September is Suicide Prevention Month, a time to raise awareness and share resources to provide support to those affected by suicide.
Adapting the 8 Phases: Considerations for Working with Clients at an Elevated Risk for Suicide
Guest Blog Post by Joshualin Dean, MS, LMHC, NCC
Addressing the needs of individuals at an elevated risk for suicide presents one of the most complex and urgent challenges when providing treatment to survivors of traumatic events. When working with high-risk populations, it’s vital to proceed cautiously when incorporating Eye Movement Desensitization and Reprocessing (EMDR) therapy.
Traditional therapeutic approaches often require careful modification to ensure they are safe and effective for vulnerable populations. While EMDR has been shown to reduce the severity of suicidal thoughts, its application in the treatment of individuals at an elevated risk for suicide requires a distinct understanding and adaptation of the standard EMDR protocols to ensure client safety (Fereidouni, et. al., 2019). This article explores adaptations of the standard EMDR protocol when working with high-risk populations and prioritizing client well-being.
Adapting the 8 Phases
History-Taking and Treatment Planning
Comprehensive risk assessments are an integral part of treatment when working with high-risk populations. Integrating a comprehensive risk assessment and safety plan into the history-taking and treatment-planning phase provides an essential understanding of the client’s history of suicidal behaviors, risk factors, and protective factors. Additionally, it allows the clinician to identify specific targets that should be addressed with a tailored approach.
Safety planning should include current coping strategies that have historically been healthy and effective for the client, accessible crisis intervention resources, and identification of their existing support system. The addition of this comprehensive assessment and safety plan provides the clinician the opportunity to thoroughly assess the client’s suitability and readiness for EMDR therapy with careful consideration of the client’s current risk level.
Preparation
During the preparation phase, it is helpful to discuss with the client the importance of their safety and well-being and encourage using their safety plan, if needed. Resource development should include developing internal resources and enhancing coping skills. The emphasis on this provides an opportunity for the client to strengthen resources for distress management and emotion regulation while reinforcing self-efficacy and increasing positive beliefs of their ability to access these tools during times of distress.
Additional adaptations include identifying supportive figures who provide a sense of connection and safety and nurturing and protective figures who provide a sense of being cared for and protected. This approach to the preparation phase not only ensures that the client has access to the tools necessary to manage distress but also provides additional resources that can be enhanced and added to their safety plan.
Assessment, Reprocessing, and Closure
When selecting the initial target while working with high-risk populations, it is important to ensure the client can tolerate discussing the target memory without becoming destabilized. Modifying target identification is a helpful way to prioritize client safety.
Thoughts of suicide frequently occur as a result of not wanting to suffer or continue to endure significant emotional pain rather than the desire to die. Previous studies suggested that the integration of EMDR therapy resulted in a decrease in clients’ desire to die by suicide as a byproduct of lessening anxiety, depression, and PTSD-related symptoms (Proudlock & Peris, 2020). With this in mind, target identification can be adapted by selecting targets with lower intensity to include emotional states that are directly related to the thoughts of suicide, recent and/or present triggers rather than going directly to deeply distressing memories (Mosquera & Ross, 2016).
Cognitive interweaves when working with high-risk clients can be a beneficial tool for validating their experiences, fostering hope, and enhancing their sense of control. Concurrently, using cognitive interweaves with this population can be beneficial in gently challenging self-limiting beliefs. It is imperative that throughout this process, the safety and stability of the client are maintained by continuously monitoring the client’s emotional state, being attentive to signs of destabilization, and resting when necessary.
Allow additional time during the installation phase to reinforce and strengthen positive cognitions that promote resilience and enhance the client’s sense of control in managing distress effectively. It is beneficial to bring the client’s attention to any felt sense of connection and safety. While moving into the body scan, the clinician should continue to monitor the client’s emotional state, being alert to any indication of significant discomfort or distress while reinforcing and enhancing positive experiences related to control, connection, and safety. At the end of each session, safety must be revisited, and the client is encouraged to utilize their safety plan if needed. Resources should also be reinforced at this time.
Reevaluation
At the beginning of each session, it is important to be intentional about taking the time to thoroughly assess how the client has managed since the previous session and identify any changes in their risk level. This should include asking directly about any safety concerns, thoughts of suicide, and ways that the client managed these thoughts and concerns, including the use of their safety plan, if concerns developed. This would also be the time to reassess and determine if the client can tolerate and continue processing or if resource work should be prioritized for this session.
EMDR Can Be Highly Effective
EMDR can be highly effective in reducing suicidal ideations, but it should be introduced carefully when working with high-risk clients, always prioritizing their safety and stabilization. Integrating these considerations into the eight phases of EMDR can help ensure that the treatment is delivered safely and effectively while maintaining a focus on reducing suicidal ideations and enhancing the client’s stability. The adaptations of the basic protocol are aimed at emphasizing attentiveness, stabilization, and fostering a flexible and collaborative approach with careful consideration of the client’s current emotional state.
Joshualin “Jay” Dean is a Licensed Mental Health Counselor, National Certified Counselor, EMDR Certified Therapist and Consultant-in-Training, TF-CBT Certified Therapist, and nationally rostered Child-Parent Psychotherapy provider. She is the founder of Transcend Therapy and Wellness (https://transcendtherapyandwellness.com/) in Tampa, FL, and specializes in complex trauma with a population focus on victims of crime. Joshualin holds a Bachelor of Arts in Psychology from The University of Alabama and a Master of Science in Counseling and Psychology from Troy University. Joshualin currently serves as a Board Director for NAMI Hillsborough and is a member of the American Mental Health Counselors Association, Florida Mental Health Counselors Association, and EMDR International Association.
References
Fereidouni, Z., Behnammoghadam, M., Jahanfar, A., & Dehghan, A. (2019). The effect of eye movement desensitization and reprocessing (EMDR) on the severity of suicidal thoughts in patients witih major depressive disorder: A randomized controlled trial. Neuropyschiatric Disease and Treatment, 15, 2459-2466. Open access: https://doi.org/10.2147/NDT.S210757
Mosquera, D., & Ross, C. A. (2016). Application of EMDR therapy to self-harming behaviors. Journal of EMDR Practice and Research, 10(2), 119-128. Open access: http://dx.doi.org/10.1891/1933-3196.10.2.119
Proudlock, S., & Peris, J. (2020). Using EMDR therapy with patients in an acute mental health crisis. BMC Psychiatry, 20, 14. Open access: https://doi.org/10.1186/s12888-019-2426-7
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