This report, written just before the COVID-19 pandemic, introduces relevant issues with regard to the virtual delivery of EMDR therapy and specifically addresses professional practice and guidelines, ethical considerations, and overarching issues for EMDR therapy delivered by virtual means. The report was presented to the EMDRIA Board of Directors on January 18, 2020. Members of the Virtual Training and Therapy Task Group included Sharon Rollins, MS-LPC, NCC; Tamra Hughes, MA, LPC; Gayle Cordes, DBH, LPC, LISAC; Mischa Cohen-Peck, MA, MSW, PhD; and Joanna Watson-Wong, LMFT.

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Guidelines for Virtual EMDR Therapy

A Report of the Virtual Training and Therapy Task Group Presented to the EMDRIA Board of Directors, January 18, 2020

• Sharon Rollins, MS-LPC, NCC
• Tamra Hughes, MA, LPC
• Gayle Cordes, DBH, LPC, LISAC
• Mischa Cohen-Peck, MA, MSW, PhD
• Joanna Watson-Wong, LMFT

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The intersection of knowledge, professional skills, and technology offers a dynamic opportunity for global healing. This opportunity may be enhanced with the accessibility of virtual therapy and telehealth. This opportunity also brings potential risks. The body of research continues to grow for telehealth in general, but the task group has found no research to support or refute the efficacy of EMDR therapy through virtual means. As EMDR clinicians begin to innovate and consider stepping into the virtual world of telehealth, EMDRIA leaders are compelled to determine the appropriate organizational stance regarding the virtual delivery of EMDR therapy.

Regulatory agencies, insurance companies, and professionals use a wide variety of terms to refer to telemedicine in general. The most basic understanding is that telemedicine involves the use of technology to provide clinical services.1

1 TeleMental Health Definitions by Ofer Zur, Ph.D.

In this report, references to virtual delivery of EMDR therapy pertain to EMDR therapy which is administered by an EMDR trained clinician online via telecommunications; it does not include companies, websites, or services which offer EMDR self-therapy without live guidance from an EMDR trained clinician. Self-administration of EMDR therapy is strictly forbidden in EMDRIA Policy and is beyond the scope of this report.

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Question 1. What do we know about our stakeholders’ needs, wants, and preferences that are relevant to this decision?

The Task Group undertook an investigation through one to one interviews, online discussion groups, and a member survey to gather more information regarding our stakeholders’ needs, wants, and preferences regarding virtual delivery of EMDR therapy. Responses in discussion groups were mixed with a wide array ranging from full support and enthusiasm to grave concern. The Task Group also held one to one interviews with clinicians who have either practiced general therapy models virtually or who have delivered EMDR therapy virtually.

A survey of membership yielded responses from 1,600 stakeholders, and results leant support for continued investigation of virtual EMDR therapy. Some respondents stated the belief that virtual EMDR therapy inherently carries more risk than traditional therapy, while others see little difference and see no enhanced threat. Fifty-three percent (53%) of respondents reported they had either delivered EMDR therapy virtually in the past or would consider practicing EMDR virtually in the future. Since EMDR therapy involves an 8 phase approach, the Task Group also asked which of the 8 phases had been delivered virtually. Respondents reported using each of the 8 phases at least 60% of the time which suggests all 8 of the phases are being delivered by virtual means rather than only the early phases or isolated parts of the protocol. Of the 800+ respondents who reported they had or would deliver EMDR virtually, the following concerns and challenges were mentioned:

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Safety 263

Relationship/Attunement 212

BLS/DAS (how to do it) 193

Abreaction 100

Technology challenges 88

Dissociation 82

Ethics/Liability/License 70

Research/Efficacy 58

“See my previous response” 55

N/A 51

Training needed 46

No concerns 33

Distractions 11

Payment 8

Resources 6

Assessment 5

All (All concerns) 3

Client’s comfort/education 2

Cost of Equipment 1

*It should be noted that in some of these cases where practitioners actually have delivered EMDR therapy by virtual means, these issues were mentioned as initial concerns but were found to be less worrisome with investigation, preparation, training, experience, and actual practice.

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NEEDS, WANTS, PREFERENCES

Members expressed interest in guidelines for virtual therapy and practice which could inform them in the following areas:

Legal/Ethical:

• Licensing Regulations and Jurisdiction: Of those interviewed and surveyed, many raised the importance of consulting one’s licensing boards and professional/ethical rules. While outlying communities and rural areas can gain access to care through opportunities for virtual therapy, our stakeholders cited jurisdictional rules and regulations as a matter of concern. Most states have rules limiting practice outside of their own licensing zone. Wide cultural differences can be found and should be studied and considered as clinicians from one population reach out to help clients from diverse and possibly unfamiliar populations. Furthermore, a vast distance may fall between client and clinician thereby limiting the response time during crises. Emergency services for the client’s region will need to be explored prior to establishing telehealth services in that region.
• Confidentiality/HIPAA Compliance: One of the highest areas of concern is that of HIPAA Compliance and efforts to maintain confidentiality. Technology opens somewhat of a Pandora’s Box with regards to maintaining security and privacy. Most email and text servers lack encryption, and social media venues are prone to security breaches. Many video conferencing applications as well as the computer operating systems they run on are not fully secure. Respected telehealth educators recommend use of video conferencing applications which carry a Business Associates Agreement to ensure HIPAA Compliance. Online payment methods also present security and privacy risks.
• Consent to Treatment: As there are additional challenges and technological/security factors related to offering EMDR by virtual means, clinicians raised concern about how to best address consent for therapy.
• Safety/Risk: Therapists voiced awareness of the need to be prepared for the range of unexpected technical problems, psychotherapeutic issues, and results or outcomes that occur during sessions, both in-office and online. Complex trauma clients may experience dissociation and/or abreaction during EMDR therapy sessions. Many stakeholders who were surveyed and interviewed raised this risk as a concern. While clinicians lose the ability to reach out to touch or be present in the room with the client, guidelines can at least give clinicians ideas of how best to manage potential risks such as these. JoAnna Watson-Wong addressed these issues through a poster session at the 2013 EMDRIA Conference.2

2 Watson-Wong, J. (2013, September). Poster titled, EMDR Internet Therapy presented at the 18th EMDR International Association Conference, Austin, TX.

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She stresses “the importance of building strong attunement and communication skills to ensure contact with the client during unexpected technical glitches and/or unclear processing. Prior to beginning reprocessing, clinicians should build an alliance with a client’s adult ego state to enable helpful communications during these moments and to check in on missed or confusing cues and clues during processing. Given the current state of technology, these skills are foundational in building strong attunement which can better help a client to stay engaged, connected and within an optimal window of tolerance for processing during EMDR therapy.” 

Technological:

• The Task Group has conducted in-depth interviews with select EMDRIA members nationally. They reported virtual delivery of all 8 phases of the protocol, and several discussion group respondents indicated they have offered virtual delivery of EMDR. Sixty percent of Member Survey respondents reported they are delivering all eight phases of the protocol virtually. Therefore, the Task Group has endeavored to provide guidelines for the technological needs of clinicians providing any phase of treatment online rather than in-office. These guidelines will address video conferencing application considerations, dual attention stimulation modalities, and security considerations.
• It should be noted that just as with in-office treatment, online EMDR therapy requires the presence of a clinician with the client. In the words of Dr. Francine Shapiro, ”It is difficult, if not impossible, to engage in intense, complex personal therapy without a clinician’s assistance. It is not generally recommended that clients be taught the self-directed use of eye movements. There is no way of knowing to what a given target or anxiety is linked, and even seemingly innocuous disturbances can be rooted in extremely disturbing childhood memories.” She goes on to warn “Attempting self-directed therapy…can also result in retraumatization since the memory may merely be dissociated once more rather than reprocessed.”3
• Along with these technology guidelines, the Task Group has determined that it is prudent for EMDR clinicians providing any treatment virtually to complete a tele-mental health certification in order to implement and maintain a safe standard of online practice. EMDR Clinicians will need to stay abreast of rapidly changing technologies and guidelines in order to stay current and maintain safety and security for their practice. Clinicians should refer to their licensing board to identify telehealth trainings that meet the standards of their specific licensing body.

3 Shapiro, Francine, PhD. (2018). Eye Movement Desensitization and Reprocessing (EMDR) Therapy: Basic Principles Protocols, and Procedures. Third Edition. The Guilford Press, New York pp.243-244.

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Training/Preparedness:

• Education for Clinicians: Many stakeholders stressed the need for training and education. Following the development of technological guidelines and the recommended pursuit of tele-mental health certification from a telehealth expert, the Task Group recommends advanced training pertaining to use of EMDR therapy by virtual means. The Task Group recognizes the need for development of advanced training of EMDRIA members related to delivering EMDR therapy virtually. It should be noted that this is in addition to members’ completion of an EMDRIA Approved EMDR therapy training.
• Regulating/Responding to reactions outside client’s window of tolerance: As mentioned previously, clinicians need to build deeply attuned relationships and the ability to handle technical problems or to check in on missed or confusing processing cues and clues to more effectively respond to clients who begin to dissociate or abreact during an EMDR session. Clinicians voiced concern about how best to manage these challenges during virtual EMDR delivery.
• Cultural Considerations and Diversity: One concern mentioned in the literature for telehealth is being culturally educated and prepared in working with diverse populations of a community which may differ from the provider’s own background. Clinicians will need to learn as much as possible about the population with which they propose to work. Additionally, they will need to contact local emergency service providers to ensure communication channels are open and active and have consent to contact appointed persons in the client’s community in case of emergency.

Question 2. What do we know about the current realities and evolving dynamics of our environment that is relevant to this decision?

Current Realities and Evolving Dynamics:

• Compared to other industrialized nations, the United States spends more on health and fails to achieve comparable health outcomes (Luxton, Nelson & Maheu, 2016). Such poor outcomes, in part, are due to widely acknowledged health disparities—including those of gender, race, age, income, locality, and more. Considering those for whom accessibility barriers may be highly burdensome and even insurmountable, telehealth provides a unique care opportunity.
• In 2010, the World Health Organization (WHO) published this linked report titled Telemedicine: Opportunities and Developments in Member States https://www.who.int/goe/publications/goe_telemedicine_2010.pdf. In this report,

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teleradiology is the most prevalent ehealth service amongst member states. The report examined telepsychiatry, and the lack of tele-behavioral health service provision may be due to the time it takes for such service delivery. However, in the years since the publication of this report, there has been a significant growth in technology and options for the delivery of telepsychology and telecounseling.

• In the United States, the Office of the National Coordinator for Health Information Technology (HealthIT.gov) notes their support for telemedicine and telehealth; sadly there appears to be limited telehealth support within this site. The Substance Abuse and Mental Health Services Administration (SAMHSA) has limited data published about the use of telehealth for mental health services delivery, although the SAMHSA website includes a report about telehealth for rural behavioral health.
• Watson-Wong, J. (2013, September). Poster titled, EMDR Internet Therapy presented at the 18th EMDR International Association Conference, Austin, TX. Mrs. Watson-Wong presented logistical and technological information as well as legal, ethical and security considerations. She made recommendations on how to effectively administer EMDR therapy through virtual means, describing the art of “Presencing” in creating a professional Internet presence, with tools to augment online attunement, work with unclear client processing, and cope with hardware problems. She handed out a paper titled, Internet Presencing Essentials that details her poster. Her recommendations are detailed in the “Guidelines” section of this report.
• Additionally, various health and counseling organizations have published guidelines and standards for telehealth and telehealth delivery. These organizations include other health and behavioral health professional organizations, including the following: the American Counseling Association, the American Medical Association, the American Psychology Association, the American Telemedicine Association, the Association for Counseling & Therapy Online, the National Association of Social Workers, the American Association for Marriage and Family Therapy, and the National Board for Certified Counselors. As a professional mental health organization it is time for us to be included in this list.
• While suicide ideation appears to have equivalent rates in urban and rural areas, the suicide mortality rate is higher in rural zones according to a study by Tarlow, Johnson, and McCord (The Journal of Rurual Health, 0 (2018), p. 1-6.) Clinicians who deliver EMDR therapy remotely in rural communities will need to pay particular attention to depression and anxiety assessments, impulse control, and access to lethal means (e.g. firearms).
• As evidenced in the EMDRIA Member Survey on Virtual Delivery of EMDR Therapy, most EMDR Clinicians are curious about but have little information on how to deliver EMDR Therapy remotely. Interested clinicians will need to find

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video conference applications which are HIPAA-compliant and which have a Business Associate Agreement (BAA).

• Many licensing boards have rules about practicing across state and provincial lines, even when clients are temporarily away from home. These rules vary widely and are continually changing. Additionally some health insurers regulate which services can be offered across geographical lines and require additional documentation for reimbursement. Malpractice insurance rules will also impact a clinician’s considerations for virtual therapy delivery. Clinicians must stay abreast of changes in the regulatory landscape.
• The Task Group has made every effort in this report to ascertain information, research and guidelines on telehealth, especially pertaining to EMDR therapy. The group has reviewed guidelines from other professional organizations and from EMDR organizations around the globe. Little evidence and few guidelines are available at this time. It appears this is an area where more research is needed.
• Standards and guidelines from other professional organizations such as the American Counseling Association, the American Medical Association, the American Psychological Association, the American Telemedicine Association, the Association for Counseling & Therapy Online, the National Association of Social Workers, the American Association for Marriage and Family Therapy, and the National Board for Certified Counselors, have been reviewed for consideration as to the most appropriate ethical guidelines for the delivery of virtual EMDR therapy. Because virtual conferencing is a relatively new method for delivering psychotherapy of any kind, more research needs to be done to ascertain the most comprehensive ethical guidelines for practice as it relates specifically to EMDR therapy.

This report introduces relevant issues with regard to the virtual delivery of EMDR therapy. The report specifically addresses professional practice and guidelines, ethical considerations, and overarching issues for EMDR therapy delivered by virtual means.

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Question 3. What do we know about the capacity and strategic position of our organization that is relevant to this decision?

With the increasing demand for access to mental health and the alarming prevalence of trauma in our present world, EMDR therapists will be asked to respond virtually to their clients and to impacted communities.

• EMDRIA’s Professional Code of Conduct does not yet address telehealth or application of EMDR by virtual means. The organization may need to develop language to address potential issues as stakeholders take EMDR to the virtual world of therapy.
• Applicable guidelines and laws surrounding professional technology standards and telehealth change rapidly and vary widely among licensing boards. They will continue to evolve as the field grows. Practitioners may experience confusion about which guidelines or rules to follow and must work to stay current.
• Presently, no guidelines for virtual delivery of EMDR therapy exist in the United States or, it appears, anywhere in the world. EMDRIA has a unique opportunity to be a leader in developing guidelines pertaining to virtual delivery of EMDR therapy.
• EMDR Clinicians are well-positioned to do pilot and research studies to clarify the efficacy of virtual delivery of EMDR therapy. The Task Group recommends the encouragement of further research in this area.
• EMDRIA lacks the in-house expertise to directly provide telehealth software applications or EHR systems. However, the organization may be able to form an affinity agreement in the future with vendors in order to offer member discounts, association revenue, and increased confidence to members in the use of secure, HIPAA-compliant video software applications.
• EMDRIA is well positioned to disseminate helpful information pertaining specifically to virtual delivery of EMDR therapy. The attached guidelines can aid clinicians with decision making, security and technology considerations, and good clinical EMDR virtual practices.
• Continuing education offered by presenters at the EMDRIA Annual Conference, advanced programs offered outside of the conference, online network meetings, and webinars can educate clinicians as well.
• EMDRIA’s “Go With That” magazine can supply additional information about virtual delivery of EMDR therapy.

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• The dissemination of information and avenues for education would not represent significant costs to EMDRIA and may even generate some revenue for the organization.
• Some EMDR clinicians are more comfortable with technology than others. The organization can help members with similar virtual delivery interests connect with one another through EMDRIA’s online community website.
• The Task Group recommends the EMDRIA Board encourage The EMDR Foundation to support groundbreaking research into the efficacy of virtual delivery of EMDR therapy by granting funds to an interested researcher. This would raise awareness of the Foundation and inform EMDR Clinicians of possibilities and cautions.

Question 4. What are the ethical implications?

Of the many ethical considerations, informed consent for therapy is essential and mandated.

Implications for the organization:

• There is insufficient evidence to endorse or deny the delivery of EMDR therapy in a virtual format, however this innovation has already begun to be put into practice by many in the field. We encourage all clinicians who are implementing this format to contribute to our growing body of knowledge and research as we strive to determine best practices for the virtual delivery of EMDR therapy.

Implications for the individual clinician:

• Consent: Many telehealth software applications offer a consent form that can be sent to and utilized with clients. Such a consent should at the very least contain the following:
  • Plans for handling problems with technology and how to respond to unanticipated failures in such
  • Possible challenges to confidentiality when exchanging information online and the importance of using HIPAA Compliant applications or software which carry a Business Associates Agreement

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• • Maintaining transparency and protection
  • Billing and payment guidelines
  • Insurance coverage and consent to exchange information if billing a third party. Note: Insurance companies continue to update policies regarding reimbursement for virtual therapy. These policies will need to be reviewed periodically by clinicians and clients.
• Security: As a matter of due diligence, a clinician’s practices, policies, and infrastructure should be reviewed annually to examine adherence to security, legality, ethical issues, and sound practice.
• Malpractice Coverage: Clinicians should consult their malpractice policies to ensure they are in compliance with their coverage and policies.
• Adequate comfort and education: Several members who were interviewed by the Task Group emphasized the importance of being comfortable with technology. Clinicians can attend training classes regarding the delivery of on-line therapy and should become well-versed in issues of security, selection and use of technology, provision of services, and HIPAA compliance.
• Additional information about ethics, and examples of ethical statements can be found at https://telehealth.org/ethical-statements/.

As we strive to make EMDR therapy increasingly available globally to all suffering individuals, the option for virtual delivery of EMDR has the potential to help us reach remote areas where no other options for quality care are accessible. For those implementing this format, we offer the following recommendations for training, legal and ethical compliance, safety and guidelines for clinically sound practice:

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GUIDELINES for Virtual Delivery of EMDR therapy:

For those who do wish to move ahead with virtual delivery of EMDR therapy, we offer the following guidelines which are non-binding but meant to minimize risk and inform clinicians:

1. Ethical Integrity: EMDR Clinicians will follow applicable laws, licensing standards, and will maintain fidelity to EMDR therapy as they deliver therapy virtually.

• Therapist Administration: EMDR therapy must be administered by an EMDRIA Approved EMDR trained clinician online via telecommunications. This does not include companies, websites, or services which offer EMDR self-therapy without live guidance from an EMDR trained clinician. Self-administration of EMDR therapy is strictly forbidden in EMDRIA Policy.
• HIPAA Compliance/Confidentiality: Clinicians are obliged to stay informed about the telecommunications software they use including whether or not the application maintains a Business Associates Agreement. Attention must be given to security and encryption to attempt to establish maximum possible environment of confidentiality.
• Informed Consent: As required by professional and licensing standards, Clinicians are obliged to obtain full consent not only for therapy but also for the risks involved in virtual delivery. In addition, clinicians and clients will need to agree and consent prior to beginning therapy on a back-up plan for when technology fails and/or when crises arise. Consent should include administrative functions such as email communications (especially if there are attachments containing personal records) and the online software application used for sending billing statements and receiving payment. Clients need to be informed if they have options other than online therapy.
• Fidelity/Integrity: Virtual EMDR must be administered in such a way that it adheres to the fidelity and integrity of the EMDR therapy model.
• EMDRIA Code of Conduct and Licensure Code of Ethics: Clinicians are obliged to follow both their licensure code of ethics as well as the EMDRIA Professional Code of Conduct.

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• Safety/Risk: Clinicians must perform reasonable safety checks and know the support systems and community services in the areas where clients are being served.
• Licensing regulations: Clinicians are obliged to know their own licensing regulations with regard to virtually therapy including jurisdiction issues such as the client’s geographical location and whether or not the clinician’s licensure applies to services in that area. “It is highly suggested that mental health professionals consult their own licensure boards for guidance and to contact other jurisdictions’ licensing boards (where the client is located) regarding the need for a temporary license and to see if they even have any laws or regulations addressing these issues.”4
  • PSYPACT is a recent agreement between certain states for Licensed Psychologists only which allows some interstate practice of telehealth services. Psychologists will want to stay abreast of these developments as it impacts their jurisdictional limitations.5
• Cultural Awareness with regard to remote communities: Clinicians should equip themselves with knowledge of the population and cultural considerations when working with populations in remote locations and in populations which differ from their own.
• Client’s environmental security: Clinicians should discuss with one’s clients the topic of protecting their security (i.e. awareness of “shoulder surfing,” using a computer that is not their own, and the vulnerability of using Internet cafés or a hotel Internet connection.)

4 TeleMental Health Services Across State Lines by Ofer Zur, Ph.D.

5 True Interstate Telehealth With PSYPACT(Just For Psychologists) by Roy Huggins, LPC NCC, April 29, 2019

2. Preparation and Training:

Clinicians are advised to receive additional training in telemental health and use of technology in order to educate and equip themselves for this specialized application of EMDR therapy. Clinicians are encouraged to seek training beyond the EMDRIA Approved EMDR therapy training. A thorough virtual therapy training program will address at the following at minimum:

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• Electronic Office
  • Basic hardware setups
  • Software for Emailing, video conferencing, and for forms and billing
  • Security: securing equipment, client records and data transmissions
  • Insurance
  • Legal / Ethical, Informed consent
• Presencing
  • Create a professional online presence
  • Using web cam & microphone successfully to enhance attunement
  • Clarifying unclear client processing & speech, without interference
  • Fixing technical difficulties without interference of client processing
• Online EMDR
  • DAS methods of delivery and equipment or software
  • Attunement
  • Safety: resourcing and containment
  • Working with new clients to prepare them for online work
  • Promoting of video conferencing among current & perspective clients

3. Relational Attunement:

Clinicians are advised to use additional screening and assessment tools to build strong attunement within the therapeutic relationship which includes building an alliance with a client’s adult ego state to ensure contact with a client to handle technical problems or to check in on unexpected or unclear processing, especially during an EMDR session. Clinicians should also maintain cultural sensitivity and awareness which includes awareness that the cultural background of the remotely located client may be different than that of the clinician. Doing so will enhance therapeutic outcome and aid in crisis management should the need arise.

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4. Technical Considerations/Infrastructure These change quickly, so clinicians must remain informed to establish safety, reliability, and security. Clinicians are advised to enroll in educational courses and obtain proper equipment to ensure technology runs as smoothly, securely, consistently, and safely as is reasonably possible.
5. Hardware and Peripherals:

• • An electronic office for online psychotherapy needs to be functional and secure. It should have a computer system with a dedicated, high speed computer that is powerful enough to support professional needs. It should minimally be able to handle communications by video conferencing and by email and to create and maintain and safely store electronic forms & records. Where possible, conveniently used encryption methods could increase the safety of communications and record storage.
  • Many also want to do paperless billing and to handle other administrative details. Software should be chosen with functionality and security in mind i.e. the selection of HIPAA compliant video conferencing software. Training may be required to use software applications. One should respond to notices of available system and software updates because they may address software problems or improve security protection. If adding the capability for social media, we recommend serious attention to security issues and adherence to firm boundary policies with clients and the type of information shared.
  • The computer should be password protected and have good anti-virus protection, fast and secure network bandwidth provided by a reliable Internet Service Provider and the ability to print and scan. The computer needs to have or be connected to a screen of adequate size for viewing one’s clients. It must also have the capability to support any external devices needed for secure video conferencing possibly including external webcam, headphones, speakers, microphone, back up discs for saving files and surge-protective power strips.
  • One’s smart phone with headphones or ear piece is not only a convenience but is necessary for dealing with security issues that occur with technical problems or client emergencies. In addition, any software or hardware

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equipment needed for dual attention stimulation should be included.

• • Another security concern is one’s local network which could be an office or home network that may be wireless. Home networks can be secured by passwords but clinicians should be aware of user privacy within their own homes. Office network security also needs to be checked.
  • The security of a clients’ computer systems and Internet connection should be discussed with them. Many clients either don’t know or don’t care. Therapists need to have a policy about how they will handle communicating with clients on insecure Internet connections and document any issues in a patient’s records. In order to do this, therapists will need adequate training so they can make sound decisions.
  • All equipment needs to be maintained on a regular basis with a backup plan in place if there is a failure of any of the components. Hardware becomes outdated as speeds and requirements change and batteries or parts may burn out. Unmaintained equipment can become a problem for the integrity of a computer system.

5. EMDR Specific Technique

• Dual Attention Stimulus methods are ideally administered by the clinician
• Dual Attention Stimulus methods are delivered in discrete sets
• Screen size should allow for full breadth of eye movements across the midline (the central plane of vision from left to right) as research has shown this to be efficacious.
• Clinicians take appropriate measures to establish adequate attunement/safety as addressed below:
  • As with any interactive therapy where strong emotion can be triggered, clients with affect phobia or with underdeveloped affect tolerance skills may dissociate or have abreactions. Clinicians should consider making additional effort during the phases of History and Preparation to establish attunement, develop resources, and build affect tolerance skills in order to provide additional support and safety for the EMDR client.
  • Clinicians can establish added safety by being diligent to build trust by graduating targets, monitoring SUDs levels and ego state changes, and

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staying highly attuned throughout the process. Clinicians may allow extra time for session closure and perform consistent follow up on the effects of EMDR from session to session to provide more safety and stability for the virtual client. Clinicians may also want to give additional follow up instructions and resourcing homework to be done between sessions. While these are all normal parts of EMDR therapy, we may need to be more consistent in our use of them and conservative when it comes to providing safety for the virtual client.

6. Crisis Management:

Clinicians must plan ahead for potential crises and should have readily on hand any contact information for the service area in which their client resides. Informed consent should include any necessary releases so clinicians can respond from miles away to ensure the client’s safety.

• Abreaction: Clinicians will want to build a strong therapeutic relationship in advance of phases 3-7 especially and develop a plan in agreement with the client as to what will happen in the case of abreaction.
• Dissociation: Clinicians will want to build a strong therapeutic relationship in advance of phases 3-7 especially and develop a plan in agreement with the client as to what will happen in the case of dissociation symptoms arising during or between sessions.
• Emergency Preparedness: Clinicians should obtain emergency information in advance. This includes contact information for first responders, clinics, help lines, and emergency services in the client’s immediate community. The 9-1-1 services in the clinician’s region cannot respond to a crisis in another location and time could be lost while trying to contact the appropriate authorities in that region. These contacts should be verified in advance of the onset of therapy.

7. Payor Sources and Insurance:

If insurance will be a potential payor source, clinicians should clarify whether insurance coverage is available for telehealth services. The APA regularly

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updates its billing codes each year and has added new codes for telehealth in recent years.

• Although each state has its own policies on telehealth, the demand for this service is growing and, as a result, each state continues to revamp their policies, and definition of, telehealth. With regards to insurance, some states are expanding their telehealth reimbursement policies whereas others are creating more restrictions. Mental health providers need to educate themselves on the policies in their state of practice, as well as know the policies in any other state from which the client is participating in the telehealth. Clinicians should make clients aware of those policies in their disclosure.

8. Malpractice Insurance:

Clinicians will want to review their own Malpractice Insurance policies to determine whether or not their services will be covered and to consider any limitations or jurisdictional restrictions which may be in place.