns with Braun and Clarke’s argument that ‘saturation’ may be incompatible with the epistemological foundations of reflexive qualitative methodologies, where knowledge is seen as co-constructed rather than exhaustively discoverable. Although this study was conducted in a single centre, it included participants whose accounts offered a rich and diverse range of perspectives on the EMDR-IGTP experience. Rather than claiming statistical representativeness, our purposive sampling aimed to assess variation in participants’ professional backgrounds, emotional responses, and engagement with the intervention. In this regard, the study enabled an in-depth exploration of the subjective meanings attached to EMDR-IGTP and the personal transformations experienced by different types of frontliners. These findings may be transferable to other emergency healthcare contexts, especially where similar psychological interventions are implemented (Braun & Clarke, 2019, 2020). We align ourselves with a qualitative epistemological stance that prioritises the contextual depth, complexity, and meaning-making over generalizability in the statistical sense.

6. Conclusion

This study provides valuable insights into the lived experiences of healthcare professionals and volunteers who were involved as frontliners during the initial phase of the COVID-19 pandemic, utilising EMDR-IGTP. Based on our findings and the meanings underlying them, some recommendations have been developed, which should inform the activities that psychotherapists engage in when conducting group EMDR within emergency contexts. These are reported in Table 5.

Table 5.

Recommendations for EMDR psychotherapists stemming from our study findings.

Deliver psychoeducation by combining cognitive inputs with a mindful and supportive attitude
Be present Legitimize Normalise Reassure Infuse trust in the process
Ensure adequate time to create a comfortable and safe atmosphere
Make a mindful use of preparation and stabilisation techniques Work to strenghten participants’ trust, mutual understanding and engagement in the group Be aware of your role as a guide and an expert of the structure of the therapy, not of the content
Constantly connect EMDR to its theorethical inderpinnings
Be clear on the hypothesised neurobiological mechanisms on how EMDR works Adjust EMDR protocols according to context and participants’ condition
Pay attention to how participants ‘inhabit’ the group setting, moment by moment
Throughout sessions, carefully monitor participants’ reactions and feedback toward the group If needed, integrate group EMDR with individual sessions Consider carrying on a pre-treatment assessment

Psychoeducation on how the human brain reacts to trauma and on the mechanisms of action of EMDR plays a crucial role in ensuring its effectiveness, especially at the beginning of treatment. Additionally, consistently linking EMDR techniques to their theoretical foundations can help participants fully benefit from them throughout the treatment sessions, as they gradually internalise the psychotherapist’s explanations of the neurophysiological variations that occur during the processing of painful memories.

The emergency scenario, which represents an unexpected and extraordinary situation, should not divert the psychotherapist from the goal of ensuring adequate time to create a comfortable, legitimising and safe atmosphere, where participants can feel they can rely on both the psychotherapist as a human being and a professional, and on the group as a provider of protection, holding and emotional support.

Since the emergency context may not make an in-depth individual assessment of potential participants in group EMDR feasible, the psychotherapist should pay particular attention to how participants ‘inhabit’ the group setting, moment by moment. This type of attention allows them to promptly understand if participants are in the proper therapeutic context for them, and possibly where else they can be referred to cope with their traumatic memories.

Further research is needed to build upon the insights generated by this study and explore the longer-term impact of group-based EMDR interventions in emergency contexts. A longitudinal follow-up of EMDR-IGTP recipients could help determine whether the observed psychological benefits are sustained over time or whether delayed reactions or symptom re-emergence occur, particularly in response to ongoing or cumulative stressors. Moreover, future studies should investigate how participant characteristics – such as gender, cultural background, or professional role – shape how individuals engage with EMDR techniques in a group setting. These factors may influence initial openness to the intervention and comfort with disclosure, perceived safety, and the integration of therapeutic gains. Finally, considering the presence of individuals with complex trauma histories or significant emotional dysregulation, it would be valuable to assess whether brief, targeted pre-treatment interventions, such as emotion regulation training or grounding techniques, could enhance group cohesion, psychological safety, and overall treatment outcomes. Such inquiries would contribute to the tailoring of EMDR-IGTP for more diverse populations and to the optimisation of trauma-informed group therapy practices in high-intensity care settings.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Data availability statement

The qualitative data generated and analyzed during the current study are available from the corresponding author upon reasonable request.