2020 – Zooming into EMDR
A KEY ASPECT OF THE NEW PHOENIX E-SERVICES
Eye Movement Desensitisation and Reprocessing (EMDR) therapy is a specific and effective evidenced based treatment intervention for people who are affected by trauma experiences that this year gained further endorsement and recognition by being added to the Social Work Medicare list of approved mental health interventions. It is particularly helpful for Phoenix clients as it assists to not only desensitise the person’s trauma memory so they no longer have frightening re-living symptoms such as flashbacks and nightmares, but it also repairs attachment bonds that were either deficient or absent in their childhood.
EMDR is an intimate therapy that requires little talking by the client but requires them to be able to tolerate and process their emotions and body sensations. Time is devoted to preparing a client to be able to manage their feelings within the window of tolerance and develop personalised resources, so they do not become overwhelmed or dissociate. When the client is ready to process their childhood sexual abuse trauma, they are asked to recall an intense target image of their trauma and notice their associated feelings, body sensation and belief about themselves now. They then carry out a simultaneous dual process of eye movements or holding vibrating tappers in their hands. The counsellor is required to be empathically in tune with the client helping them to feel grounded in the present and check in and track with them what emotional, visual, sensory, or cognitive changes they are experiencing.
EMDR processing is unique to every client so no one session is the same, which means the counsellor needs to have their skills at the ready at all times to be able to manage any abreactions or dissociation shown by the client. Ensuring the client feels fully present and in control at all times is paramount which can be explained by the metaphor of the client being the driver and having control of the steering wheel and where to go with the session whilst the counsellor is alongside them as their navigator and suggested guide.
In March 2020, the global pandemic started to have its effect on the delivery of counselling services worldwide and Phoenix adapted by developing policies and procedures to be able to deliver counselling via telephone and online video conference.
The question was could EMDR be done online and would it be as effective as in-person counselling? We consulted widely with colleagues in WA, nationally with APS and EMDRAA and internationally in EMDR UK and EMDRIA and the answer came back with an affirmative yes.
Fundamentally, EMDR UK notes that EMDR is EMDR, whether delivered online or in person however, if you or the client is in doubt, or not confident about online EMDR, then do not proceed. Guidelines have been drawn up by the various EMDR governing bodies as an aid to ensure online service delivery is safe and effective. Their advice includes:
PREPARATION OF TECHNOLOGY
Ensure both client and counsellor have good Internet connection, the right lighting, stable positioning of an online device (especially if using a mobile phone) and the counsellor has a neutral background. For EMDR work it is very important for the counsellor to have quality headphones and it is highly recommended also for the client. Without headphones the sound quality can be muffled and distant, but with headphones there is much more clarity as you are literally speaking into the client’s ear. It can be very powerful as the counsellor can lower the tone of their voice to speak to the client’s child ego state kindly and gently.
PREPARING AND RESOURCING THE CLIENT BEFORE EMDR PROCESSING
The same strategies of grounding, calm place, light stream, diaphragmatic breathing, support figures, Flash Technique etc, are used online as in person to person as is checking out the client’s ability to apply their resources. Risk assessment should be carried out in the usual way. EMDR UK advise essential criteria for online therapy are:
- A good-enough therapeutic relationship.
- The client can self-soothe.
- Sufficient confidence that any risk of self-harm is manageable.
- That the client is functioning to a sufficient degree outside of sessions, with a significant other or social support.
To prepare and manage dissociation the client is encouraged to have a ball or an orange that they can throw from hand to hand to ground. They can be instructed to splash water on their face, stand up, stretch, look around and describe colours, objects to bring themselves back to the present.
The counsellor should establish the client is in a quiet, a confidential part of their home, and is not going to be disturbed. Tissues, water, and any grounding items should all be to hand, but also some clients benefit from having someone from their social support to be available to help if they do dissociate or become too upset during processing.
Their support person should be prebriefed as to the best way to help the client under these circumstances. It is also important to allow enough time to close-down and see that the client is well grounded at the end of each session.
BILATERAL STIMULATION (BLS)
Use the preparation phase to work out which BLS works best for the client. Online Apps are available to purchase to facilitate EMDR processing, but butterfly tapping works equally as well, is free, low tech and can provide the client with added containment and comfort having their hand over their heart and chest. The client can also simultaneously tap their feet which can aid the desensitization process and facilitate grounding.
There is mixed experience and advice as to whether to suggest to a client to close their eyes during EMDR processing. If they close their eyes the client can get in touch more easily with their emotions and the processing experience, but the counsellor is then solely reliant on hearing the client to pick up cues of dissociation. This underlines the importance of agreeing an explicit stop signal, such as saying ‘And Pause’ or making an agreed gesture.
EMDR VIA TELEPHONE
Consultants from the Netherlands Suzy Matthijssen and Ad De-Jonge (April 200) have shared their successful experiences of using EMDR over the telephone. They have demonstrated how a trauma memory can be desensitized by asking a client to hold the trauma memory whilst simultaneously doing varied multi tasks of tapping, saying out loud tick tock tick toc spell triggering words, counting backward and or listening to rhythmic music.
All of these can be asked over the phone and then checked in with the client what changes they are noticing to their trauma memory and if their units of distress are reducing.
THE PHOENIX EXPERIENCE – CHALLENGES AND REWARDS
Providing EMDR via telephone or online video conference as an aspect of the new E-Services has afforded Phoenix clients to be able to have treatment within their own home environment. This has come with the benefits of clients not having to travel long distances for their appointments and be able to have their home comforts around them, so they are starting their appointment from a feel-good calm place. If they experience any emotional upset in the session, they are not having to drive home, but rather can move straight into their familiar relaxing space.
Linking up to Zoom technology was an issue at the start of some counselling sessions but talking clients through the initial setup and supporting them through the new procedures has all helped to give clients confidence in the Zoom technology. It has been important to have the clients phone number at the ready so on rare occasions when we have lost sound or connection on Zoom, they are assured they will get a phone call. Safeguarding the client is not be left without contact helps the client trust in the therapist and the technology.
When clients have not had or not been comfortable using technology link up EMDR has been delivered via the telephone which has received mixed reactions. One client reported although they had made significant progress processing their trauma memory, they also found the use of the telephone too impersonal and not emotionally connected enough to the counsellor, conversely another client reported she preferred using the telephone as it felt comfortable and familiar to her.
When doing bilateral stimulation all Phoenix clients currently use the butterfly tapping whilst the counsellor synchronises with tapping on the desk. This is useful because it gives an extra task for clients to attend to, which further taxes their working memory helping to desensitise their past trauma. One client reported that the desk tapping was like a drumming sound that made her feel more connected to the counsellor and the process. The counsellor ceasing tapping on the desk can also serve as an added cue (if the client has their eyes closed) to know that an EMDR set has ended.
When using online video conferencing there can be a loss of physical transference between the client and counsellor so it can be harder to be in tune with what the client is fully experiencing emotionally. A learning curve has been to explicitly check in with clients regularly throughout an EMDR processing session to assess if they are managing to stay within the window of tolerance. However, when therapeutic trust and Zoom communication has been established it has been Phoenix’s experience that EMDR processing of childhood sexual abuse trauma memories has been just as emotionally charged, insightful and healing as ‘in person’ therapy with one client saying ‘I now feel relief and empowered.’ This is also borne out by quantitative outcome data of the trauma PCL-5 questionnaire scores going from indicative of PTSD diagnosis to having non-clinical symptoms.
In conclusion, from the literature and Phoenix experience we would recommend embracing the online medium for EMDR treatment. It does not suit every client, and time does need to be taken to set up and establish good connections both technically and therapeutically, but online EMDR can be very effective and rewarding experience for both client and counsellor and a good option when services are impacted by COVID-19 Restrictions.
SALLY WOODS SENIOR COUNSELLOR EMDR PRACTITIONER
– EMDR UK www.emdrassociation.org.uk
– EMDRAA www.emdraa.org
– EMDRIA www.emdria.org
– APS www.psychology.org.au
– Suzy Matthijssen and Ad De-Jonge www.enhancingtraumatreatment.com