It is wise to be adequately prepared for any journey. Preparation is particularly important with my clients because most have extensive trauma histories spanning decades, many have severe PTSD symptoms, many also have severe and chronic pain (usually from either a series of accidents or from one or more autoimmune diseases), most have at least some history of psychiatric hospitalizations, and the vast majority have few sources of current and past social support. Most clients who initially come to see me do so because they are hoping to find a way to feel less miserable, not because they expect a comprehensive restoration of health or functioning.
This preparation seem to help improve the patient’s experience in EMDR reprocessing, increase the chances that they will return to continue therapy, and provide a consistent foundation that will guide many aspects of treatment and recovery. For some clients, it is possible to do all of these in three sessions (even for clients with extensive trauma histories). For other clients, preparation will need to last an additional several sessions. For a few, preparation takes months. Some clients will need much more than is captured in this checklist.
My Own Assessment
- My clients who most obviously meet criteria for PTSD will often come to me with a long list of past diagnoses and PTSD is usually not one of them. I have never met a client who has received any structured treatment for trauma, despite many of them being in therapy for much of their lives. Because trauma is the invisible elephant in mental health treatment, I want to conduct a trauma informed assessment with the client.
- It’s an art to do a comprehensive assessment in ways that minimize triggering when working with severely traumatized clients. These rough guidelines help:
- When nearing questions related to trauma I explain that we don’t need to talk about anything related to past trauma today. I explain that it’s more helpful to know how past experiences impact the client now than any details about what may have happened to the client in the past. “We can get to that stuff later, when or if you feel more comfortable with me.”
- Clients are much more comfortable talking about present trauma symptoms than they are talking about what has happened to them.
- The PCL-C is a great public domain assessment of current symptoms in ways that are rarely triggering. It uses vague language related to “stressful experience from your past” when asking about current symptoms.
- There is no need to push in the first session or two to make a definitive PTSD diagnosis because you lack information about specific traumatic events. An anxiety diagnosis, depression diagnosis, or other traumatic stress diagnosis is usually fine initially and the client will usually easily meet criteria for one of them. You can always change your diagnosis as you get more information.
- Dissociation is a common feature of trauma. For clients with high PCL-C scores, I may administer the Dissociative Experiences Scale (DES) in the first or second session. I read the questions. This allows for a conversation that is usually very helpful. It’s rarely triggering.
- You can learn a lot about how the client has learned to go away by studying the client’s scores in specific domains. You will need to do extra resourcing with clients with severe or extreme DES scores.
- Looking closely at the patient’s score on the Burns Anxiety Inventory (a standard instrument at my agency) can also be helpful. If the client’s score is high in all domains except somatic sensations, you can expect some level of problematic dissociation.
- If a client reports severe or extreme anxiety or depression and can’t identify where sadness or anxiety sit in the body, you can expect some level of problematic dissociation.
- A comprehensive assessment provides an early glimpse at client’s current support system, history of functioning in assorted domains, and ways that the client carries trauma. It’s also can be an important look into periods where things were good or when people or family members may have loved the client in healthy ways. All of this (when it exists) is helpful in later resourcing.
Good metaphors can save a lot of time when it comes to psychoeducation and promoting a shared language of the problem and its treatment. My clients seem to understand intuitively the seeping box/leaking box metaphor for trauma (see: The Seeping Box Metaphor for Trauma). It is also helpful to conceptualize trauma recovery as a journey, with each session as a segment of that journey (see: A Workable Metaphor for the Therapist Role in EMDR).
Assessment of Client’s Capacity to Notice
Noticing is an essential component of EMDR. For most clients, I inquire during the assessment (and in subsequent sessions) where the client notices emotions in his body. Most clients are acutely aware of somatic sensations when anxiety is near the panic range, but many sensations below that range are simply not on the client’s “radar.” Not noticing the body is a long-term coping mechanism for many clients. We will spend time developing resources that may help improve the client’s capacity to notice.
Psychoeducation about Trauma and Recovery using EMDR
As soon as possible, I want to start providing education about trauma. This education includes:
- The idea that trauma symptoms are a completely natural response to overwhelming experiences. I want to stress the idea that I don’t think there is anything “wrong” with the client and I certainly don’t think that the client is “crazy.” “Your brain may just be responding in ways that healthy brains respond when they are subjected to horrible and overwhelming experiences.” But, the brain and body also know how to heal from these experiences.
- I want to gently introduce the idea that healing is possible. This can be a triggering and unbelievable idea for many of my clients. I stress that it is not necessary that the client believes in the possibility of healing.
- Before treatment planning, I want to provide a clear explanation of EMDR and the client and therapist roles throughout.
- I provide a clear explanation of things that need to be in place before we will begin reprocessing any trauma:
- The client will need to be embodied enough to notice/have the capacity to notice (for some clients, this may vary from one session to the next).
- The client will need a “brake” or resources to manage things that may come up during and after sessions.
- On any day that we plan to reprocess past trauma, the client will have the capacity to feel worse for a little while (not just in session, but between sessions).
Clients with a clear thought disorder or mood cycling will be referred to an agency psychiatrist for an evaluation for medications. My preference is to allow psychotic symptoms or mood cycling to stabilize some prior to starting reprocessing. With my clients, stabilization on medication rarely takes more than a few weeks. I’m unlikely to start reprocessing with a client who is not on medication and is having active psychotic symptoms, mania, or is in the middle of a severe bipolar depressive cycle.
I provide information related to benzodiazepine and marijuana use and I inform clients that reprocessing will work best if no use has occurred earlier in the day of a reprocessing session. If a client has taken a benzo, consumed alcohol, or used marijuana within 8 hours of our session, I usually suggest that we defer reprocessing until the client can come to session without use. I educate clients that use after sessions may interfere with the ongoing reprocessing that occurs between sessions. I may work with the client to schedule sessions earlier or later, depending on patterns of use.
Careful Review of Existing Resources (Including Presence of Adaptive Information)
Many of my clients have few social resources, very little history of nurturing relationships, and extensive and life-long trauma. When searching for resources, I may ask questions like: “When you are really upset, how do you calm yourself?” “In prior counseling, did you learn anything helpful?” “When you were young, who was there for you?” “Who is there for you now?” The presence of existing adaptive (or neutral) coping strategies, spirituality, long term friends, any history of nurturing childhood relationships (including aunts, friends, mothers of friends, teachers, etc.), or memories of the client nurturing her own young children may contain elements that can be leveraged in resourcing (particularly when developing helper figures or nurturing/protective resources).
I also listen carefully for potential deficits in adaptive information. I’m likely to spend more time developing resources for clients who report no positive attachments throughout childhood or with clients who feel responsible for everything that has ever happened to them. Themes surrounding shame, blame, and responsibility are very common among trauma survivors. They are also among the most common blocks to reprocessing.
Develop New Skills to Manage Acute Trauma Symptoms: Fire Extinguishers
For clients with acute PTSD or trauma symptoms, I work in the first and second session to help the client to develop resources to more effectively manage some those symptoms. For clients who have frequent flashbacks, I introduce a structured visual grounding exercise that helps nearly all of my clients displace flashbacks within seconds (see: Displacing Flashbacks with Visual Grounding). For clients with severe anxiety when triggered (or frequent panic attacks), I introduce deep breathing. We may spend a lot of the second session exploring any difficulties with deep breathing (see: “Deep Breathing Doesn’t Work for Me”).
Informed Consent and Treatment Planning
I provide all clients a simple and clear understanding of the history of EMDR, what an average session looks like, what changes commonly occur related to the target memory during an average session, and a detailed explanation of therapist and client roles. I’m also very clear about the options clients have related to approaching a targeted memory (see: Some Notes on Abreaction in EMDR). For clients with severely complex trauma, starting with the worst part of a target or starting with the worst memories may not be the best approach. I am also clear about the possible benefits and potential risks of starting trauma reprocessing right now. It is possible that life might become more difficult in the short term as the client starts this healing journey. We have a detailed conversation about client fears and concerns related to starting this journey.
Client is Adequately Resourced
It is possible to do EMDR reprocessing with some clients without doing any resourcing, just like it is possible to drive across town in a vehicle without reliable brakes. It may be possible, but it’s terrible idea. I will not do reprocessing with any client that does not have a working and demonstrated resource in place to help manage what may come up in session and between sessions. I feel more confident that the resource is accessible to the clients when they are able to model it in session, use it between sessions, and we are able to successfully “load it/tap it in” as resource in EMDR. I’m not picky at all about the type of resource. It can be embodying or dissociative. It can be a spiritual figure. We go with whatever the client has or is able to develop. It is not unusual to add new resources after the initial reprocessing sessions to address deficits or to supplement existing resources