Engaging the technology: therapist and client
A number of EMDR enthusiasts held a comprehensive online discussion early in 2018 on the benefits and challenges of delivering EMDR online, and with thanks to Paul Gebka-Scuffins, we’re posting here a summary of what we explored. Note that various names crop up – their owners will know who they are, but we decided not to include surnames in this public-facing account.
We discussed the benefits of the group developing a crib sheet, a list of ‘do’s and don’ts’ to help therapist and clients engage with the technical aspects of preparing and participating in an online EMDR session.
It was highlighted by Gary that it was important not to reinvent the wheel and create guidelines that might conflict with ones developed by online governing bodies, e.g. The Association for Counselling and Therapy Online (ACTO). He said we should be cautious.
Consensus was that the crib sheet would merely provide a practical informal guide on how to use technology, to engage better in online EMDR therapy and to improve the client experience.
We agreed to email Mark with ideas for the crib sheet. Paul agreed to do some fact finding on other online therapy bodies and what they use.
Mark suggested it might be good in the future if the EMDR Association partnered with a governing body for online therapy like ACTO, to develop guidelines specific to online EMDR. He said he would mention it at the meeting of the coming week’s meeting of regional reps at the Association national conference.
It was noted that it is important that the first online session for clients to go as well as possible, and not be discouraged by technical problems.
It is the responsibility of the therapist to have an adequate level of PC/Online literacy before embarking on online EMDR. To make sure equipment is adequate, e.g.
- Working webcam, positioned webcam straight on and not directed up therapist’s nose;
- Minimum Windows 10/updated Apple operating system;
- High speed broadband;
- and they are familiarised with the use of online platforms (see below for the best, and for security implications);
- Have a professional appearance online, well lit, neutral room background;
- Remembering to ask the client to bring their own tissues to session.
It was also important to have a backup strategy, i.e. to be able to phone client and guide them through any technical problems. A few therapists said they used WhatsApp, or mobile phone as an alternative method of communicating with client.
On a positive note, solving technical problems together can strengthen the therapeutic relationship. It’s important to be positive for the client. It is important to explain to clients that the first session may have technical challenges and to give permission and time to learn about it.
One colleague felt it can be exhausting when first setting out to provide online therapies (not EMDR) because of the new skill set employed and not being able to fully read the client’s body language.
Examples of platforms used by therapists include ZOOM, VSEE, WhatsApp, Skype, Facetime and Messenger.
It was highlighted that only a few platforms are certified encrypted and therefore protect the client’s confidentiality. The best is ZOOM, VSEE, and WhatsApp. The worst (and not recommended) were Facetime, Skype and Messenger.
Overall the group was impressed by the ZOOM platform due to its ease of use. It was possible to send an invitation link to a client and they simply click on it and they are guided to the session instantly. No need for client to subscribe to ZOOM beforehand.
Mark said he had essentially tried all platforms and ZOOM had never lost connection. He has several hundred hours experience of providing online EMDR.
A personal account with Zoom costs nothing and allows for unlimited one-on-one conversations, with the option (with client permission) to record. For working with more than one participant at a time for longer than 40 minutes, a subscription is required (about £12 a month).
ZOOM is encrypted but this feature must be activated manually in settings.
Mark emphasised that online therapy will become increasingly mainstream, and it benefits us to engage with it now.
Online EMDR especially can be a very intensely focused and effective treatment for clients. In his own experience it can be even more effective than face to face therapy.
Possible reasons for its effectiveness might be due to: participating from the safety and comfort of the home, and the focused attention created by the screen and headphones.
Gadgets and modalities: What BLS do therapists use online?
Paul said he preferred the use of headphones for BLS. He invites his clients to buy cheap open cup headphones from Poundland (£1) and download the BSDR app on their smart phone (£10). There are also free downloadable BLS soundtracks as well but we will mention them next discussion. Open-cup headphones allow the client to listen to the BLS on their smartphone and hear the therapist clearly on their PC monitor.
Judith asks client to put a little red sticker spot on either side of the PC screen. And the client does eye movement BLS from spot to spot. The client can find their own speed and be aware of the therapist being with them on the screen. Very simple. Doesn’t cost any money. But Judith also gets client to use butterfly tapping or tapping their thighs. Judith encourages the client’s own choice and varies it.
Mark says he works with audio BLS online (very comfortably) using headphones same as Paul.
Gary prefers eye movement BLS and found a YouTube video that the client can access on their PC and it shows a light spot going left and right on a black background. The speed is adjustable. Gary says “type EMDR into YouTube to find the link”.
Sarah uses a light bar behind her, lined up accurately from edge to edge of the computer screen or even on her phone (WhatsApp) at it works well.
Mark found eye movement BLS works extremely well if the client was experiencing high affect due to a large T trauma. But otherwise is comfortable using Audio BLS with client’s eyes closed, which works well for meaning-based work.
General online therapy training: ACTO
Gary shared his experience of training with the Association for Counselling and Therapy Online (ACTO).
It was four months of training involving online webinars, very practical hands on guidance, e.g. working with email, texting and using web cams. It involved role-playing as clients with the tutors.
The important ‘take home’ message Gary had was that eventually it will become a mandatory requirement for online therapists to have some type of General Certificate in Online Therapy to fulfil minimum government standards. These standards are not monitored so closely at this time but understandably it will tighten up soon.
Sarah is in the middle of doing her ACTO training and is doing a tailored version that focuses on web-cam based therapy (synchronous video) appropriate to EMDR. Finds it helpful learning about session structure, putting together an agreement, if clients want to use Skype, OK too but therapist needs to make clear the security implications for which the client needs to accept responsibility.
The training, said Sarah, involved a lot more paraphrasing, summarising, and going back to basic counselling skills which is exhausting, and the writing up of a weekly journal.
This course is 5 weeks, 1-hour webinar each week with an accredited ACTO trainer. It involves lots of reading, you write a personal journal of 1500 words, which Sarah says she finds difficult as she is not naturally academic, but she must show how she uses what she has learned in her practice.
Gary says his training was different and it sounds like there is a lot of variation.
Online EMDR session
The call heard feedback from Gary (as client) and Mark (as therapist) on a very real and full online EMDR session they had done earlier that day.
Gary kindly shared an attachment-based issue from the past that was affecting him in the present as feelings of rejection.
Gary shared that he had preconceived expectations of what the therapy would involve, e.g. he expected it to be Eye Movement-based BLS, and to have to first find a list of small T or big T traumas in his history.
On this occasion, Mark just did a very short history and used Laurel Parnell’s Bridging Technique (a simplified and focused version of the Affect Bridge/Floatback taught on basic training) as a diagnostic tool to identify a meaningful upsetting event that related to present issue around rejection.
Gary was surprised to find it worked so fast. The bridge went straight to a childhood memory around his father – an event he would not have looked for under the label of trauma memory.
Also, the BLS used were headphone audio with the BSDR app.
Gary said the Mark helped him to move “seamlessly” to reprocess these memories and feel “very grounded” at the end of session. He reported a significant improvement in his issue around rejection immediately afterwards.
Gary emphasised several times in his feedback the smooth, seamless movement from the important issue to feeling grounded at the end. He said it was a real piece of work about real issues.
Gary and Mark both noted that the intensity and intimacy of therapy was not hindered by being online. It was a connected authentic piece of work. And Gary felt safe and comfortable having EMDR treatment at home via computer (an external safe space as well as an internal safe space).
Gary said it was user-friendly and eliminated a whole load of stressors, like getting dressed up to go to therapy on someone else’s territory.
Mark took the opportunity to share more about his area of interest, which is Attachment-Focused work, and the benefits of using bridging. He said he witnessed Laurel Parnell doing many such demos and has done similar demos himself with trainees. He said this way of working means you can often complete a good piece of meaningful work in one session, ending every session with the tapping in of a positive.
Other therapists shared their positive experiences of using the affect bridge or float back as a diagnostic tool, and to promote the transpersonal benefits of EMDR when used in this way.
Suzi explained the bridging technique. You are looking at an issue in the present. What’s the picture that relates to that present issue? What do you feel when you see that picture? Where do you feel it in your body? What’s your belief about yourself that goes with that? And now, drop back in time, as far as you can, without censorship.
Mark (with Laurel) does not like the word floatback, as too disembodied. Bridging is straightforward, to the point, and simple. Clients get it, and bridging gets to the roots of the network.
Paul said he uses bridging regularly in therapy and it gets to the important implicit material.
Christina asked about clients deciding when to stop BLS. The number of passes in a set was discussed. Mark agreed with Shapiro that 24 is a good sensible starting number, but clients process in waves and intuitively know when they come to the end of a wave of processing. So, it can be increased as therapy progresses, with the client determining the length of set.
Some clients, said Mark, process for three minutes at a time, and up to even 15 minutes. If you are aware of the session time limit and you know what you are doing, EMDR is a marvellously permissive treatment.
Mark shared from his own personal experience receiving EMDR in this way in recent months healing a deep issue from his own childhood, talking also about the value of tapping in nurturing figures and archetypes, as he does routinely, including today in Gary’s session.
Mark shared example of using EMDR with couples. Sarah asked for a copy of the write up for this. (Note – the article Mark wrote for EMDR Now in 2014 is posted under Resources here. )
Clare asked can we suggest good quality equipment as the buzzers and headphones break often. Mark suggested Neurotek.
Alternative BLS audio CD- Mark suggested UpLevel by Robert Yourell
Everyone came away with new ideas, particularly on how to vary their BLS by trying BSDR, YouTube, and stickers.
Suggestions for next discussion:
Suzi would like to put ‘How to manage dissociation’ on the agenda for next discussion. As we are not in room with client. What can we do to keep our clients safe and manage risk?