In online EMDR Therapy networking groups, people often post the question, “What EMDR protocol should I use for [insert population or condition]?”
I am that cheeky consultant and trainer who answers with, “The standard protocol, modified if necessary to address a well-conceptualized case.”
You may, like the young EMDR clinician I once was, be scratching your head and asking, “What does case conceptualization mean, really?” When a newer EMDR therapist asked the same question of me in response to my comment, I figured it was time to explore the phrase in an effort to demystify it. Case conceptualization is a phrase that all of us received in our EMDR Therapy training, assuming that it was an EMDR International Association (EMDRIA) approved training. The phrase is not directly used in EMDR founder Francine Shapiro’s Eye Movement Desensitization and Reprocessing: Basic Principle, Protocols, and Procedures (3rd edition), although she cites some academic papers that use the phrase. Yet in the EMDRIA standards that we trainers must follow, the phrase is used thirteen times, often appearing together with the phrase treatment planning. Throughout this article I will make some references to those standards, in addition to the EMDRIA definition of EMDR Therapy.
In explaining case conceptualization to my students in the simplest way possible, I describe it as the process by which we get to know a client and their unique needs that we must account for in the delivery of EMDR Therapy. Case conceptualization, described as the step before treatment planning in the EMDRIA standards, certainly informs the treatment plan. And in classic EMDR Therapy, the adaptive information processing (AIP) model guides it. In plain language, AIP is a model developed by Shapiro that is based on learning theory. In giving my 20-second elevator pitch on the AIP model, I explain: We learn stuff about ourselves and/or the world as a result of traumatic (wounding) or adverse life experiences. When we can have a look at what we’ve learned that’s not so helpful, link it up to what other things we’ve learned that are helpful, change happens. Some people would call this unlearning, others would call it relearning and then moving forward in life with that new knowledge. Even simpler, if you are the kind of therapist who believes that, one way or another, unhealed trauma is the source of human suffering and addressing it directly is the key to healing, EMDR Therapy and its AIP model is likely a good fit for your therapeutic practice.
A major aspect of case conceptualization is determining if the EMDR approach to therapy is a good fit for your client. Like when trying on new clothes, sometimes the piece is not a good fit (and there are other forms of therapy that may better suit), and other times it can fit if some adjustments are made or if any items, like a fun scarf or a cool pair of socks are brought in to enhance the outfit. This idea can make some new EMDR therapists nervous especially if you were trained by a rather stringent “follow-the-standard-protocol-exactly-as-Shapiro-wrote-it-and- don’t-bring-in-any-other-kinds-of-therapy” type of trainer, or if you have been enticed by the growing number of special trainings out there that promise just the right “protocol” or step-by-step update that you can follow to work with more complicated clients. While reading Shapiro can be puzzling because she emphasizes the importance of scientific research and adhering to good technique, she also articulated that EMDR is an interplay between client, clinician, and method (Shapiro, 2018). Right in the middle of a passage in the third edition when she discusses rigorous, scientific scrutiny, her artistic side comes out with this comment: “Clinicians must utilize everything they have ever learned to best serve their clients” (p. 426).
In reference to one of my specialty areas, clients struggling with substance use disorders, Shapiro famously wrote that EMDR ought to be implemented “as part of a system designed to make the client feel safe and supported. It works best when it is used in conjunction with counseling groups that provide a nurturing atmosphere, such as group therapy, Alcoholics Anonymous (AA), and Narcotics Anonymous (NA)” (Shapiro & Silk-Forrest, 1997; p. 178). Bear in mind that AA and NA are just examples here; I’ve never interpreted her teaching to mean that they are required. What is required is the understanding that unless the client has the privilege to access intensive or in-patient treatment for EMDR Therapy, the client will be on their own the other 167 hours of the week outside of the one hour that they see you. What do they have existent or what can you give them therapeutically to prepare them for fully embracing the reprocessing phases (3-6) of EMDR Therapy, and to manage life before, during, and after EMDR or other forms of trauma treatment? While the science that exists on EMDR Therapy is important to the evolution of EMDR, no amount of empirical research or neuroscience findings will ever trump the art that is case conceptualization: getting to know your client and adjusting what you do on a case-by-case basis.
The EMDRIA Definition of EMDR Therapy (2019) supports my contention:
As a psychotherapy, EMDR unfolds according to the needs, resources, diagnosis, and development of the individual client in the context of the therapeutic relationship. Therefore, the clinician, using clinical judgment, emphasizes elements differently depending on the unique needs of the particular client or the special population. EMDR treatment is not completed in any particular number of sessions. It is central to EMDR that positive results from its application derive from the interaction among the clinician, the therapeutic approach, and the client.
Case conceptualization requires that we use Phases 1 not just to select targets, but to get a bigger picture about what brings the client or the system to treatment, the themes that are at play in their presentation story, what strengths or resources that they already bring to treatment, and what areas may need to be explored and addressed as part of Phases 1 and 2 before we proceed with targeting traumatic memories in Phases 3-6. For most EMDRIA-approved training programs, giving a Dissociative Experiences Scale (DES) is part of this process. Engaging in the practice has never been about “ruling out” which clients are too dissociative to benefit from EMDR Therapy. We do this to determine what additional skills we may need to help the client cultivate in their lives and as part of Phase 2 preparation, assuming that the client is on board to try EMDR Therapy. I like to say in my training that in Phase 2 and throughout all of the phases, EMDR can play very well with other therapies, especially approaches like Dialectical Behavior Therapy (DBT), expressive arts therapy, mindfulness-informed strategies, and various approaches that exist to identifying and working with parts or ego states.
If you’d like to see an example of how I guide my consultees in conceptualizing cases where there are high degrees of dissociation, please click HERE for the best practices PDF used in our training program. You will notice on this form that I am not giving you a direct step-by-step approach because we embrace that no two people, or no two systems, will be the same. Rather, these are general principles to bear in mind in working with clients who dissociate, with things to look out for and modifications that you can consider in each phase. If you are stuck on emphasizing elements of the EMDR standard protocol depending on the unique need of each client, seek consultation. The longer I’ve consulted on and have trained using EMDR Therapy with complex trauma and dissociation, the more I am convinced that consultation can be more valuable than advanced training in learning how to work with more challenging clients in EMDR Therapy. Because the art of working with a client who doesn’t seem to respond well to a script can be best cultivated by talking through your initial struggles on a case-by-case basis. Getting another scripted specialty protocol in another specialty training, for me, has never been the answer to developing authentic skills in case conceptualization.
You can also check out another recent blog published here on the Institute for Creative Mindfulness blog written from the client’s perspective. This contributing blogger is Hero, dissociative system and a survivor of ritual abuse, a type of case that many consider too hard or even impossible to treat with EMDR therapy. This contributor (well-known to me as a member of the plural community) shows us how EMDR therapists can approach working with someone like her. They offer us a valuable insight into the art of case conceptualization not just in working with ritual abuse, truly with all variations of complex trauma.
Another valuable piece of guidance that Shapiro gives us that I regularly cite in my trainings in assuring ethical practice is to not do EMDR Therapy with a client you wouldn’t ordinarily feel comfortable treating without it (Shapiro, 1997; 2001). For me, this has always meant that you need to know your clients and have a general sense of the best practices required in working with that population, or the issues and symptoms affecting them. Really knowing how to work well with children and teens is imperative for translating and adapting the peculiarities of the EMDR protocol with young folks. When I train on dissociative disorders, I know that we often frustrate our EMDR students because I do not give them step-by-step instructions on what to do with clients with dissociative disorders. If you have an understanding of dissociative disorders and their uniquenesses before approaching such clients with EMDR, you would know that I can’t give you a text book list of what to do. At best I can give you general recommendations on what to consider, yet all of that comes out of knowing your population first.
So instead of asking, “What EMDR protocol should I use for [insert population or condition]?,” my dream as a trainer and qualitative researcher would be to see EMDR therapists ask instead, “What do I need to consider in using EMDR with [insert population or condition]?”
Then listen to your clients about what they might need in the way of modifications or adjustments. If you are truly concerned as a new EMDR therapist that the mythical EMDR Police will come and punish you for making an adjustment or modification, get consultation. You can also read the original Shapiro (2018) text to see how she even modified it from the standard protocol with a variety of conditions such as phobias or recent events. Yet hopefully in this reading you will discover that even her specialty protocols were simply modifications of the standard, tweaked to meet the unique needs of the people that EMDR can serve.
References
EMDR International Association [EMDRIA]. (2019). EMDRIA Definition of EMDR. Retrieved from https://www.emdria.org/about-emdr-therapy/
Shapiro, F. (2018). Eye Movement Desensitization and Reprocessing: Basic principles, protocols, and procedures. (3rd ed). New York: The Guilford Press.
Shapiro, F., & Forrest, M. (1997/2016). EMDR: The breakthrough “eye movement” therapy for overcoming stress, anxiety, and trauma. New York: Basic Books.
Interested in More From This Author on Qualitative, Artistic EMDR Case Conceptualization?
Marich, J. (2011). EMDR made simple: Four approaches to using EMDR with every client. Eau Claire, WI: Premiere Publishing & Media.
Marich, J. (2022). Dissociation made simple: A stigma-free guide to embracing your dissociative mind and navigating daily life. Berkeley, CA: North Atlantic Books.
Marich, J. & Dansiger, S. (2018). EMDR therapy & mindfulness for trauma-focused care. New York: Springer Publishing Company.
Marich, J. & Dansiger, S. (2022). Healing addiction with EMDR therapy: A trauma-focused guide. New York: Springer Publishing Company.
Coming March 13, 2025 Thematic Client History Taking in EMDR Therapy: Enhancing Your Clinical Effectiveness with Complex Trauma (a 4 CE/EMDRIA credit course by Dr. Jamie Marich and The institute for Creative Mindfulness)
