Getting to grips with time-limited online EMDR
A JISCmail question from Ruth Alborough on time-limited online EMDR has kindled huge interest from EMDR therapists all over the world. Lisa Haydon was a key player in bringing the EMDR Online Practitioner Forum into existence and reports on progress so far.
When Ruth Alborough asked how others were working with EMDR in a time-limited way she evidently hit on something that many of us were tussling with. This was in particular reference to working with clients who do not meet the threshold for secondary care but who have greater needs with more complex presentations and histories, including childhood developmental trauma, attachment wounds and enduring experiences of domestic abuse. They currently sit in-between primary and secondary care within an NHS setting and are most likely to be identified as ‘Step 3+’. IAPT (Improving Access to Psychological Therapies) services and other agency-led services (for example, insurance companies, Employee Assistance Programmes and some charitable services are also known to provide only a limited number of sessions). This is bringing about a level of pressure, anxiety and general enquiry and concern as to how EMDR might be delivered in a safe, effective and ethical way.
The question caught my interest. I wasn’t sure whether I had anything of value to add but I was being interested in this ethical dilemma and eagerly watched out for responses; I was disappointed when the thread seemed to die away. Ruth sent a further email to explain that a few people had got in touch; they did not feel they had anything of significance to share but were interested in the subject and keen to explore more. By this time, I could not ignore my own need for further insight and support on this subject so I got in touch with Ruth to ask if she thought the people who had responded might be interested in a peer-to-peer chat over Zoom. This would be nothing more than an informal conversation to share our thoughts and experiences. Maybe nobody would respond but at least I could take it to supervision. But within half an hour of sending out the email request, 25 people had responded and by the end of the day more than 70 members had expressed interest in getting together to explore this in more detail. It was clearly a subject of great interest and perhaps you could say it revealed a level of uncertainty that many of us have about how to work effectively in a time-limited way with EMDR.
It revealed a level of uncertainty many of us had about how to work effectively in a time-limited way
The group itself was positioned as an informal gathering of interested parties with a willingness to be open and share of the own experiences in their practice. The chat was to take place via Zoom and the link was sent out to the Jiscmail group along with Mark Brayne’s Attachment Informed Google group. Two dates were set in advance and a framework for the two-hour session giving scope for the group to inform its direction. Twenty-five members joined together for the first catch up connecting from across the UK and Ireland to as far away as Australia. Sixteen attended the next gathering, some new to the discussion and some who were keen to continue it. Gloria Howard, another valued member gave her support through offering her upgraded Zoom account for the second meeting to enable this to go ahead also offered technical support. Members sent their ideas for discussion and thoughts around future plans for free webinars and resources on the subject, hopefully hosted by the Association. It felt very much like a team effort, bringing people together, particularly in this time of lockdown and restrictions due to COVID-19.
Mapping the territory
Many of us came seeking some direction, guidance or framework on how to work with time-limited EMDR therapy. Essentially everyone wants to work safely and ethically and seeks guidance on how to do this, particularly with complex presentations. Some themes were common to those experienced in standard person-to-person EMDR. For example, the pressure we can feel to start the desensitisation phase quickly. This often unspoken pressure perhaps comes from the client’s desire to get to the ‘eye movement part’ and also the implicit pressure from the agencies we may work for. We know of course that EMDR therapy is much more than Phase 4 and that it starts with history taking and preparation; maybe we need to remind clients and referring agencies who are expecting a ‘quick fix’. Given the importance of these phases, what might ethical time-limited EMDR look like, and in what circumstances would we refuse to offer it at all?
The trouble with timelines
It was established that a detailed timeline can sometimes generate too many targets to process and may lead to expectations that they will all be sorted out. Again, we know that you do not have to process absolutely every item on the trauma timeline. One can be selective rather than exhaustive, bearing in mind the therapy goals and any time constraints on the number of sessions available etc. One suggestion made in the first session, was to consider starting with a trauma in the present moment and then see what other traumas come up in the processing that may need attention.
But where does that leave the ‘10 worst traumas’ approach, or the ‘hunt for the touchstone memory’? Or should we in a time-limited frame opt to go with the client’s prioritisation of the worst trauma or where they feel it is best to start? Indeed, should the process be more client led?
Resourcing for complex presentations
Many believe that resourcing is essential for complex presentations, but does time-limited therapy demand compromise here? And what might that mean in practice? One suggestion was to use Parnell’s float back (or sometime called bridge back) to when the client first felt like that i.e.: the present activated emotion with the selected EMDR target; then input resource figures as per Laurell Parnell’s attachment model. Parnell suggests a person (such as a guardian angel), an animal or magical power. There are some EMDR practitioners developing the CRM (Comprehensive Resource Model) and use power animals from the Shamanic tradition. They return to target but bring the resource they identified for themselves in the past, into the present predicament / current target. Philip Manfield’s book on dyadic resourcing was recommended, which included a ‘parts work’ approach allowing the client to revisit the past from an adult perspective to support their child who was in distress. Start with building a ‘relational scaffolding’ and inviting all the parts in, providing a script for offering good parenting messages or affirmations with slow BLS throughout.
This applies to our clients’ expectations, the expectations of the agencies we work for and our own expectations. One participant shared a powerful metaphor she uses to describe the process to clients. She talks about ‘working with the cracks caused by the earthquake before getting to the big hole in order to be able to access it’ to help manage expectations. Another participant talked about using ‘your future self’ as a resource and shared the research paper with the rest of the group. Helping the client to focus on their preferred future – ‘what outcome do you want’ – remembering that it is rarely possible to work on everything the client brings – also helps to manage expectations . In the Assessment Phase the therapist can help the client to identify a target based on what the client wants to achieve in therapy, so that the work remains linked to ‘therapy goals’.
A free webinar is on the cards from the Association for early 2021. The Beds, Bucks and Herts Regional EMDR Group is developing a workshop on formulating, tools and approaches to time-limited EMDR and is planned for 2021.
Our group is now called the EMDR Online Practitioner Forum (thanks to Ruth Armstrong in Australia who coined this). We have had three collaborative peer-to-peer discussions to date and have agreed and planned to do these every six weeks on a Saturday morning for two hours going forward. They are very much inclusive groups, peer-informed with a collegiate approach and all levels of experience are welcome. You don’t need to ‘book’ on either. A link to the Zoom call will be sent out a couple of days before to the Jiscmail email, Mark Brayne’s Attachment Informed Google group and Dianne Mee’s Facebook group so you can decide nearer the time. The group happened quite accidentally but the coming together of each and every one of you so far has proved to be a really key piece of support of not only each other but also of EMDR as a credible and powerful tool for change, healing and recovery.