Naomi Fisher is based in Paris, and has been working with EMDDR online for a good two years now – finding it, as I (Mark Brayne) and many of my colleagues do often at least as good as face-to-face (which of course it also is) and sometimes even better.
Naomi is an EMDR consultant and facilitator, and an independent clinical psychologist. She offers clinical supervision and therapy exclusively online, and can be contacted here.
And now, her guidelines, also downloadable here as a PDF: Using EMDR Online – Naomi Fisher.
Ten Tips for Using EMDR Online
Practice Based Article
I never thought it was possible to do EMDR online. As a clinical psychologist and EMDR Consultant who has been using EMDR since 2005, I occasionally did other sorts of therapy online if I had to, but EMDR? No. It seemed safer to keep that for my clinic room.
Then I moved to France. Suddenly I was not able to set up a practice or get a job, because here I had no core profession; my title did not automatically transfer. As I looked around for alternatives, working online – with people outside France – was an obvious choice. But I was still wary about using EMDR online.
As I started to build up my online practice, I couldn’t help trying out some EMDR preparation techniques. EMDR is the basis of my therapeutic practice, it forms the majority of what I do. I use CBT and ACT as well, but without EMDR I felt like there was a huge hole in my approach. So I started with some resource installation, installing a safe space, and tried out preparation techniques such as Flash, CIPOS and Loving Eyes. In order to do this, of course I had to work out how to best use BLS online. As I did this, I become more confident and started offering full EMDR processing to people who I felt confident could manage this.
It worked. Just like it does in the room. In fact, in some ways it felt even more attuned. I felt deeply in touch with my clients, thousands of miles away. We created a little therapeutic bubble, in virtual space. Now I’ve been using EMDR online for nearly two years, and this is what I’ve learnt.
1. Expect technological problems in the first session. I see the first session in online therapy as a chance to sort out issues and create the space. I don’t send out lots of guidelines in advance, I just ask them to find a quiet uninterrupted space with a good internet connection, and to make sure someone else is looking after the children if this applies. I use the first session to talk about how we can create a therapeutic space together and form an online therapeutic relationship. I always have a phone number for people and if there’s a problem with logging on, I ring them. Sometimes I talk them through installing Zoom, sometimes we have to continue talking on the phone.
Check out what device they are using. One of the advantages of Zoom is that clients can use it on smartphones, tablets and computers. This does mean, however, that they may be on their phone on the sofa, making it difficult to do any sort of BLS. The device they are using needs to be handsfree in some way – or they need to prop it up against a cushion or book. Check with them that their battery will not run out half way through.
2. You may not be able to create a safe space for processing. If they can be overhead by other people, if they are in the house with people who are abusive to them, if they can’t find someone to care for their young children – then you can’t do trauma processing. Use your judgement. I find that if I keep the first session open, without too many advance requirements, clients are more likely to be honest with me about their family environment and what’s possible. If you send an exacting list of things that they’ve got to get it right in advance, then you may find they don’t feel able to tell you that actually they live in a studio flat with their children and the only private space would be the bathroom.
3. You can’t effectively use your fingers for eye movements over the computer. They blur. It’s hard to follow. You can’t see their eyes well and you don’t know what size of screen they are on.
I use three different types of BLS online. My preferred method is tapping together. I tap, visibly, and they follow my tapping. They can tap on a cushion, on the table or on their knees. I learnt this technique from Philip Manfield who trained me on the Flash Technique and I like it because we are doing the BLS together, I can control the speed and when we start and stop, and there is no other technology to go wrong. Clients say they like how it feels, and the processing works.
If this doesn’t work for some reason, I sometimes ask them to use butterfly tapping. I might also switch to this if processing is blocked. As a back up, I ask them to download an EMDR app to their phones. Sleep Restore is a free one by Mark Grant. They put in their own headphones, and they start and stop it using an agreed visual signal. Any headphones will work as long as there is sound in both ears. Other colleagues use EMDR apps on their computer, I haven’t done this because I haven’t needed to and I like to keep it simple.
4. Leave space for the transition. If you’re changing from face to face to online, don’t expect the transition to be seamless. You’re in a new space together, use the first session to talk about how that feels and to work out how it work. If you’re already into trauma processing, you may need to back out and go back to the preparation phase for a while. People may also feel angry or scared about the reasons why you’re moving online. Make space for that discussion.
5. Make life easy for yourself, set up your whole clinic on one platform. I don’t offer clients a choice of platform. I used to do this and it became very stressful, trying to remember who used Skype, who used Zoom and who preferred FaceTime or WhatsApp. Sometimes I would be on Zoom whilst they were waiting on WhatsApp. Now, I use Zoom for everything. I schedule the whole day in advance, send out invitations the night before or early in the morning. They click on the link and there we are. We both have to do something in order to get into that meeting, so we are both consenting to be there.
6. I dissuade clients from closing their eyes.
(Comment from Mark: this is the one thing in these brilliant guidelines with which I take issue – I, Mark, have my clients always close their eyes, using BSDR Player or butterfly-hugging themselves, and have never had a problem!)
The one thing (Naomi continues….)you really can’t do online is physical grounding. You can’t throw a cushion to your client, you can’t easily move around the room, and you can’t wave essential oils under their nose. You can’t touch them.
This means that if they dissociate, you have fewer tools that usual for bringing them back. I deal with this two ways. I encourage them not to close their eyes. You only have two senses through which to communicate online, hearing and sight. If they close their eyes, you’re down to hearing. Clients say that they can get into the memory more easily with their eyes shut, to which I say that in EMDR we need to keep one foot in the present, one foot in the past, and that keeping their eyes open will help keep part of them with me as well as going into the memory. This applies most to clients who I am concerned will dissociate, more straightforward cases do sometimes close their eyes.
The other thing I do is enlist a ‘co-therapist’ if there is a supportive person in the house who I can talk to about dissociation and grounding techniques. This person needs to be in the house but not in the session, and you want to be able to contact them, perhaps by text or phone. This way, if your client is dissociating and you can’t bring them back, you call in your co-therapist. You can then guide them through using physical grounding techniques.
7. The unexpected will happen. Working online is different to being in a clinic room. It’s more like a home visit in some ways. You are in the client’s home, and you see snippets of their real life. If you take this into your stride, the clients will do so too. Sometimes urgent deliveries arrive, and I find it’s better to let them go and answer the door. Otherwise I can see how they become preoccupied with wondering if the postal worker will come back, or if they’ll have to rearrange it. Particularly now, it’s easier just to let them go. I have had children interrupting – again, ask your client to try to make sure this doesn’t happen, but if it does, take it into your stride. Pause, give your client time to take the child out and settle them, and then pick up where you left off. Letting them deal with it causes fewer problems than if you and they try to ignore it.
8. Check who else is in the room. I’ve found that people interpret ‘a quiet uninterrupted space’ in all sorts of ways. Sometimes I’ve found myself in a corner of someone’s living room, with the TV on and children watching it. Dogs wander in and out. You need to problem solve with them how they might find a private space where they will not be overheard and this might require some creativity right now when everyone is home. In particular, ask who else is there with them. I was once doing a session and I heard a laugh. I asked who it was and my client said that her sister was sitting the other side of the computer, out of my eyeshot. Now, I ask all clients to tell me who is in the room at the start of each session and sometimes to move their device around to show me what the rest of the room looks like.
9. You can always say no. Your clinical judgement is important. Don’t feel you have to offer EMDR online to anyone who asks. Do your usual full assessment and if you feel uncomfortable or unsure, don’t do it. Start slowly with the preparation phase, and use that as a way to test out how they respond. I’d start with using CIPOS, the Flash Technique or ‘tip of the finger’ processing before I used full EMDR. This way, you get an idea of how they will manage thinking about the trauma.
Only progress to trauma processing when you and they are confident. If it feels unsafe, back out and do more preparation. If you want to record the sessions for your own records, it’s very easy using Zoom. Obviously they have to consent and they will know that you are recording because Zoom tells them so. I don’t think it’s easier for clients to record us without our knowledge online than in person. They could always be carrying a phone in their pockets with the Record function running. If you want a record of the sessions, record them yourselves.
10. Working online can remove barriers to participation. Clients will be anxious about this transition. So you need to be confident that this is a good alternative, not a second-best stop gap. The reason I don’t send out lots of guidelines in advance is that I don’t want to give the impression this will be difficult for them, or that they can get it wrong. Use the first session to work out your way forward together.
Working online gives us a new flexibility. I sometimes offer much shorter sessions online, I’m working with an autistic teenager at the moment who prefers 15-minute sessions. Online, this is easy to arrange. Working online also means that people can be more at ease since they are in their homes. We can work with people who aren’t able to leave their homes. For children and young people it’s possible to have parents around but not directly in the session, if that is what is helpful.
Online EMDR therapy isn’t a poor substitute for the clinic room. It’s something slightly different, with its own advantages and pitfalls. For many clients it’s a choice between no EMDR at all, or EMDR online, rather than between EMDR online and EMDR face-to-face. It takes most therapists out of their comfort zone, but if we can face that anxiety, the potential benefits to our clients are great. The challenge is ours.