EMDR Therapy Quarterly

I was prompted to write this article after listening to a recent podcast in which Rotem Bayer interviewed Annabel McGoldrick about EMDR and Internal Family Systems (IFS) therapy. I was shocked to hear her quote research that reported that of the therapists who do EMDR training, only 10–12% progress and add it to their therapeutic repertoire by becoming accredited in EMDR. (Farrell & Keenan, 2013).

My supervision of groups and individuals would echo this, but as I am not a research or numbers person, I had not given much thought to the fact that the number of trainees going on to incorporate EMDR into their work would be so low. It led me to think about why this is and what could help to improve the numbers, given that it is not cheap to train in EMDR and that we all know how efficacious it is as a therapy. It is now extensively used in the NHS, where I offer supervision for several specialist and child and adolescent mental health service (CAMHS) clinics, all of whom are now providing training for their therapists and thus EMDR for the clients and supervision for their staff.

Barriers to practising EMDR

It seems that the reasons trainees do not practise EMDR once they have learned it can be summed up as follows:

• The belief that it can only be used with single-incident trauma or that they are only qualified to use it with single-incident trauma
• The belief that the client will not like it
• A lack of confidence to deal with an abreaction
• The therapist’s discomfort with the intervention
• Training occurred during lockdowns.

My experience supervising these services is that many therapists who have completed their EMDR training have not yet used it in practice, making rueful statements such as “I haven’t had a single-incident trauma” or “I can’t work out how to change from talking therapy into EMDR; it feels too unnatural and clunky” or “I’m not sure what the client will make of it; it’s too different from the work we’ve been doing.” One supervisee commented that “sitting with the manual and asking questions that don’t sit within a client’s normal vocabulary feels so unnatural and deskilling that it becomes hard to step over the threshold.”

I have asked a few supervisees for their thoughts and heard from one that “there is no mechanism to get support after EMDR basic training, and supervision is not necessary unless you’re going for accreditation” and from another that they weren’t warned that an abreaction could include a physical response, such as vomiting, and this had alarmed them when it happened and they had not wanted to use EMDR again.

It seems that the longer the wait to find the required single-incident trauma, the longer it is between training and using EMDR in practice. I wonder if, indeed, there is such a thing as a single-incident trauma. Bruce Perry (Hambrick E, Brawner T and Perry B, 2019), amongst others, tells us that early ‘good enough’ attachment and resilience (Winnicott DW, 1971) allow individuals to shrug off most of the incidences and vagaries of life’s journey. Therefore, those people who present themselves to us as clients are, by definition, more complicated humans for whom there have been ruptures and less than adequate repairs in their early lives.

Often, training was undertaken during the pandemic lockdowns, which was challenging enough without trying to practise EMDR while getting to grips with using video conferencing software, when most of us have worked only face-to-face.

Encouraging trainees to use EMDR

I am a family therapist and EMDR consultant for adults, children and adolescents. When I was first accredited, there was not a separate category for child work. I have always worked with children and adolescents and was fortunate enough to be in CAMHS with Joanne Morris-Smith from 2003. She was very generous in allowing me to watch her use EMDR in sessions with my clients. She also did live work that clinicians watched through a two-way mirror, and post-session, she talked through what happened in the session. So along with group supervision, I learned a huge amount without really appreciating it at the time.

I wonder if that experience influenced my approach to working with EMDR with both adults and children in a way that has never left me afraid of where it might go and how I would manage an abreaction.

Joanne’s way of working was flexible and dynamic, sometimes moving around the room to follow a child to a whiteboard to draw. Although I didn’t recognise it at the time, and although the child and parent/carer would not have known which phase of the protocol she was in, as I learned more, it was absolutely clear that Joanne knew exactly where she was. She demonstrated that there was not a sense of ‘now we’re doing EMDR’; it was simply part of the whole process.

When I started in private practice, it was not long before I realised I needed to train in EMDR to get into the parts that talking therapies alone did not seem to reach. Since my basic training, I have learned more and more about using EMDR. I have witnessed numerous improvements in clients’ functioning, seen seemingly miraculous changes and I have found that EMDR has a cumulative effect. The changes continue to build upon each other long after the EMDR intervention has stopped. This has been reported in children when parents have contacted me to give me updates on how their children are doing, even many years later.

Overcoming discomfort and trusting the process

My first child client was an 11-year-old boy who had been sick in the night on a school residential trip in Year 3 when he was aged eight. There was no one there to help him, and he lay frightened and alone. This was an obvious attachment rupture, and sadly, there was no immediate repair. He had become increasingly anxious since this and had been refusing to go to school since transitioning to secondary school.

I stuck to the eight-phase standard protocol that I had recently been taught, and it did feel clunky and unnatural, but luckily, he bore with me, and we dropped back to the target event. We then processed this, and he came to his own resolution that untoward things (such as being left behind) would not happen because “the teacher has a list and ticks people off when they get on the coach.” This was followed by some work with his mum around understanding anxiety and attachment, and she sent me a card some months later saying he was transformed. I learned that the period of feeling discomfort with the unnatural style of EMDR, compared to the familiarity of core clinical training, is a phase to go through until it becomes familiar and less formulaic.

Positive reinforcement  

I noticed a pattern of resilience in many of the young people I worked with at Beacon House (an excellent centre whose staff work mostly with children and young people post-adoption). I was dogged in my application of bilateral stimulation (BLS) to all our work together: bouncing balls left and right, hopping, squeezing playdough or therapy putty and anything bilateral that could be added to the session. Using buzzers (sometimes in a pocket or socks) and headphones, trusting in the process and that the brain would do what it needed to do to reprocess their trauma.

I often wondered what was going on inside for these young clients because there did not appear to be any obvious outcomes at the time. The young people were not always overly reflective or articulate.

But despite the trauma of adoption, along with numerous moves from birth family to foster carers and sometimes back again, a seed of resilience would have been sown if there had been some presence of safe and available adults at the time of the trauma. It was this that became evident in their response to EMDR. 

Some of the parents of the most troubled adopted children and adolescents have contacted me since. They reported quite remarkable things about how their young lives were now developing, such as holding down jobs and forming relationships, having abandoned their drug and alcohol use, and dysregulated and aggressive outbursts. “Being a normal teenager,” as one mum emailed me.

I see EMDR as a therapeutic approach that may be interwoven with everything that is part of the session and used with almost all clients, even if it is just for resourcing and resilience building.

Developing as EMDR therapists

As a supervisor, I love to bring therapists into a place of being able to relax into their EMDR, weaving it in and out of the therapeutic space along with all their core clinical expertise and tools for change. My aim is that it becomes a part of their whole practice rather than a ‘now, we’re going to do EMDR’ approach, helping them to recognise that their confidence as clinicians can be present with EMDR too.

Of course there are caveats, and one is that therapists need to have a good sense of their client’s safety, who is around to care for them, and how EMDR may leave them between sessions. This comes through an understanding of their negative cognitions and positive (preferred future) thoughts, their emotions and their behaviours. As part of the preparation work, I aim to bring the client to a place where they will be able to notice their body and what is going on there.

Francine Shapiro brought the numbers into EMDR when it was a new model the (SUD and VoC), to measure outcomes in research. For some clients, being asked to think of a number may move them back into their head and out of their body. Here, it may be helpful for a therapist to intuit what they think the numbers might be by observing body language rather than attempting to get a number at all costs.

Questioning the content of training

I am not sure how delaying teaching about interweaves until the part-three training helps practitioners to do what is natural, such as adding an encouraging word or some psychoeducation. I work for Trauma Aid UK with a Tunisian child and adolescent psychiatrist who is an EMDR consultant-in-training and is leading a group of EMDR trainees in Tunisia, Syria and Iraq. The group has completed part one, and in our recent supervision, the psychiatrist shared that the trainees were stuck with finding a single-incident trauma and with blocking and looping during phase-four processing because they have not yet learned about interweaves.

There is more focus on trauma processing in the training, rather than the resourcing of nurturing figures and a safe and calm place. From my experience, ‘tapping in’ any good moments in the week between sessions, pausing and enhancing that moment with body sensation, helps to grow resilience and core self (Parnell, 2007). Sometimes it can be like pulling teeth to find something good, but it is rare not to find something, however small. I have found it as effective to encourage this resilience in clients as it is to process trauma, particularly where the sliding between anxiety and depression is not articulated and connected to a particular trauma. The metaphor I use in supervision is of the brain as a tank filled with dirty water (trauma) and adding clean water (resourcing) splashes some of the dirty water over the edge of the tank. The more resourcing, the more the clean water replaces the dirty water.

This ‘tapping in’ also helps therapists and clients feel comfortable with EMDR before moving into trauma processing. A calm or safe place, if that is an appropriate word for the client, can then be tapped in, along with the resourcing of nurturers, protectors and wise beings. After my initial training and first child client, this is how I have worked ever since, and the outcomes show the effectiveness of the model.

As a family therapist, the idea of the dance between family members and the therapist encourages a mutual dynamic of movement in the sessions, so that despite whatever may have been thought about and planned beforehand, in the moment, the therapist follows the client and attends to what is coming into the therapeutic space. This idea can be brought to EMDR and woven in and out, looking for and catching moments to process unhelpful, stuck memories or thought patterns, or building resilience and growing a more positive sense of self. The EMDR phases can equally be woven into other modalities, such as IFS. Some clients move onto more targeted specific memories, but often, when using the approach above, functioning improves, and the specific memories identified in the history taking are resolved spontaneously.

Summing up

In conclusion, I wonder whether the flexible approach of child work and the dynamic approach of systemic thinking have enabled an easier ride for me into EMDR work.

While recognising that the training, both in its selection of suitably qualified, experienced candidates and in its approach to the theory, needs to remain rigorous, can there also be space for a lightening of touch? What if this could include the idea that bringing one’s own style of working can be integrated into the EMDR while sticking to its core principles?

What if there were follow-on clinics for trainees to join to hear questions and discussions, rather than having to pay for another expensive supervision session in addition to the requirements of their professional body? The NHS groups I lead have proved to be fertile ground for learning from each other’s experiences.

It feels necessary, as an EMDR community, that we give more thought to improving the uptake statistics for EMDR trainees along their journey to accredited practitioner status. We need to help new EMDR therapists overcome their fear, grow in confidence, and trust the process of using this powerful, almost magical, healing therapy.

Resources

Beaconhouse.org.uk excellent free resources and training for complex developmental trauma, but please attribute to Beacon House.

Nicola Dyson is a family therapist and C&A EMDR consultant and supervisor. She has worked with EMDR since 2003.