Overcoming clinicians’ fear of using EMDR therapy: Practical Steps for Success


Andrew M. Leeds
Director of Training, Sonoma Psychotherapy Training Institute, Santa Rosa, California

This article can be downloaded as a PDF free of charge
https://andrewmleedsphd.gumroad.com/l/iotqn

Introduction
EMDR therapy can be intimidating for newly trained clinicians. This article addresses common fears that may hinder clinicians from implementing standard EMDR reprocessing procedures and provides practical steps to overcome these challenges.

Three Common Fears
Three common fears can inhibit newly EMDR trained clinicians from using standard EMDR reprocessing procedures. These are:
1) The fear of leaving the client more disturbed (worsening symptoms) than before reprocessing.
2) The fear of the clinician experiencing vicarious traumatization from exposure to aspects of the client’s memory.
3) The fear of not being able to adequately use standard EMDR therapy procedures.

Standard EMDR Therapy Procedures
EMDR therapy is a widely recognized (VA/DoD, 2023; World Health Organization, 2013) and effective method for resolving adverse and traumatic experiences in clients. Standard EMDR therapy procedures are taught in EMDR training programs accredited by EMDR national professional associations. These include the EMDR International Association (EMDRIA USA), the national EMDR Associations of EMDR Europe, and National EMDR Associations in Australia, Africa, Japan, and India. Standard EMDR procedures are detailed in textbooks by Francine Shapiro (2018) and Andrew Leeds (2016) and summarized in journal articles (Hase, 2021). EMDR therapy involves an overall eight-phase approach. This article focuses on the specific challenges that can prevent clinicians from using the reprocessing procedures in Phases 3 through 6.

The fear of leaving the client more disturbed
The fear of leaving the client more disturbed is one of the most common fears recently EMDR trained clinicians have about using the standard EMDR therapy procedural steps. In thinking about this fear, we can start by asking three questions. First, what do clinicians fear might happen? Second, how often does this happen? Finally, who gets to decide whether to take the risk of this happening?

What are the worst responses that clinicians fear? Clients could hurt themselves. Unless clients have a recent history of hurting themselves, this is unlikely. In fact, recent research shows that clients in an acute mental health crisis with suicidal ideation experience decreased suicidal impulses with EMDR therapy (Proudlock & Peris, 2020).

Clients could become more disturbed by an incompletely reprocessed memory than before the session. This can and does occur. The possibility of this happening is essential to be included as part of informed consent to EMDR therapy.

The bilateral stimulation procedures (BLS) used in EMDR therapy have long been described as increasing the risk of remembering more details about traumatic experiences (Lipke, 1995). EMDR trained clinicians are instructed to disclose the potential for the level of disturbance to go up or for additional disturbing details to emerge during reprocessing. This could also include briefly experiencing increasingly vivid sights, sounds, smells, emotions, or physical sensations associated with the traumatic experience before these aspects of the memory are fully reprocessed. Clients are asked if they are willing to assume this risk before starting and clinicians explain that for most clients any increased disturbance is likely to be brief and will generally be resolved most quickly by simply continuing with reprocessing. When clients understand and consent to this risk, clinicians trained in EMDR should honor the clients’ wishes and provide standard EMDR therapy.

Clients could decide not to return for another session. When clinicians provide sufficient information to obtain informed consent, clients will generally show a stop signal before they get overwhelmed. Then clinicians can address their concerns and resume reprocessing or discontinue reprocessing for that session and transition to closure procedures to reduce the client’s activation of their memory. So, it can be essential to have practiced or at least discussed a range of preparation phase exercises, so clinicians are properly prepared to close sessions that become overwhelming for clients.

How often do adverse outcomes happen in EMDR therapy? To answer this question, let us look at research studies on the use of EMDR therapy in complex cases.

A pilot study by Slotema, et al. (2019) explored changes in symptom severity in individuals with personality disorders during adjunctive outpatient treatment with EMDR offered in addition to ongoing sessions with their regular psychotherapists. They reported a significant decrease in the severity of symptoms of PTSD, dissociation, and insomnia after an average of four sessions of EMDR treatment. There were no adverse effects such as suicidal behavior or hospitalization. Approximately one-third of the outpatients discontinued their EMDR treatment. These patients described EMDR treatment as either being too stressful or not helpful. A few patients discontinued both their treatment for personality disorders and EMDR therapy. The decision to discontinue EMDR was most likely in those with the most severe forms of insomnia.

Adams, Ohlsen, and Wood (2020) carried out a systematic review of six studies of EMDR treatment of individuals with psychotic symptoms. No adverse events were reported in the six studies. None. Two of the studies reported initial increases in psychotic symptoms before these were decreased with further reprocessing. Dropout rates in the six studies were the same or lower than in other trauma-focused treatments for PTSD. The authors commented that “maybe the most poignant finding of this review is that EMDR can also be successfully and safely administered to people with a psychotic disorder with or without a comorbid PTSD.” (p. 9)

Who gets to decide?
Who decides whether to attempt or refuse to try EMDR therapy, the therapist, or the client? Individuals seeking treatment have the right to make an informed decision about starting standard EMDR therapy procedures. Most individuals with histories of adverse or traumatic experiences benefit from standard EMDR therapy even among those with personality disorders or psychosis. Adverse responses to treatment were not reported in these controlled research reports. Individuals have the right to discontinue EMDR treatment should they find it too stressful, but they also have the right to start and continue EMDR treatment.

Fear of the clinician experiencing vicarious traumatization
Delivering EMDR therapy to individuals with histories of adverse and traumatic experiences exposes clinicians to knowledge of these experiences. Some clinicians fear this exposure.

Kadambi and Truscott (2007) examined the rate of vicarious trauma among therapists working with either sexual violence, cancer, or in general practice. They found no higher rate of vicarious trauma in therapists working with trauma survivors. Devilly, et al., (2009) surveyed mental health professionals in Australia and found that exposure to patients’ traumatic material did not affect secondary traumatic stress (STS), vicarious trauma (VT) and workplace burnout. Rather, work-place related stressors best predicted therapist distress.

Torres, Ignacio, and Gottlieb (2023) studied vicarious traumatization in those practicing EMDR therapy, compared to those using trauma-focused cognitive behavioral therapy (TF-CBT) and prolonged exposure (PE). They found a trend toward higher compassion satisfaction in the group practicing EMDR therapy and commented that in contract to TF-CBT and PE, in EMDR therapy the client is not required to share details of their trauma narrative. There is even a specialized “Blind to Therapist EMDR Protocol” (Blore, et al., 2013; Farrell, et al., 2020) that further reduces clinicians’ exposure to the details of the trauma narrative.

There is no published evidence that exposure to clients’ narratives during EMDR therapy is risk factor for developing vicarious traumatization. Clinicians with this concern may have personal histories that have sensitized them to certain kinds of triggers and these individuals would benefit from resolving these concerns with a brief course of EMDR therapy.

Lack of confidence in EMDR therapy skills
Most EMDR trained clinicians find it essential to participate in ongoing consultation to achieve the necessary degree of confidence and fidelity in application. This need led to the decision to require a minimum of 10 hours of consultation as part of basic training in EMDR. But 10 hours of consultation is not enough for most clinicians newly trained in EMDR therapy.

Grimmett and Galvin (2015) reported on a survey of 239 EMDR trained clinicians. Those who continued to use EMDR reported they did so because of its effectiveness and due to receiving ongoing consultation. Lack of confidence due to a need for ongoing consultation was also discussed by Lipke (1995) and by Farrell and Keenan (2013).

While individual consultation may be best for confirming fidelity for credentialing purposes, group consultation may provide the best opportunity for helping clinicians to gain confidence by observing videos of other clinicians’ work or reading their near verbatim transcripts of reprocessing sessions and discussing feedback with accredited consultants.

It is normal for clinicians to go through a period shortly after training when they decide to keep close at hand a copy of the script for the standard EMDR procedural steps and a list of commonly used interweaves. Making and reviewing near verbatim transcripts of sessions allows clinicians to learn from their own work. Most clinicians learn from making technical mistakes and then correcting them. While exposing our work to others can feel uncomfortable, it is the fastest way to gain confidence. Senior EMDR consultants often have an ability to discern more from written clients’ histories, near verbatim transcripts, and session videos than newly trained clinicians. Obtaining qualified consultation appears to be the most effective way to achieve the knowledge, skills, and confidence needed to achieve positive treatment outcomes.

Summary
Newly EMDR trained clinicians can have fears that affect their ability to effectively deliver EMDR therapy. It is helpful to realize that the vast majority of EMDR clients benefit from EMDR therapy and that there are scant reports of adverse outcomes. Therapists treating trauma have no higher rates of vicarious trauma than general practitioners. In fact, EMDR clinicians may experience greater rates of work satisfaction than those delivering TF-CBT and PE. Finally, the best ways for clinicians to gain confidence in EMDR therapy are to review one’s own clinical work and to receive regular and ongoing consultation from a qualified senior consultant.

References

Adams, R., Ohlsen, S., & Wood, E. (2020). Eye Movement Desensitization and Reprocessing (EMDR) for the treatment of psychosis: a systematic review. European Journal of Psychotraumatology, 11(1), 1711349. https://doi.org/10.1080/20008198.2019.1711349

Blore, D. C., Holmshaw, E. M., Swift, A., Standart, S., & Fish, D. M. (2013). The Development and Uses of the Blind to Therapist EMDR Protocol. Journal of EMDR Practice and Research, 7(2), 95-105. https://doi.org/10.1891/1933-3196.7.2.95

Devilly, G. J., Wright, R., Varker, T. (2009) Vicarious Trauma, Secondary Traumatic Stress or Simply Burnout? Effect of Trauma Therapy on Mental Health Professionals. Australian & New Zealand Journal of Psychiatry. 2009;43(4):373-385. doi:10.1080/00048670902721079

Farrell, D., & Keenan, P. (2013). Participants’ Experiences of EMDR Training in the United Kingdom and Ireland. Journal of EMDR Practice and Research, 7(1), 2-16. https://doi.org/10.1891/1933-3196.7.1.2


Farrell, D., Kiernan, M. D., de Jongh, A., Miller, P. W., Bumke, P., Ahmad, S., Knibbs, L., Mattheß, C., Keenan, P., & Mattheß, H. (2020). Treating implicit trauma: a quasi-experimental study comparing the EMDR Therapy Standard Protocol with a ‘Blind 2 Therapist’ version within a trauma capacity building project in Northern Iraq. Journal of International Humanitarian Action, 5(1). https://doi.org/10.1186/s41018-020-00070-8

Grimmett, J., & Galvin, M. D. (2015). Clinician Experiences With EMDR: Factors Influencing Continued Use. Journal of EMDR Practice and Research, 9(1), 3-16. https://doi.org/10.1891/1933-3196.9.1.3


Hase, M. (2021). The Structure of EMDR Therapy: A Guide for the Therapist. Front Psychol, 12, 660753. https://doi.org/10.3389/fpsyg.2021.660753

Kadambi, M. A., & Truscott, D. (2007). Vicarious Trauma Among Therapists Working with Sexual Violence, Cancer and General Practice. Canadian Journal of Counselling and Psychotherapy, 38(4). Retrieved from https://cjc-rcc.ucalgary.ca/article/view/58744

Leeds, A. M. (2016). A Guide to the Standard EMDR Therapy Protocols for Clinicians, Supervisors, and Consultants (2nd ed.). Springer Publishing Company.

Lipke, H. (1995). EMDR Clinician Survey. In F. Shapiro (Ed.), Eye Movement Desensitization and Reprocessing, Basic Principles, Protocols and Procedures (1st ed., pp. 376-386). The Guilford Press. https://howardlipke.com/emdr-clinician-survey/


Proudlock, S., & Peris, J. (2020). Using EMDR therapy with patients in an acute mental health crisis. BMC Psychiatry, 20(1). https://doi.org/10.1186/s12888-019-2426-7

Shapiro, F. (2018). Eye Movement Desensitization and Reprocessing, Basic Principles, Protocols and Procedures. (3rd ed.). The Guilford Press.

Slotema, C. W., van den Berg, D. P. G., Driessen, A., Wilhelmus, B., & Franken, I. H. A. (2019). Feasibility of EMDR for posttraumatic stress disorder in patients with personality disorders: a pilot study. Eur J Psychotraumatol, 10(1), 1614822. https://doi.org/10.1080/20008198.2019.1614822

Torres, P. B., Ignacio, D. A., & Gottlieb, M. (2023). Reducing the Cost of Caring: Indirect Trauma Exposure on Mental Health Providers. Journal of EMDR Practice and Research, EMDR-2022. https://doi.org/10.1891/emdr-2022-0044

VA/DoD Clinical Practice Guideline. (2023). Management of Posttraumatic Stress Disorder and Acute Stress Disorder Work Group: Provider Summary. Washington, DC, U.S. Government Printing Office. https://www.healthquality.va.gov/guidelines/MH/ptsd/VA-DoD-CPG-PTSD-Provider-Summary.pdf

World Health Organization. (2013). Assessment and Management of Conditions Specifically Related to Stress: mhGAP Intervention Guide Module (version 1.0). WHO. https://www.healthquality.va.gov/guidelines/MH/ptsd/VA-DoD-CPG-PTSD-Provider-Summary.pdf

Correspondence regarding this article should be directed to Andrew M. Leeds, Director of Training, Sonoma Psychotherapy Training Institute, 1049 Fourth St, Suite G Santa Rosa, CA 95404. E-mail: andrewmleeds@gmail.com

This article can be downloaded as a PDF free of charge https://andrewmleedsphd.gumroad.com/l/iotqn