"Is EMDR the Right Therapy for You? Here's What You Need to Know Before Your Next Session"

Disclosure: I am a Certified EMDR Therapist and a EMDRIA Approved Consultant and practice EMDR as my primary model of therapy. Some say I’m given to hyperbole, but when you’ve spent centuries and bazillions of dollars training you tend to be the best therapist who ever lived! (a joke!) Seriously, this article contains things I’ve learned from scholarly studies and training, but much of it simply comes from my own experiences in my own practice of EMDR. One thing I’ve learned is that some clients simply respond better than others to EMDR. I have attempted to outline these, along with some very serious warnings that will be helpful whether you are a therapist or a client.

EMDR therapy is rapidly becoming the “go to therapy” for trauma, anxiety, and other significant mental health issues. Research in EMDR continues to expand the applications and efficacy of EMDR. With all of the good news it may be easy to see EMDR as a “silver bullet” therapy. As an EMDRIA approved consultant I am a firm believer in the efficacy of EMDR therapy. That said, even EMDR has some limitations and will not work under every condition.

Before discussing the bad news, there are important factors to consider that make EMDR extremely effective. Some of the more important factors that make EMDR fast, gentle, and effective are listed below.

1.      Higher level of functioning. Generally speaking, clients who function well individually tend to do well in EMDR. This is, perhaps, due to the fact that processing occurs in the prefrontal cortex. This doesn’t mean that, in order for EMDR to be effective, you have to be a NASA engineer. A normal level of functioning is more than adequate to allow effective processing during EMDR therapy. The principle is that higher functioning clients typically do a little better, with processing being faster and easier.

2.     Client Engagement. This is a critical factor, not only in EMDR, but most models of therapy. Clients who are engaged in therapy generally do better and complete therapy faster. Engagement in EMDR usually means participation during sessions and occasionally homework between sessions. There is a concept in therapy called “spread of effect”. This means that the results of therapy can range between extremely positive to extremely negative and harmful. One of the factors that determine the effectiveness of any therapy is client engagement.

3.     Client Insight. Client insight is your ability to look inside yourself objectively and see your own internal world. This means having the ability to identify your emotions, body sensations, and even your motivations. None of us have perfect insight and none of us are able to perfectly detect and identify every emotion and motivation. The idea is that the better the insight, the better the outcome.

4.     Open Mind. Having an open mind does not mean trusting your therapist unconditionally. That is entirely unrealistic and even unhealthy. EMDR is a different kind of therapy that works from a “bottom up” (nervous system) perspective, rather than a “top down” (thoughts and behaviors) perspective. In EMDR therapy, you may be asked to notice feelings in your body and notice the emotions as you feel them. It is not uncommon for a client to say “I’ll do it but I don’t believe this can help”. This is usually followed later by “I’m shocked. I didn’t think it would work!”. One of the really impressive surprises in EMDR is that, as a client, you don’t have to believe it will work for you. You just have to follow along with your therapist. This, of course, assumes your therapist is properly trained in EMDR and working ethically. EMDR is a little different so just keep an open mind as your therapy develops.

Actually, the bar is pretty low to experience impressive results and fast healing from trauma and trauma/anxiety issues. The above items represent the ideal and make EMDR much faster and more effective. If you believe that one or all of these issues don’t describe you, don’t worry. Your therapist can guide you effectively into healing. These issues are some of the things that make EMDR much easier but you don’t have to fit the ideal to participate effectively.

With good news often comes the “not so good news”. While EMDR is normally fast, gentle, and effective, there are some clients that are likely to struggle with EMDR therapy. This is NOT an EMDR specific problem and the issues below will likely apply to most other models of therapy, but are worthy of mention. Some issues that can make EMDR more difficult are:

1.      Very low intellectual or cognitive functioning. If you are reading this article and are following the general concepts, this does not apply to your situation. Low functioning, in this context, means difficulty understanding basic concepts, instructions, or language. Because trauma is processed in the “executive center” of the brain, this area has to be functioning at an acceptable level. Examples of low functioning of this magnitude might include borderline intellectually disabled, severely delayed intellectual development or other issues that make normal day to day functioning impossible or very difficult.

2.     Recreational drug use. This may include marijuana, methamphetamine, cocaine, alcohol, hallucinogens, or other “non-prescribed” drugs. Many of these drugs impair cognitive or emotional processing by “dulling” or “numbing” the very parts of the brain required to adequately process traumatic stress. This list also includes all opioids. There is a very long discussion attached to this issue and is often intense and emotional. Still, the evidence is clear that some drugs can hamper processing of traumatic stress. Having said that, some drugs, under doctor supervision have shown promise in treating treatment resistant trauma. Ketamine assisted therapy is a prime example. While the research is not conclusive, and I do not recommend or discourage this type of therapy, there is promise.

3.     Benzodiazepines. Benzodiazepines deserve a special place in the cautions of using EMDR or any other trauma therapy. The research I was able to find indicates that benzodiazepines hinder memory recall and processing of traumatic memories. In the past I have worked with clients that have discontinued benzodiazepines and occasionally those taking low-level maintenance doses. I have become much more cautious when accepting these clients. The tendency is to have a strong desire to help and see healing. The hard and cold fact is that benzodiazepines significantly complicate therapy. Memory retrieval is difficult and often disjointed and blurry. This can, on occasion, make the past trauma seem even worse than they are, and can occasionally activate the fight or flight reaction in the brain stopping processing. A general rule is that benzodiazepines should be discontinued long before attempting trauma therapy. The GABA receptors in the brain and the GABA and dopamine system should be completely healed before commencing EMDR therapy or any other trauma therapy.

4.     Neurological Damage. Neurological damage of any kind can often hamper or inhibit processing. This, of course, depends on the area(s) of the brain affected and the extent of the damage. Severe neurological damage in the brain itself tends to cause difficulty with trauma therapy. If the prefrontal cortex, the hippocampus, or the amygdala is unable to adequately activate and retrieve implicit memories, processing is difficult at best.  If the client is completely unable to access any implicit memories processing is most often, impossible. Many of my clients have had mild TBIs and have done extremely well. If you have suffered mild neurological damage due to an accident, injury, or disease, this, in itself, will likely not prevent your successful healing with EMDR.

5.     Personality Disorders or other co-occurring serious mental illnesses. Often clients with significant childhood trauma have developed personality disorders. Often these personality disorders prevent the client from being able to access or even see the trauma. These clients often just don’t see the past trauma itself but attribute the problems to current situations or people. This makes trauma processing extremely challenging. Having said that, many therapists have had successful outcomes using EMDR with clients suffering with personality disorders. For clients with personality disorders, the ideal solution is with a therapist that specializes in personality disorders. You may also find a group that employs EMDR therapists and therapists that specialize in personality disorders.

6.     Disengaged Clients. We’ve all been to our primary care physician and had our temperature, blood pressure, and heart rate checked. We may have even had other tests run or had injections. This type of healing usually is more passive. We stick out our arm and the medical professional measures, pokes, and prods while we sit there passively. Psychotherapy is quite different and is an interactive exercise. Your therapist will likely teach skills along with the regular sessions. These are to be practiced between sessions and will greatly contribute to your therapy and personal healing.

While these warnings should be seriously considered, I was unable to find definitive peer reviewed research that would preclude success in EMDR therapy. The bottom line is that every client and every therapist is different and what might preclude one client may not another. Unfortunately, this is something we learn from experience and training. Early in my career I believed I was God’s gift to the therapy world and accepted almost any client with any condition or goals. Over the years I’ve learned that, while I believe EMDR is the most effective treatment available for trauma, there are certain conditions that make it especially difficult. I have had to learn my own limitations and accept that not every client is a good EMDR candidate. I hope this short post has been helpful. Please feel free to contact me if I can be of any assistance.