Guidelines for Using EMDR Online
The Covid-19 pandemic starting in early 2020 has brought a revolution in how therapy and in particular EMDR is delivered, reinforcing our own decade-long experience at EMDR Focus of the power of online work.
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Before You Start
Our standard go-to platform for remote EMDR is Bilateral Base, offering therapist-driven eye movements and bilateral sounds at the client end, with remote-controlled buzzers also coming (this written March 23 2021) soon.
Bilateral Base is fully security-compliant (HIPAA, GDPR etc), and works best in Chrome or Edge. The first month’s subscription is free, and rates thereafter are very reasonable.
Zoom is of course also widely used, and free for one-to-one work, and there are other platforms.
The Setting at Your End
Make sure your laptop/camera is at horizontal height so that the client is not looking up your nostrils. (Think how triggering that might be for clients who were sexually abused by a tall male looking down on them from above in childhood…)
A handy guide is that picture of you that goes out should not show either your room’s ceiling or floor.
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.
It’s essential that you do not put yourself in front of a light source, either a window or a lamp. Position your camera so that the source of light in the room falls on your face.
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.
Check what device they are using. iPads will have the client looking to one side of the screen. Mobile phones will generate an image that is tall and thin. A laptop is often positioned too low for good work, with the client peering down at the camera – you can ask them to prop it up on some books.
Zoom and Bilateral Base can of course be used on smartphones, tablets and computers. But this does mean that clients may be sitting on the sofa rather than at a desk. If so, make sure that the device there is handsfree, propped up if necessary against a cushion.
Check with them that their battery will not run out half-way through. Check the same at your end too, needless to say.
Make sure there is no-one else in their room. People interpret “a quiet uninterrupted space” in all sorts of ways. You may need to problem solve with them how to find a private space where they will not be overheard, and this might require some creativity.
Mark has actually done a highly effective EMDR session with a client literally lying, clothed, in her bath, as there was nowhere else private. Several colleagues have also done excellent EMDR with clients sitting in the safety and confidential space of their car.
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 live 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.
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.
You can however 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. With a child’s party-bubble tube you can blow bubbles at their screen which they can pretend to pop.
If you are concerned someone will dissociate and that you may 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 with whom you can talk in advance about grounding techniques.
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 either BB or Zoom. Obviously, they have to consent, and they will know that you are recording because the screen tells them so.
Do your usual risk assessment, and make a plan if necessary. This is no different from in-person work. If they are living alone, who else might they be able to ring after a session with you?
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 powerfully 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.
It’s helpful to include a stop signal, such as saying ‘Shall we take a pause’, or moving your hands.
The unexpected will happen. 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 remember ALWAYS to have your client’s telephone number readily to hand) and move on.
These days, urgent deliveries will often arrive in the middle of a session. It’s best to name that possibility, and it interferes less if you let them go and then just pick up again. The same applies to you as therapist.
Pets will walk into shot. Children may interrupt. (Click that link for a hilarious real-life example of how that can happen…)
Pause, give your client time to take the child out and settle them, and then pick up where you left off.
If these things happen, take them into your stride – it’s all part of how we build a safe and trusting online therapeutic “container” for the work.
Make a buffer zone between therapy and home life.
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 that time to write down their reflections, do a breathing exercise or listen to a visualisation.