Not So Much of a Rebel: Making Peace with the Standard EMDR Protocol

I’m often met with surprised looks when I respond, “I use the standard protocol mixed with good common sense about how addiction works, which informs my preparation approach. I don’t find any of the specialty protocols particularly useful.” 

I realize you may be gasping right now since, in EMDR circles, lots of buzz can be heard about the specialty protocols and methods that EMDR practitioners are developing. I participate in several Facebook EMDR groups and almost every day I read a question to the tune of, “What protocol do you use for addiction?,” “What about dissociation?,” or, “Is there a specialty protocol for condition x, y, z?” 

So many times I have bluntly responded, “Um, the standard protocol mixed with clinical judgment about preparation needs and how to use appropriate interweaves.” 

One of the reasons I decided to write this piece is so that I can cogently share my position as an EMDR therapy trainer, author, long-time clinician, and notorious EMDR therapy rebel. What’s funny is that when I wrote EMDR Made Simple in 2011 I called out many problems that I saw with party line EMDR. Yet as I’ve matured as a person, a clinician, and a trainer, I’ve realized that maybe I’m not so much of a rebel after all. For me, the standard protocol really is where it’s at. Learn the standard protocol well within the context of the client’s goals for treatment and know where to point the targeting sequences, and you really have all you need to do successful EMDR with a wide variety of presentations. The adaptive information processing model will guide you, as will the larger breadth and depth of what we as trauma-focused clinicians are learning about the importance of embodied, somatically-informed affect regulation skills. 

In this piece I further explore my position by explaining my approach as a trainer to client context and adequate preparation. Then I explore my thematic perspective on client history, which allows me to direct the standard protocol in the direction it needs to go in order to work with a particular client presentation. Finally, I look at where interweaves and modifications may be appropriate depending on the complexity of the case involved. Since addiction and dissociation are my two main specialties in EMDR therapy (and the two main conditions for which I have been personally treated), I will draw on several case conceptualization strategies for these special populations.

One of the first pieces of wisdom I internalized from reading Dr. Shapiro’s early works is not to do EMDR with a client you wouldn’t normally feel comfortable treating anyway. In my interpretation, this means that the task falls on us as clinicians to learn more about a particular condition that may be stumping us as a general best practice. One of my biggest concerns with the rising popularity of addiction protocols is that well-intentioned EMDR clinicians who know little about addiction are simply pulling out the protocols and hoping for the best. When this happens absent the larger knowledge about the various models of addiction, the interplay between trauma and addiction, and the impact of the stages of change, inadequate care can be delivered. In one of her first books Shapiro wrote that “addiction should not be treated in a vacuum,” (Shapiro & Forrest, 1997) yet I fear this is what happens when EMDR therapists just pull out one of the specialty protocols without educating themselves more on the intricacies of addiction first. The same applies for dissociation and dissociative disorders, or any other specialty presentations that may puzzle you—start by reading up or furthering your continuing education on the generalities of that population and their needs. 

Adequate preparation in EMDR therapy involves much more than just doing one Calm Safe Place exercise. Although I train the skill in my program, I discuss its limitations, and it’s one of only many strategies that I teach. While the classic skills of Calm Safe Place (which often involves changing up the descriptive adjectives to meet the client’s needs), Light Stream and Container are still very useful, they can all be very visually biased if not modified. Furthermore, to truly help a client manage affect, tolerate distress and be prepared for what may arise during trauma reprocessing (Phases 3-6), we must explore other skills.
 
In our program, we teach a wide variety of mindfulness strategies in a trauma-focused way (i.e., allow for modifications, emphasize not just reading the skills out of the book, rather, having a personal practice yourself as a clinician and teach from that experience). Mindfulness strategies can include traditional sitting meditation, moving meditations, mindful exploration of the expressive arts, and learning how to turn all activities of daily living into chances to practice present-moment awareness. Teaching a client breathing strategies and body scanning skills in a trauma-focused way is also imperative. Existing skills or approaches that you utilize in other modalities like dialectical behavior therapy, 12-step facilitation, or yoga can all be very helpful in teaching principles of lifestyle change and grounding. In the spirit of true trauma-focused care, the needs will vary from client-to-client depending on their existing experience with such skills and the intricacies of their presentation. I’ve learned that the more complex the client, attending to preparation in this total matter is more helpful than any specialty protocol just slapped into the treatment process. You can visit a comprehensive library of these skills and watch how I use trauma-focused language in apply them by visiting the resource site Trauma Made Simple by clicking HERE.

And no, I cannot give you a script about how many of these skills you’ll need and in what dosage. That is where clinical judgment and having done your own personal work comes in to make you as effective as possible. Personal work with these skills is important so that you know what it means to modify and adapt skills for your optimal benefit, which puts you in a better position to do this with clients. While scripts can help us build our skills, a practice that most adult learners need and that I endorse, scripts can rarely help you apply them in the absence of practice and context. To intone the wisdom of Jennifer Emch, one of my program graduates and director of Ubuntu Wellness in Chardon, OH, “Life isn’t scripted and neither are people.”

In addition to understanding the imperative of trauma-focused and enhanced preparation in EMDR therapy, we must also consider as EMDR therapists that taking a chronological history is not the best way to go. Although I agree with Shapiro’s essential position that targeting the earliest memories first is ideal for getting to the root of any given problem, due to the nature of how complex traumatic memories are stored in the limbic brain, taking a chronological client history may be impossible. Or at very least, impractical. Most clients I’ve worked with over the years cannot track a chronology, have blanked out significant pieces of time, or get very tangential when we try to take a conventional history due to the disorganization in the limbic system. When I was trained many years ago I learned the 10 best memories and 10 worst memories method for taking client history, and I’ve also found this ineffective. The most effective approach to holistic client history taking I’ve found over the years, and the approach I teach in my program, is to discover potential targets thematically. Let’s use an addiction-specific example.

For many clients new to a recovery process, there is a willingness to do EMDR therapy reprocessing and yet there may be insufficient affect tolerance to go to the earliest instances of abuse or trauma. For optimizing engagement, you may be better suited to work with their goals for recovery first, while respecting the trauma history that led to the problem in the first place. Many individuals struggling to get better, regardless of their specific goals, carry a negative belief like, “I cannot deal with my feelings without alcohol (or other drugs/behaviors). That is a negative belief that can be “floated back” using questions like, “Thinking back over the course of your whole life, when is the first time you got the message that I cannot deal with my feelings without alcohol.” You can also ask the question for the worst or most recent. What you get from the client all represent potential areas that you can target. Might these targeting sequences link in to earlier, more impacting traumatic experiences? Of course. Yet targeting them this manner is, in my experience, a kinder, gentler way to go and helps them to see the relevant connection of the EMDR work to what may be their biggest issue of concern in therapy. To see some examples of how I conduct client history in a thematic way, please visit the video demonstrations section of the Institute for Creative Mindfulness website by clicking HERE.

One of the wisest pieces of direction I received in my rather traditional basic training many years ago is that the greater the degree of complexity in the case, the more level of interweave you will need. I feel that learning the principles of cognitive interweaves (as described by Shapiro in her texts and further elucidated by other great minds in the EMDR community) is essential to doing EMDR with addiction, dissociation, and other special situations that may throw you for a loop. Yes, the classic directive in EMDR therapy is to stay out of the way as much as possible. Yet I was delighted to see Shapiro (2018) use the phrase proactive measures so much in the third edition of her text. To me, solid interweaves work as a plunger of sorts. When the flow of reprocessing is clogged, we can apply good open-ended questions, gentle pieces of encouragement or psychoeducation, and mindful or somatic techniques to get the flow going again. Although I teach a list of common interweaves in my program and Shapiro offers some solid examples of them in her text, the best interweaves are the ones that you develop through constant practice of EMDR and working with consultation to hone your craft.

Sometimes we can get nervous talking to consultants or other EMDR therapists about modifications, fearing that we’ll get “called out” on deviating from protocol. Yet consider how all of these specialty protocols that we can get so excited about in the scripted books or special trainings are really just twists and turns on the standard protocol anyway. They are proactive measures. One final modification tip that I can offer from my clinical experience on working with complex issues like addiction and dissociation related to the part of the standard protocol where we are asked to get an image (or worst part) from the client. I’ve always liked the language of worst part because it recognizes that some memories, especially pre-verbal ones, may not be stored with an image. With folks who may not have sufficient affect tolerance to handle going to the “worst part,” yet who have done all they can with preparation skills, you may be better suited to ask, “What part of this target memory are you willing to work on today?” Then proceed with the standard protocol from there. This may make reprocessing more digestible for the client in the spirit of EMDR therapy Phase 2.5. Yes, you will likely have to go back later and check to see if there is an image or worst part in a separate targeting sequence in order to achieve completion of the target in a technical sense. Yet consider how this modification may be more tolerable for individuals.

If you are the type of adult learner who needs more of a scripted protocol to learn new information, that is more than okay. I know that as a trainer I could not survive without using scripts with my students. And yet there comes a point in your development as an EMDR clinician when you must realize that the scripts are just modifications. These specialty protocols we can all get excited about are just very necessary modifications. No, modification is not a dirty word as long as you are able to clinically justify why you are making the modification or, in the case of Phase 2 preparation, enhancements. Doing this well and in the most trauma-focused manner will eventually involve you moving away from scripts and other peoples’ protocols and working to hone your own clinical common sense.

References
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Shapiro, F., & Forrest, M. (1997). EMDR: The breakthrough “eye movement” therapy for overcoming stress, anxiety, and trauma. New York: Basic Books.
 
Shapiro, F. (2018). Eye Movement Desensitization and Reprocessing therapy: Basic principles, protocols, and procedures, 3rd ed.  New York: The Guilford Press.