Troubleshooting in Early EMDR Sessions

This is an ongoing list of things I have noticed (or things to remember) about doing EMDR with clients.  Much of this will not make much sense if you aren’t EMDR basic trained.  I’m only several hundred EMDR sessions in.  This list will be revised often.  These are tentative noticings that are a mix of my experience, reading, training, and consultation. Your use/experience may vary and I’m interested in conversations about any or all of these.

Starting EMDR

Common newbie EMDR therapist mistakes (many of which I made).

• Client is not properly resourced to handle the intensity of his work. Resource with every client.  The more severe the client issues, the more intensive the resources and the longer it may take before the client can tolerate the distress or intensity of reprocessing.  It’s OK to spend a whole session developing resources, helper figures, etc.  If you are doing work related to early and middle childhood attachment issues, you want to bring in helper/spiritual/nurturing figures to help clients end initial sessions in ways that aren’t horrible.
• Allowing the client to open too many or all of the targets at once in the first EMDR reprocessing session. This is likely to be overwhelming and can feel like dozens and dozens of flashbacks simultaneously.  It’s good to “light up” a single memory network at a time.  If the client is “lighting up the whole city,” there is likely to be little movement on any individual memory network (and little generalization).  Work to pick a target (ideally representative or touchstone) and process that target.  As new/adjacent memories come, help the client transition to them slowly, particularly when starting out.  Clients are more likely to “end in sunshine” if you help them focus on specific and targeted memories.  When working on the memory level with a client new to reprocessing, help the client to light up a single street at a time and not the whole city of memory.
• Focusing on only a single channel and not providing psychoeducation to the client related to the other channels that movement may occur on. Processing can occur on thought, memory, body memory, body sensation, and emotion channels.  If a channel fizzles (say, body sensation), ask the client to check the other channels to see if something is coming or blocking.
• With complex trauma clients that have very high baseline anxiety, be careful with starting with “earliest or worst.” Start with something that is a little isolated from earliest or worst, but is still hot enough to reprocess.  Clients get more comfortable with EMDR the more they do it.  You can target almost anything.
• Tapping in resources, but not actually using those resources to help ease the client out of session or abreaction at the end of a session. Generally, you want the SUDS to be as low as possible when a client leaves your office, even if you have to deep breathe or go to another grounding resource the last five minutes to get it down.
• Not teaching the client to use containering between sessions. Adjacent memory networks are likely to rattle between sessions.  Demonstrate thought containering and prepare the client to use coping skills between sessions.  Encourage the client to container thoughts that cause high levels of distress between sessions if this occurs.
• Not providing psychoeducation related to the potential to feel “out of alignment” or emotionally vulnerable after EMDR. For most of my clients, this vulnerability is worse the first 24 hours and gets much better as the week progresses.  Even when clients report an ending SUDS of 0 and report that they are more relaxed than they have been in months, they can still feel “out of alignment” many hours after the session.  Anticipate this and educate clients to be aware of it an plan to take it easy.
• Not leaving enough time to close the session down. Start winding down 10-15 minutes before, unless the client is really close to closing a target (yes, sometimes it’s hard to tell if a target will close quickly or not).  Hold off on new targets when you are near the end of a session.
• Not coming back to an open target from prior sessions to close them and install the positive belief. If you closed a target at the end of the last session or SUDS went to zero since last session, install the positive belief.  It’s fine to have open targets, but it’s also important to close the ones that you can because you’ll need to leverage the “good” that emerged for subsequent reprocessing.
• Not checking in with client about benzo or marijuana use. You will see a lot of looping with recent benzo and marijuana use.  The whole chest and stomach area may be offline and may only report sensations shoulder level and above.  I ask clients to avoid both at least 12 hours before we do reprocessing and I encourage clients to avoid them for as long as they can after (reprocessing continues after session).
• Not directing the client back to target when the client needed to be directed back to target (things have fizzled, have become too verbal/cognitive, or the client loses the activation).
• Delaying starting EMDR with clients because of therapist insecurity about EMDR. You learn to do this by doing, reading, and by participating in consultation.  The tragedy is never getting around to using it.

Concerns about a client being healthy enough or ready to do EMDR.

• Many clients will not get better until they do reprocess their trauma, so stabilization before starting EMDR isn’t necessarily the short-term goal.  Preparation is.  On the most basic level, clients should have the following in place to reprocess traumatic memories using EMDR.  1) Be embodied enough to notice 2) The capacity to feel worse for a little while 3) Resources to tolerate the distress of activation AND an emotional “brake” in place (if needed) to avoid panic 4) And have enough good and adaptive “stuff” for the maladaptive stuff to merge into.  More about each of these below.
• Be embodied enough to notice. This may change from session to session, particularly for clients who have high dissociation scores. For all clients with complex trauma, I complete a Dissociative Experiences Scale in session.  I read and explain each item if needed.  Many clients who have a long history of dissociation find this an important part of the process, because it normalizes behaviors and internal processes that many clients assumed were unique and peculiar to themselves.  Another way to check embodiment is to ask where the anxiety is currently sitting in the client’s body across several sessions.  For some clients, whole body regions are “offline” and this information is good to know before you try to do reprocessing.  If the client is completely disembodied between the neck and stomach, it may make sense trying to help the client slowly bring those parts into awareness.  If the client is fairly stable, you can invite him to intentionally open up awareness of those areas.  You can start this with a slow body scan, then several minutes of deep breathing, then another body scan.  Ask the client to notice things, however small, in those areas between session and during breathing homework.
• The capacity to feel worse for a little while (both in session and between sessions). Obviously, do not jump into reprocessing with a client who comes to session and is shaking, sweating, and reports that she is near panic because of a recent incident.  The client must have the capacity to feel worse.  On the other hand, the client may benefit greatly from using EMDR to reprocess the recent incident after some deescalation or using of coping skills has occurred in session.  Targeting recent incidents is a good idea when they provide a gateway into potentially more central targets.
• Resources to tolerate the distress of activation. The first of these resources is awareness.  The client needs to be aware of when he is getting out of his range of distress tolerance.  Things need to be hot, but panic attacks in session are not good and should be avoided.  Taking at least one slow and deep breath before each check-in between sets can help “tap the brake.”  Encourage the client to take several deep breaths if needed.  Just be careful not to call on rescue or containering resources if they are not absolutely needed and you are not at the end of a session.   “Are you okay to notice that some more,” is the golden question.
• An emotional “brake” in place to avoid panic. If the client is rapidly heading outside his range of tolerance and is near panic, the client and the therapist need to have a plan in place to deescalate quickly.  These resources should have already been tapped in and strengthened before reprocessing started, so that they are accessible.  Unless the session is almost over, the goal is to decrease distress enough to continue reprocessing.
• Enough good and adaptive stuff for the maladaptive stuff to merge into. If the client does not have this, you need to help her create it and this can be started before reprocessing or as interweave (providing psychoeducation about guilt, blame, and childhood development so client has some cognitive framework for not blaming himself for his abuse, etc).  This can be more directive than the standard protocol, but Shapiro’s core cognitive interweaves in Chapter 10 all help the client create enough “good” for the maladaptive stuff to merge into.  Keep in mind that successfully processed positive beliefs are some of the best “good stuff” that there is, so don’t miss opportunities to highlight those recently developed assets as well.

When Resources go “Bad”

• Some clients may have strong reactions to resources.  Some may cry.  Some may escalate to the edge of panic with no warning.  Focusing on a stream of light may trigger the darkness, focusing on breath may open internal voices, and imagining a calm place may open memories of terrible places.  It happens.  Just normalize it as part of the process.  Validate the client’s experience and emotion.  It’s neither good nor bad.  When you work with trauma, you work with lava.  It seeps out.

Target Selection

Client identifies a target, but reports a lower than expected SUDS (4-6) at beginning, but you suspect that the target may be hotter than the client is reporting.  This does not happen often, but when it does it can be tricky because of the way things are almost happening and progressing (like an engine that is sputtering).  You can try one or more of the following:

• Proceed as normal and see what happens. There may be enough to reprocess.
• If the other parts of the setup are good, you can try giving a few sets for the client to “load up” the target and it may get “hotter” as the client focuses on it. If the distress level increases (based on what client is reporting and what you are seeing), you can continue as usual without rechecking the SUDS verbally.
• Ask if there is something that is getting in the way/interfering with the emotion of this target (dissociation, weed, benzos, “woke up with flat/detached mood today,” etc).

Reprocessing Issues

Client has identified a target that is likely to be intense.  These things can help manage that intensity.

• Encourage the client to keep his eyes open during reprocessing.  If clients aren’t sure where to look, I invite them to pick a spot of bookshelf, floor, or wall that is next to me (so that I’m not the center of his focus).
• Remind the client before and during that this memory is “old stuff” and that she has already survived it.  Remind the client that time travel is not necessary or recommended.  I tell clients, “as you have that memory, make sure that you keep your feet on this floor and your seat in this couch… it’s not important to go fully there… just remember a little piece of it at a time and remind yourself where you are right now.”
• Distancing techniques. Inform the client that she can “see” the memory on a notecard from across the room (to provide some distance on the visual component).  You can ask the client to imagine the memory on an opposite wall and imagine a large glass wall between that memory and the client.  Ask the client to imagine that he is riding on a bus and the memory is passing outside as landscape.  Invite the client to “turn down” one of the senses.  Try to remember it without sound, then bring sound in later.  As intensity decreases, you can invite the client to have the memory more directly and fully (and by then, the client will likely be able to handle the memory closer).  Many clients with severe trauma will struggle with distancing techniques because of the way traumatic memories tend to saturate sensory and visual memory (again, eyes open can help).
• Encourage the client to engage in deep breathing while reprocessing. Take one (or more) deep breaths with the client at the beginning of the check-in between sets.
• If the target memory is more of a video than a picture (and it usually is), invite the client to “play” that memory, but use the play, rewind, pause, and fast forward buttons. Invite the client to fast forward through difficult parts initially, then transition to playing and holding the whole memory (or whatever feels most comfortable).  I use the play and pause buttons in many sessions with good results.

When clients have a lot of pain or other baseline sensations in their bodies. 

• Many of the clients that you see will have physical health issues that may intersect EMDR reprocessing.  Clients often say “I’m noticing it in my neck muscles now, but my neck muscles are always tight and painful.”  Just have them notice it there for several sets.  Often, the tension will change, move, or relax.  The extra sets of noticing often helps clarify if the sensation is an element of the client’s reprocessing.

Dealing with holes in trauma memories (when these hole exists where there was once visual memory).  Clients sometimes have parts of a memory that drop off, often leaving some memory on either or both sides of that void.  Clients tend to get frustrated when they get to that void.  These things can help:

• Normalize that this does occur in trauma and that those memories may come back or may not, but frustration or anger will not bring them back.  A good metaphor is a book that has had a page torn out.  If the page is in the kitchen junk drawer, it might be possible for that page to be found and taped back into the book.  If the page went out with the recycling 20 years ago, it’s likely gone.
• The good news is that it does not have to come back for deep healing to occur (small pieces of memory, contextual details, or perspective changes are likely to occur).
• You can target the “heat” on either side of the void (you target what is there).  You can target the body memory and emotions that often occur when the client thinks about the event.
• Clients can often identify other targets that are related to holes in memory and healing can come from processing those adjacent memories or body memories.

When the traumatic events occurred in early childhood and no visual memory exists:

• Clients tend to get frustrated at the inability to remember all or parts of horrible events.  Normalize this and explain that those memories may or may not come back. They do not need to come back for healing to occur.
• There are often body memories when the client thinks about that time.  Target what does exist, even if it’s just a “gut feeling.”
• During targeting of body memory, clients often imagine themselves in the early childhood home and there are emotions attached to specific places and body sensations related to those places.  Follow that.
• The client likely has memories later in childhood of instances of body memory or strong emotional responses that are linked to the trauma that occurred earlier in childhood.  For instance: “I always felt nauseous every time I saw [someone]” or  “I remember seeing a picture of myself from that time and I immediately felt [emotion].”  These are all potential targets.
• You can target what it means that “I don’t have visual memories of what happened to me.”
• Be careful not to fill in the blanks for the client.

Try to attune with (or tune into) the processing of your clients.

• Notice shifts in client energy, changes in breathing, changes in movement, or changes in facial movements and pace your check-ins accordingly.  Give the client at least several seconds after a change or shift before checking in.
• Shapiro talks about EMDR reprocessing as being like a train.  You want to stop at the stations and not when the train is trying to chug up a hill.  This is easier to do with some clients than others.  Your clients can help you with this.  Just ask them.  Do you need longer or shorter check-ins?  For clients that you have been doing EMDR with for several sessions, you can ask them to signal you when they are ready by looking up at you.
• If you have trouble attuning or following a client’s energy shifts, at the very least stay very still and quiet in your chair.  Your attentive presence helps ground the client.  Tell the client that you are not going to move while she is reprocessing (particularly those who process with eyes closed).  Obviously, don’t text or type on your computer while the client is on the machine.  Your attention counts, even if you struggle attuning.
• It works well to take a big breath with your clients before each check-in.  I prefer to check-in near the end of the client’s out breath, so that the client can go into a deep in breath.  I have never had a client ask me to not breathe with him.  I’ve never had a client indicate that taking a deep breath before check-ins isn’t helpful–quite the opposite.

Dealing with unspeakable targets.

• Several clients have expressed interest on working on targets, but didn’t want to tell me what the target was because they didn’t want that image from their experience “in my head” (i.e. they want to protect me from it) or they didn’t want to verbalize it (too intense for language). I tell my clients that it is ok to not tell me.  After they have processed the memory, the usually do.
• This is going to come up, so you should be prepared for it. You will need to implement a interweave on occasion that allows the client to separate bodily sensations of pleasure/arousal, particularly during childhood sexual abuse, and the incorrect belief that “because my body responded in a certain way, that means I wanted it/I’m bad/etc.”  This is a tricky interweave and the belief is guilt and shame saturated.  Adaptive reprocessing may not occur until you provide some psychoeducation separating and normalizing arousal.  Likewise, many clients report extreme guilt and blame about wanting the adult attention that sometimes came before the traumatic experience.  An interweave that separates the client’s longing for attachment from the trauma that the abuser inflicted is essential.  “It sounds like you just wanted someone to pay attention to you, but you did not want him to do what he did to you.”

Anticipating unspeakable sensations.

• Part of my initial psychoeducation before reprocessing is to tell clients to follow body sensations wherever they appear in the body.  I say things like, “if it moves down to your toe, notice it in your toe.”  Also, “notice whatever comes up and if things come up in strange places, just notice those sensations there.  You don’t need to tell me what or where you are noticing things if you don’t want to, just notice it.”

Client is using the tapers and reports that he is dizzy.  This happens once or twice weekly with my clients.

• Let the client know that this is normal and invite the client to open her eyes on the next set. Opening eyes seems to quickly resolve dizzy and once the dizziness subsides, it is usually gone for the rest of the session.

Strategy to manage general intensity (client and mine) in session.

• With most of my clients, we take a slow and deep breath before every check-in. I often introduce a long pause, sometimes 3-6 seconds after the end of the breath to ask “What are you getting?”   This is consistent with my observation that if you want to get a lot of things done, sometimes the best way is to slow things down.  This deep breath that we take together taps the brake, helps the client come more fully back into the present (google: Levine titration), and can help with therapist-client attunement.

What if a sensation seems stuck…

• If you intuit that the client is stuck because he is aware of body sensations but not actually noticing them, you can ask the client to turn down other channels and focus on the body sensation channel.
• Some other common causes: blocking beliefs, something coming in on one channel or another that client is actively pushing away, or some form of difficult to resolve conflict or tension between multiple channels at the same time (which often ultimately involve blocking beliefs).  Ask the client if anything is coming in on any of the other channels.
• Some bodily sensations are stubborn.  They may take more than several sets of BLS to shift and clear.  It’s hard to tell.  You don’t want to have the client noticing many times if the client is fruitlessly looping and you should be targeting the block.
• One quick and sometimes fruitful interweave that is particularly helpful near the end of a session when a client seems stuck on the same somatic sensation is to say, “Do you have any sense of what [that sensation] needs to be okay?  Can you ask it?”  Sometimes a blocking belief appears.  Sometimes that question encourages clients to notice that sensation from a different angle.  You can ask the client if something is coming in on another channel that explains why that sensation has the tendency to stay where it is.
• If I suspect that a “stuck” sensation isn’t really stuck, but shifting slowly, I may ask the client to notice the edges of that sensation.  Or “can you notice what happens when you try to pay attention to its size or its edges?  Or, can you try to weigh it with your noticing?”  Again, this encourages them to notice it differently and often results in a shift or movement.  During this process of exploration, a client that recently appeared to be “stuck” with a persistent stomach sensation was able to discover that there were many different layers of stomach sensations and each corresponded to a different emotional state. The client was able to explore and move down through those various layers in ways that were important to reprocessing that session and subsequent sessions.
• When a client reports sensations in multiple parts of the body and little movement, an interweave that connects sensations with emotions is often helpful.  If the client reports being both angry and anxious, ask where each is sitting in the body.  This can allow the client to focus first on one and then the other.
• When a client appears stuck, it can be difficult to determine the cause.  Don’t just assume that the same client report across several sets always means that looping is happening or that something is blocking processing.  Some sensations move and shift slower than others.

Client is “coming up” from intense reprocessing and body sensations have been releasing.  The patient reports that they feel like they are light/floating, that they feel tingling, or that they feel waves of sensations. 

• Sometimes these sensations are scary to clients who experience them for the first time. This happens most often when the client has been working on an intense target and was able to resolve it quickly (and “surfaced” from the distress quickly).  Reassure them that these are normal and common experiences in EMDR and to just notice them.
• If using tappers and the light/floating sensation feels dizzy, invite the client to open his eyes through the next set (if eyes have been closed).

Everything goes as expected the first few sets, but things fizzle or go blank and it’s unclear why.  You can try one or more of the following

• Was the client’s reaction to this event after it happened to go numb or blank?  If so, this is a completely expected reaction.  Validate that.  You may need to talk briefly about that response.  You can ask the client to just notice that reaction before attempting to restart (if noticing that reaction is a dead end).
• You can always go back to target.
• Reset the target. Have the client push the image or the snippet of video memory away for a moment and bring it back fresh and notice what comes up as it comes back.
• Check other channels (particularly thought and emotion), they may contain clues related to what is happening.
• Check for blocking beliefs and target those blocks.
• Check for awareness of anything that happened/last thing that happened before things fizzled.

Ending Sessions

Trouble managing time/process of EMDR in session.

• EMDR requires that the therapist pay even more attention to time throughout the session than in talk therapy. It is important to find ways to wrap the session down in ways that don’t send the client home in the middle of an abreaction or in high distress.
• When starting EMDR with a client, try installing resources in the session before the first reprocessing session (I sometimes spend a full half session or more working with the client to install resources, particularly for my most complex clients). Before the first EMDR reprocessing session, quickly check the status of each resource using slow bilateral of one set of BLS for each resource.  If the resource still feels strong and accessible, we continue as normal.  This takes very little time.  Installing resources and highlighting them often adds grease into the EMDR process and can make reprocessing go smoother and faster.
• The client reports that a new memory is coming, but there are only 15 minutes left in session. Inform the client that we will need to wind down soon and ask if there is enough time to take on that memory.  If the client hesitates because of its “heat” or if this is one of the client’s first reprocessing sessions, encourage the client to move that target to the target list, possibly next session.
• In general, you want to leave plenty of time to close the session and to access resources as needed to close the session safely.

Client has lots of movement through sessions, but consistently ends on 3-5 SUDS without time in the session to go lower.  You can try one or more of these going forward so clients get better session closure:

• Make the time, if possible.
• Try starting reprocessing in the next session earlier. Ask the client if it is OK to do a short check-in at the beginning of next session and to start reprocessing.  You can do reprocessing in a 55 minute session, but 40-45 minutes isn’t enough for many clients to clear targets in a single session.
• You can ask the client focus on the body sensation channel as a way to close the session. With about 10 minutes left, ask the client “Where is that [3, 4, or 5] sitting in your body?”  Have the client focus almost exclusively on that sensation.  The vast majority of the time, when clients focus on that residual body sensation, it will shift or release and the client will report an SUDS of 0 or 1.  Check back in with it at the beginning of next session.
• Make sure that you return to open targets in subsequent sessions. Often clients only need a little bit of additional time to close them (the SUDS may have gone down since last session).  Don’t forget to install positive belief.  It’s okay to have open targets, but it’s also important to close them.
• If a 3, “What is keeping it from going below a 3?” If it is because of what this memory connects to (i.e. larger adjacent targets), ask the client to focus just on the target memory and check the SUDS for just the targeted memory.  Make note of potential future targets that are hot enough to bleed into this target.  These are prime targets for future reprocessing.
• Is the target having trouble linking with the adaptive network? If the client makes good progress the first part (drilling down with a lot of movement and shifts) but struggles with the second part (release, linkup, and assimilation): check for blocking beliefs, work to provide adaptive information (help support or create the “good”), or work to scrutinize or target the blocking guilt, shame, or fear.