NYC Psychotherapist Blog

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Wednesday, May 9, 2018

EMDR is a Transformative Therapy for Trauma, But There Are a Few Exceptions

As a trauma therapist in private practice in New York City for over 20 years, I have been using EMDR therapy regularly since 2005 with excellent results.  I have found EMDR therapy to be a powerful and transformative therapy to help clients to overcome traumatic experiences.  I've also written several articles about EMDR therapy.  See my articles:
Over the last 13 years, I have seen many clients for EMDR therapy for developmental and shock trauma.

EMDR is a Transformative Therapy For Trauma, But There Are a Few Exceptions

Clinically Assessing Clients For EMDR Therapy
As part of the initial consultation, I talk to clients about the types of trauma experiences where EMDR is effective which, fortunately, are most.  However, there are some exceptions when EMDR therapy would be contraindicated or where clients need more preparation to do EMDR, which is the focus of this article.

If a client comes to me for an initial consultation for EMDR therapy and reveals one of these contraindicated exceptions, I will discuss this with the client and will usually, if possible, provide him or her with another alternative recommendations.  If I don't do the particular alternative therapy that is needed, I usually offer to help this person to find another referral.

Although the exceptions to doing EMDR aren't many, when a client comes for a consultation and is told that EMDR therapy is contraindicated, this can be disappointing, especially since s/he may have heard about EMDR from a medical doctor, friends and the efficacy of EMDR to help resolve trauma.

But it's important for a psychotherapist who specializes in helping clients to resolve trauma to be a responsible and ethical therapist, even if the client will be disappointed and annoyed.

It's better to be honest with the client rather than go along with the client's wishes and place the client in harm's way or waste their time and money.

When is EMDR Therapy Contraindicated and When Is Additional Preparation Needed to Do EMDR?
For all EMDR therapy, after the initial consultation and a session or more to get family history, there is a preparation stage to help the client to develop the necessary internal resources and coping strategies to prepare to do EMDR.  However, there are times when EMDR is either contraindicated or additional preparation, beyond the usual, is needed.

The following is a list of the most common issues:
  • Clients Who Are Psychiatrically Unstable:  Clients, who are psychiatrically unstable, need to be stabilized first before doing EMDR therapy or almost any other type of outpatient psychotherapy.  Clients who are actively suicidal, homicidal, too emotionally fragile, or who have some other serious psychiatric condition that is causing significant emotional impairment, need a period of stabilization, and after stabilization, they will need to develop the internal resources before EMDR can be considered.  Once clients are stabilized and they have the inner resources to do trauma work (of any kind), the psychotherapist can reevaluate clients to see if EMDR therapy would be the therapy of choice.
  • Clients Who Are in An Unsafe or Unstable Home Environment:  Clients, who are in an unsafe or unstable home environment where they are being physically abused or they are the ones who are abusing a spouse or family member, are not ready to do trauma therapy.  They might need other types of help first, including but limited to:  supportive psychotherapy, domestic violence treatment, legal advocacy from an domestic violence agency, services from a child welfare agency, batterers' program and so on.  It would be irresponsible for a psychotherapist who does trauma therapy to ignore the fact that a client is in an unsafe home environment or is creating an unsafe environment.
  • Clients Who Are Actively Abusing Alcohol, Drugs or Other Addictive or Self Destructive Behavior: Clients who are actively abusing alcohol, drugs or engaging in other addictive or self destructive behavior are often not candidates for EMDR therapy until they have had a period of sobriety.  When clients are engaging in self destructive behavior as a maladaptive way of coping, chances are good that, if they began to delve into traumatic memories, they might become more symptomatic and their addictive or self destructive behavior would become worse.  This is a situation where the EMDR psychotherapist would have to evaluate on a case-by-case basis.  There are some clients in this situation who could benefit from the EMDR protocol that is specifically designed for addictive behavior (if the psychotherapist is trained in this type of EMDR).  However, even in those circumstances, the client would have to already have the necessary inner resources and there might be a significant period of preparation work before traumatic memories can be processed with EMDR.
  • Clients Who Are Unable to Engage in Dual Awareness in the Psychotherapy Session:  In order for trauma therapy to be safe and effective, clients must be able to maintain dual awareness in the therapy session.  In other words, they must be able to focus on the traumatic memory they are working on with their psychotherapist and also be aware of their here-and-now circumstances--that they are in a psychotherapist's office and not back in the traumatic situation.  So, for instance, if a client begins processing a traumatic memory with an EMDR therapist and the client plunges into the memory, she loses all consciousness of where she is, and she thinks she is actually back in that situation--rather than that she is with a psychotherapist, EMDR and other forms of trauma therapy are contraindicated.  There might be more preparatory work that needs to be done first to help the client to maintain dual awareness or, if that doesn't work, the client might not be ready for EMDR.  This might include clients who have DID (Dissociative Identity Disorder) where they become highly dissociative or switch into alters or clients who get thrown into flashbacks and have no awareness of where they are.
  • Clients With Certain Eye Problems:  Clients who have certain eye problems might need clearance from their doctors in order to do EMDR.  As an alternative, the psychotherapist can use other forms of bilateral stimulation (BLS) like tappers, tapping, listening to music that alternates from one ear to the other.
  • Clients With Certain Head Injuries:  Clients who have certain head injuries might need to get medical clearance from their doctors before doing EMDR.
  • Clients Who Are Unable or Unwilling to Adhere to EMDR Therapy Recommendations and the Therapy Frame:  EMDR therapy is a weekly therapy.  There if often a lot that comes up in session and between sessions so if clients are unwilling or unable to come to weekly sessions, they should seek another type of therapy.  In general, consistency in therapy is necessary for any form of psychotherapy to be effective.
  • Clients Who are Looking For a "Quick Fix":  Although EMDR therapy tends to be faster and more effective than regular talk therapy, it's not a "quick fix." Some clients come for an initial EMDR consultation with misconceptions about EMDR.  There are a few circumstances where EMDR therapy can be effective in 10-12 sessions.  These circumstances are rare.  They usually involve shock trauma where there were no other traumatic events prior to the shock trauma.  Even when clients come to EMDR therapy thinking that they have no other underlying trauma, in the course of doing EMDR therapy other underlying traumatic experiences might arise that are related to the current presenting problem.   In those cases, it is best to work on the underlying trauma or the client could get emotionally triggered again under similar circumstances (see my article: Beyond the Band Aid Approach to Overcoming Psychological Problems).
  • Clients Who Are Engaged in Lawsuits Related to Their Trauma Should Consult With Their Lawyer First:  Clients who have a pending lawsuit are often advised by their attorneys not to do EMDR therapy before their case is settled.  There can be many reasons for this, but one of the main reasons is that if a client goes to trial after the trauma has been resolved, it might be difficult to convince a judge and/or jury that s/he was traumatized because they will not be exhibiting any traumatic symptoms.  This is more of a legal issue than a clinical issue.  However, many clients, who have lawsuits are unaware of this.  So, it's advisable to consult with your attorney first.
  • Other Clients Who Need a Significant Preparatory Phase in Therapy Before Processing Traumatic Memories:  Aside from the other conditions already discussed above about clients who would need significant preparatory work, there are other conditions that might require preparatory work and reassessment.  One example of this might be clients who are unable to identify the emotions that they are experiencing.  This is important because in EMDR clients are asked to identify the emotions that they are experiencing now with regard to their traumatic memories.  If clients are so cut off from their emotions, as part of their preparation for doing EMDR, they will need help to identify their emotions (see my article: Experiential Psychotherapy Can Facilitate Emotional Development and Developing Internal Resources and Coping Strategies).  Another example might be clients who have personality disorder traits and who are emotionally unstable.  
EMDR is an evidence-based therapy that can help clients to overcome traumatic experiences.  This includes longstanding trauma that has not responded to other forms of psychotherapy.

There are a few circumstances where EMDR therapy is either contraindicated or where preparatory work, beyond the usual preparation, must be done first in order to determine if clients can do EMDR. This is part of the psychotherapist's clinical and ethical responsibility.

An EMDR therapist continues to assess the client during the initial consultation and throughout EMDR processing for situations that might arise in the therapy where EMDR might need to be combined with other forms of therapy to be effective (e.g., Somatic Experiencing or clinical hypnosis) as part of an integrative psychotherapy.

Although I have included the most common examples of where EMDR therapy is either contraindicated or additional preparation is needed first, there might be a few other circumstances.

Getting Help in Therapy
If you have been struggling with unresolved problems on your own, you could benefit from seeking help from a licensed mental health professional (see my articles: The Benefits of Psychotherapy and How to Choose a Psychotherapist).

Working through your traumatic problems could free you from history and allow you to live a more fulfilling life.

About Me
I am a licensed NYC psychotherapist, hypnotherapist, EMDR and Somatic Experiencing therapist (see my article: The Therapeutic Benefits of Integrative Psychotherapy).

I work with individual adults and couples.

To find out more about me, visit my website: Josephine Ferraro, LCSW - NYC Psychotherapist.

To set up a consultation, call me at (917) 742-2624 during business hours or email me.