Setting Client Expectations in EMDR Therapy

One thing EMDR therapists know to be true is the importance of setting client expectations. It is exciting that EMDR therapy is becoming more and more recognized as an effective and important treatment for healing trauma. Public acceptance of EMDR therapy has grown, especially as well-known people like Prince Harry and Sandra Bullock have shared their personal stories about EMDR therapy. With a wider audience hearing about EMDR therapy, both clients and therapists need to clarify expectations for successful EMDR therapy. Clear expectations create more certain conditions for hope that painful symptoms can be alleviated. One size does not fit all in therapy, and EMDR is no exception. Each client’s journey and current situation are unique. Open communication about the client’s experience, questions, and concerns is key to tailoring EMDR therapy to a client’s individual requirements. This article will cover a few common questions that clients bring to EMDR therapy and realistic expectations for success in EMDR therapy.

Is EMDR therapy a quick fix?

Some people have the impression that EMDR is a “quick fix.” While research has indicated that EMDR therapy is more cost-effective for PTSD than other therapies (Mavrenzouli et al., 2020), it is still important to remember that each client and each set of presenting issues have their own unique fingerprint and timeframe. For instance, treatment time for resolving one traumatic incident like a car crash will be different than treatment for recurring childhood abuse. In addition, there may be personal differences in how two different clients who experienced the same type of incident perceive the impact of that incident. The focus of EMDR treatment for a person who just experienced a traumatic incident (like a natural disaster) is different than for a person who repeatedly experienced abuse during childhood.

It is important for a client to understand that EMDR therapy has 8 phases, and all phases are just as important as Phases 4-6 (the reprocessing phases). EMDR therapists need to take a thorough history (Phase 1) with the client, which can take time. This Phase 1 work helps the therapist and client to work collaboratively and set the course of therapy so that the client feels their needs are being met and the therapist can guide how best to meet those needs. Phase 2, preparation, is also important and may take some time to establish. In Phase 2, the therapist explains the EMDR therapy process, addresses client concerns and questions, and works with the client to develop tools and resources that the client can use to cope with emotional disturbance that may arise. Knowing about all 8 phases can help a client seeking services better understand the timeline for EMDR therapy.

Is the therapeutic relationship important in EMDR therapy?

We’ve heard the question ‘Does the person really matter? Can’t I just find someone who can move their fingers back and forth?’ The therapeutic relationship is a key factor in the success of EMDR therapy and will influence the outcomes for the client (Hase & Heinz Brisch, 2022). Trauma therapy can be difficult and requires vulnerability. Trauma usually occurs within the context of relationships so it is powerful that healing also happens in relationship. Developing a trusting and intentional relationship between EMDR therapist and client will help the client feel supported through the difficult moments of reprocessing. The therapeutic relationship helps the client develop trust in their own mind and body’s capacity to handle distress and regulate emotionally. The therapy relationship itself ideally becomes a client resource. In a similar way to having a loved one remind you of the end goal for running a relay race when in the middle of the race, it is important to have support from a therapist who “has your back” when you are in the hardest parts of therapy.

An EMDR therapist is non-judgmental, supportive, and understands that a client’s current concerns are based on memories of past events that are being triggered by present daily life. An EMDR therapist has the ability to attune to the client, titrate the intensity of the therapeutic work, maintain a mindful presence, and respond to the client’s needs and clues to adjust treatment (Hase, 2021). This attunement with the client happens in the context of the therapeutic relationship. Research shows that the most common reason psychotherapy is effective has to do with the relationship a client and therapist have (Norcross and Lambert, 2011; Wampold, 2015). Trauma often occurs because someone feels alone in their overwhelm. Trauma involves a sense of disconnection, broken relationships, and attachments, so the need for a trusting relationship when healing trauma makes sense.

Since EMDR therapy is a psychotherapy that was initially designed to treat trauma and PTSD, the need for a trusting relationship during the EMDR therapy process is especially important. Prospective EMDR clients can use this information to empower their sense of agency when looking for an EMDR therapist – set up consultations with multiple therapists to determine if that therapist “fits your vibe” or feels like a good fit for you.

Is EMDR therapy only for ‘Big T’ trauma?

Trauma comes in all shapes and sizes. Many clients come into therapy thinking that they have not had any traumatic experiences in their lives. Throughout therapy, they realize that past events and experiences did indeed feel traumatic. ‘Trauma’ does not refer to an event itself but the impact it had on a person. Suppose a person is still a developing child when faced with difficult life experiences like their parents’ divorce or job loss, a death in the family, or a stressful family move, and this person doesn’t have a trusted adult relationship to help them navigate these difficulties. In these case, these experiences might leave a big – traumatic – impact.

In addition, there is a spectrum of complexity for trauma. Acute trauma might be something like a car accident, whereas developmental or complex trauma might be multiple incidents (i.e., abuse, bullying, neglect) over time. There is also inter-generational trauma (parents with untreated trauma passing wounds or abuse to the next generation) and historical trauma (trauma at the scale of an entire community, country, or ethnicity, like genocide or slavery).

One way to think about the impact of trauma is that there is both ‘big T’ trauma and ‘little t’ trauma. ‘Big T’ trauma is what many people typically think about as trauma: extreme events that are potentially life-threatening. Examples might include violence in war, school shootings, car accidents, gun violence, severe illness, etc. ‘Little t’ trauma might occur from events that are not typically viewed by society as traumatic but are still deeply impactful to the person who experiences them. Examples might be bullying in school, a difficult move, highly critical parents, a difficult break-up or divorce, financial difficulties, or job loss. EMDR therapy can help clients reprocess and heal both ‘big T’ trauma and ‘little t’ traumatic events. For example, Maria (age 25) reprocessed a ‘big T’ trauma of being sexually assaulted by a close friend. Mathew (age 52) reprocessed a ‘little t’ when he experienced stage fright as a 10-year-old in a school performance and how that event impacts his present-day ability to do presentations in his current job.

Additionally, a person can be impacted by the trauma of things that were supposed to happen but did not happen. For example, Sophia (age 35) has a lot of anxiety when she sees someone angry close to her. Sophia did not learn from her parents how to deal with anger. They both carried their trauma so they numbed feelings of anger, especially in front of her. Children need at least one caregiver who can teach them how to cope with emotions, how to express anger in a healthy way, and how to love and accept themselves even when experiencing uncomfortable feelings. Although people do not have a conscious memory of infancy, babies’ early experiences have a profound impact on the brain (Szalavitz & Perry, 2010). Adults who did not receive proper care and attention from a caregiver when they were children often experience symptoms of depression, PTSD, dissociation, and learned negative beliefs toward themselves. Although the effects of this lack of support and attachment can be treated with EMDR therapy, it requires more time and consideration in treatment planning.

Will EMDR therapy make me feel worse?

In the same way a physical wound that is healing feels a bit more sensitive than after it is completely healed, emotional wounds may make us feel a bit more sensitive when the healing process is beginning. The good news is that this is not a bad thing, and nothing is going wrong, it simply means our wounds are beginning to heal. Shapiro (2018, p. 6) stated “The goal of EMDR therapy is to achieve the most profound and comprehensive treatment effects possible in the shortest period of time while maintaining client stability within a balanced system.” Some initial discomfort might happen and the stability of the client is important. If a client needs additional support to feel stable, it is important to discuss this with the therapist and get additional internal and external resources to support such stability.

When someone begins to go to the gym after not working out for some time, they may experience soreness and discomfort as they start exercising those muscles again. So, looking at healing trauma with a similar lens is helpful. Once we look at experiences in our life when we were hurt, it may feel uncomfortable as we bring those experiences back to our awareness and build our capacity to move through the discomfort. This could happen with any trauma treatment. It is not the treatment itself that creates the discomfort. The wound has been there and might have slipped out of awareness for a bit, even if the effects are still present as patterns in one’s life.

In the example above with Sophia, she may feel anxiety when seeing someone angry around her but not realize the source is from her childhood. When she begins to make sense of how scary it was as a child not to understand angry emotions (maybe her emotions made her feel out of control, or maybe she witnessed violence when anger was present), she may initially feel uncomfortable before she can understand the link between her anxiety and others’ anger. As Sophia reprocesses the moments when she learned that anger was inappropriate (for example, witnessing her parents deal with anger or times when she heard that being angry is bad), her current understanding of self, her emotions, and others changes. She can manage her anxiety and anger more adaptively.

Some people describe feeling drained, irritable, emotional, or tired after EMDR therapy. Be kind to yourself if this happens, give yourself some extra sleep, time to journal, talk with a trusted friend, or create your own way to decompress. However, if the client feels stable enough, as Shapiro states above, it is not recommended to stop the process of EMDR therapy in the middle. Talk with your EMDR therapist, use the tools you have created to regulate, expect that feeling uncomfortable is part of the process, and continue reprocessing events. This allows the healing process to continue until complete. This is similar to the way that a person continues going to the gym even after some initial soreness to get the desired results.

If I start EMDR therapy, do I have to address ALL my traumas since childhood?

Not always. Sometimes people have a specific experience that they need to address in order to continue with their daily lives. Let’s use a metaphor and compare therapy to cleaning a house. There are moments when you can and need to do a deep cleaning and clean every room of the house. Other times you only need to wash one plate in order to have something to eat (Urdaneta, 2020). Some clients begin therapy with the desire and the internal and external resources and capacity to deal with the various traumas they have experienced in life. Other times, a client might need to reprocess one or two traumas for now, and later, they might come back for more work. For example, students in a university might come to a mental health center to cope with a sexual assault or a disaster like a fire, an earthquake, or a car accident. They simply need to reprocess one or two events for now to continue their studies and graduate. During this reprocessing, they might realize the connection to other events from their past but decide not to engage in reprocessing for those events yet.

The paper “What is EMDR therapy? Past, present, and future directions” (Laliotis et al., 2021) outlined the idea of viewing EMDR therapeutic work on a spectrum as well. Laliotis et al. (2021) wrote, “EMDR therapy is an integrative, client-centered approach that treats problems of daily living based on disturbing life experiences that continue to have a negative impact on a person throughout the lifespan.” They go on to outline three ways to go about treating the problems of daily living:

EMDR psychotherapy can be used in the context of a therapeutic relationship to address long-term goals to “treat the whole person, addressing the full clinical picture to include individual, relational, and behavioral domains.” (Laliotis et al., 2021)
And there are EMDR protocols that can be used to address “specific disorders or symptoms, or special clinical situations.” (Laliotis et al., 2021)
And there are EMDR Derived Techniques that can “reduce distress, increase stability, improve capacity for emotional self-regulation, and prepare for memory reprocessing, as well as strengthening positive experiences.” (Laliotis et al., 2021)

Establishing clear expectations for EMDR therapy is pivotal in fostering a safe and effective therapeutic journey. Openly discussing the process, goals, expectations, and potential outcomes empowers clients to trust their therapist and their healing process. The therapeutic relationship with an EMDR therapist is essential to facilitate attunement and titration of the trauma work, considering the client’s specific needs and situation. Remember, every individual’s experience with EMDR therapy is unique, and with a solid foundation of understanding and communication, clients can embark on a path toward profound transformation and healing.

Viviana Urdaneta Melo, MDiv, LCSW is an EMDRIA member, EMDR certified therapist and consultant. Urdaneta Melo has worked with survivors of trauma, intimate partner violence, and sexual assault for more than 12 years. She uses an intercultural and intentional approach around issues of diversity, equity, and inclusion. She has worked in different settings such as mental health agencies for domestic violence survivors, university health centers, and private practice. She is an immigrant from Colombia, South America, and practices in both English and Spanish. She works at the EMDR International Association as the Chief of Clinical Affairs. Urdaneta Melo is committed to increasing awareness around the challenges, strengths, and opportunities of working with diverse populations and their intersection of identities.

Susanna Kaufman, MA works with content at EMDRIA. She compiles and edits the Focal Point Blog while working toward her full LPC licensure in Texas. She has worked in mental heath agency settings, counseling group practice, and opened her own private practice Light and Heart Therapy PLLC. Kaufman believes in promoting an inclusive community and is passionate about compassion and intentionality in her work with EMDRIA and clients.

References:

Hase, M. (2021). The structure of EMDR therapy: A guide for the therapist. Frontiers in Psychology, 12, 660753. Open access: https://doi.org/10.3389/fpsyg.2021.660753

Hase, M., & Brisch, K-H. (2022). The therapeutic relationship in EMDR therapy. Frontiers in Psychology, 835470. Open access: https://doi.org/10.3389/fpsyg.2022.835470

Laliotis, D., Luber, M., Oren, U., Shapiro, E., Ichii, M., Hase, M., La Rosa, L., Alter-Reid, K., St. Jammes, J. T. (2021). What Is EMDR Therapy? Past, Present, and Future Directions. Journal of EMDR Practice and Research, 15(4), 186–201. Open access: https://doi.org/10.1891/EMDR-D-21-00029

Mavranezouli, I., Megnin-Viggars, O., Grey, N., Bhutani, G., Leach, J. Daly, C., Dias, S., Welton, N. J., Katona, C., El-Leithy, S., Greenberg, N., Stockton, S., & Pilling, S. (2020). Cost-effectiveness of psychological treatments for post-traumatic stress disorder in adults. PLoS ONE 15(4): e0232245. Open access: https://doi.org/10.1371/journal.pone.0232245

Norcross, J. C., and Lambert, M. J. (2011). Evidence-based therapy relationships. In J. C. Norcross (Ed.), Psychotherapy relationships that work: Evidence-based responsiveness (pp. 3-22). Oxford University Press. https://doi.org/10.1093/acprof:oso/9780199737208.003.0001

Perry, B. E., & Szalavitz, M. (2010). Born for love: Why empathy is essential — and endangered. William Morrow.

Shapiro, F. (2018, 2001, 1995). Eye Movement Desensitization and Reprocessing Therapy: Basic Principles, Protocols, and Procedures (3^rd ed.). New York, NY: The Guilford Press. https://www.guilford.com/books/Eye-Movement-Desensitization-and-Reprocessing-EMDR-Therapy/Francine-Shapiro/9781462532766/summary

Urdaneta, V. (2020, October 3). EMDR therapy in college and university settings in a brief therapy model [Online Course]. EMDR International Association. www.pathlms.com/emdria/courses/33451

Wampold, B. E. (2015). How important are the common factors in psychotherapy? An update. World Psychiatry, 14(3), 270-277. https://doi.org/10.1002/wps.20238

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Setting Client Expectations in EMDR Therapy