Online EMDR Therapy

The arrival of the Corona virus has catapulted our EMDR community worldwide into sudden and, for us at EMDR Focus very gratifying (we’ve been doing this for a decade) acknowledgement that EMDR can work extremely well online.

At EMDR Focus, we’ve been providing therapy, including full-on EMDR, to many erstwhile colleagues and organisations in the journalistic field, where Mark was for 30 years correspondent and editor for Reuters and the BBC World Service.

With thanks to our friend and colleague Naomi Fisher (working from France) you’ll find on this page, with [square bracket comments, and the occasional edit] from Mark as it goes along, a useful and simple outline of how to do EMDR.

For EMDR therapists, our colleague Alexandra Dent has put together a very useful note here which you can share with clients about how online EMDR works – noting that we’ve tweaked Alexandra’s note somewhat to highlight the use of Zoom in particular rather than other online platforms.

Note here that at EMDR Focus we are now using Bilateral Base as our almost exclusive online platform for remote EMDR with individuals. It’s still in beta testing mode, and free to use until October. BB now works pretty much seamlessly if both therapist and client are on Windows machines, and glitches are being ironed out with Apple products.

Here also some very useful and comprehensive guidelines for Online EMDR from the EMDR Association UK, compiled with detailed input from both Naomi and Mark.

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Guidelines for Using EMDR Online

Adapted from guidance first drawn together by our colleague Dr Naomi Fisher as the Corona virus pandemic hit Europe in Spring 2020. Naomi is an independent clinical psychologist, EMDR Consultant and Facilitator (EMDR-Europe) based in Paris. The following thoughts include updates from us at EMDR Focus.

EMDR online is effective and powerful. Full EMDR can be done online, even with new clients, if you consider the guidance below.

Before You Start

  • Make life easy for yourself, set up your whole clinic on one platform. If you use a variety of platforms, you have to remember who uses what, and perhaps switch devices.  Skype is not secure and should not be used except as a back-up to troubleshoot.
  • Bilateral Base is a new Remote EMDR platform which comes highly recommended, working just on a browser and offering therapist-driven Eye Movements and bilateral sounds at the client end. Remote-controlled buzzers also coming soon.
  • Zoom is of course recommended by many, and free for one-to-one work. You can schedule your whole day in advance. Clients do not need an account to use it. You can also use a virtual background, ideally with as green screen behind you as in the picture of Mark’s work station at home.
  • It doesn’t matter who starts the meeting. It’s not possible to force someone to have a video call with you. You both have to connect (and therefore consent) in order for it to happen. People can and do DNA online.
  • It’s up to you if you send guidelines in advance. The essentials are to ask them to find a quiet uninterrupted space with a good internet connection, and to make sure someone else is looking after any young children. A long list of guidelines can give the impression that this will be complicated and they might get it wrong. You know your client group best, adjust what you send out to them.
  • Clients are often anxious about meeting online. So be confident that this can be a good option for them and that it won’t be difficult.
  • Always have a back-up way to contact people. Phone numbers are best because they aren’t reliant on the internet. If there’s a problem with logging on, ring them quickly, don’t wait for them to become anxious. You may need to talk them through the details of Zoom and sound.

The Setting at Your End

  • Make sure your laptop/camera is at horizontal height so that the client is not looking up your nostrils. The picture of you that goes out should not show your room’s ceiling or floor.
Mark in front of his virtual background, a photo of his actual bookshelf in the room next door to his office.
  • Check your outgoing picture before you start. Your eyes should be about one third of the way down from the top of the screen.
  • Do not sit too close to your camera. The client should be able to see your upper body down to roughly between breastbone and navel, and to see the room behind you.
  • Make sure too that your background is neutral and appropriate, perhaps with pot plants in the picture.
  • Do not position yourself in front of a light source, either a window or a lamp. Position your camera so that you yourself face the source of light in the room. Experiment with lighting to ensure the client has a good, professional view of you as therapist.

The First Session

  • Online therapy is powerful, but different from working with a client in the same room. It’s half-way to a home visit.
  • Assess the environment that someone is in, and see whether together you can work out a way to do therapy. For some clients the first session is about engagement and working out the technology.
  • Use the first session to sort out technical issues and create together with your client an appropriate and welcoming therapeutic space.
  • Check what device they are using. One of the advantages of Zoom is that clients can use it on smartphones, tablets and computers. But this does mean that they may be on their phone on the sofa rather than at a desk. 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. (Check the same at your end too, needless to say!)
  • Check who else is in their room. People interpret “a quiet uninterrupted space” in all sorts of ways. You might be in the corner of someone’s front room. This can be to your advantage. You get to see their life.  However, 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 in these times of Corona when everyone is home.

Risk

  • Be aware that you may not be able to create a safe space for processing. If your client can be overheard 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.
  • If you keep the first session fairly open, clients are more likely to be honest with you about their family environment and what’s possible. If you send an exacting list of things that they’ve got to get 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.
  • [Though Mark adds here that he has actually done a highly effective EMDR session with a client literally lying, clothed, in her bath, as there was nowhere else private.]
  • One thing that’s a challenge online is physical grounding. You can’t throw a cushion to your client, you can’t give them a squeeze ball 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.
  • Note that, with a child’s party-bubble tube you can blow bubbles at their screen which they can pretend to pop. You can also ask them to stand up, to stretch, to look around them and identify colours and objects, to throw a screwed-up ball of paper from one hand to the other, and much more – just as you would in the room with them.
  • Enlist a ‘co-therapist’. If you are concerned someone will dissociate and that you will not be able to bring them back, you might still be able to do the work if there is a supportive person in the house who you can talk to about grounding techniques in advance. For young people this could be a parent. You need to have their contact details and they should be in the house but not in the sessions when you are processing. If your client dissociates, call or text the other person, get them to come in and talk them through physical grounding techniques. Again this is not necessary for more straightforward clients or those who can bring themselves back if they dissociate.
  • If you want to record the sessions, it’s very easy using Zoom. Obviously, they have to consent and they will know that you are recording because Zoom tells them so. It’s no easier for clients to record us without our knowledge online than in person. They could always be carrying a phone in their pocket with the Record function running in the clinic room. If you want a record of the sessions, or are concerned they will say you said something that you didn’t say, then record them yourself.
  • Do your usual risk assessment, and make a plan if necessary. This is no different from in-person work. Know who else is in the house and who you might be able to call on if necessary. If they are living alone, who else might they be able to ring after a session with you?

Bilateral Stimulation

  • 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.
  • As always, use the preparation phase to work out which BLS work best for your client.

Online options for BLS:

  • Bilateral Base allows you to generate and adjust highly-effective Eye Movements and bilateral auditory taps at the client end. This works extremely well, and is our first recommendation (though note that there can be connection problems still where either of you is using Apple products, especially an iPad or iPhone. These glitches are being addressed.)
  • Butterfly tapping with hands slightly higher up so more visible. The therapist models the tapping and the client imitates.
  • Self-administered auditory BLS. Clients can download a free app with BLS onto their smart phone or iPad. BSDR Player can be downloaded onto a phone, then wearing in-ear buds connected to the phone underneath over-the-ear headphones through which to hear you as therapist.
  • Sleep Restore with EMDR is another example. The client chooses ‘bilateral stimulation’, puts on their own headphones and starts and stops the BLS when you give them the signal.
  • It’s preferable for both client and therapist to be using headphones, rather than speaker and mic in the laptop or computer. Headphones at each end create an at times extraordinarily intimate therapeutic bubble, with the therapist speaking, sometimes whispering, directly into the client’s ears. This can make online work even more powerful than EMDR in person.]
  • Tapping Together. The therapist taps on the computer or table, and the client imitates them. They can tap on a cushion, the table or the outside of their knees. This way, the therapist can control the speed of the BLS, though it’s harder to see when and if the client is actually tapping. It’s helpful to include a stop signal, such as saying ‘and pause’, holding your hands up or moving your hands in an arc. Otherwise clients may continue tapping when the therapist stops if they can no longer see your hands.
  • There are EMDR apps or YouTube videos of BLS. However, they make the process slightly more complicated as you need to share your screen and there can be a delay. If you want to do this, try it out first with a colleague to sort out the technical issues. In addition, check out screen size, since many clients use their phones.

Therapeutic Issues

  • In Mark’s experience, often working with clients he’s never met in person, it’s fine to initiate EMDR with a new client in exactly the same was as one would in-person. As ever, it depends on the individual, but the online environment is in itself no barrier.
  • If you’re changing from in-person to online, there’s every chance that the transition will work very well, but it does take effort, on both sides. You’re in a new space together, so 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 might find 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.
  • The unexpected will happen. Working online is different to being in a clinic room. You are in the client’s home, and you see snippets of their real life.  If you take this into your stride, the client will do so too.
  • Things will go wrong. The sound will cut out, the picture will freeze, there will be people who can’t log on, the WiFi will drop out. These are all teething issues and not a big deal unless you make them so.  Apologise (by phone if necessary) and move on. Online work is very intense. You may find that clients can only tolerate shorter sessions.
  • Pets will walk into shot.
  • Sometimes urgent deliveries arrive.  If you don’t let them go and answer then they are worrying about whether they have missed their parcel.  It interferes less if you let them go and then just pick up again. Same, by the way, applies to you as therapist, especially in these Corona days, where it’s not OK to miss a delivery.
  • Children may interrupt. (click that link for a hilarious real-life example of how that can happen…) Ask your client to try to make sure this isn’t likely to occur, 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.
  • 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.  Start with using CIPOS, the Flash Technique or ‘tip of the finger’ processing before 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.
  • Make a buffer zone between therapy and home life. When clients come to see us, they have to travel, creating a space between their life and the session. When they meet us online, there’s no space.  You can encourage your client to take ten minutes after the end of a session before opening the door, particularly if they are caring for children. They can use the ten minutes to write down their reflections, do a breathing exercise or listen to a visualisation.

Working online can remove barriers to participation

  • It enables us to offer therapy to those who could not otherwise access it. People who live far from a therapist, people who are agoraphobic, or people who find meeting people in-person so anxiety-provoking that they can’t get to a clinic. It’s often easier for children and young people to access therapy online.
  • It enables us to be very flexible. It’s easy to vary session length when working online.  You can offer very short sessions for children.
  • It can take the pressure off. Not being in a clinical room means that people can be present in the session with less pressure. Children can be in the room whilst their parents talk, but they don’t have to be sitting next to them listening. Parents can be around whilst their children have therapy, but again, without sitting right next to them.

 

Remember: If it’s a choice between no EMDR and EMDR online, then EMDR online is the better option.