Practical steps in pacing, titrating and managing EMDR therapy

This is taken from a new chapter I have written for an edited book by Allen Rubin. Even though this title focuses on EMDR for children in the child welfare system, the section on "targets of opportunity" and "episodes of care" applies to EMDR with any client of any age. This section helps therapists conceptualize how to pace and titrate therapy given the limitations of number of visits and length of sessions.

I am frequently asked if I can do EMDR in a 50 minute session, and I do. For some clients who do not come every week, I will do a 90 minute session twice a month, but weekly clients I do 50 minute sessions. How? The end of this exert from the chapter tells you how I think about the work.


THE IMPACT OF CHILD WELFARE INVOLVEMENT ON EMDR WITH CHILDREN

The stability of the child’s living situation is a complicated factor in treating children in the child welfare system. Because children in the child welfare system may experience multiple placements, changes in caregivers and school placements, legal proceedings including visitation with the parents who have not protected and/or abused the child, along with attachment fractures and the unknown future, psychotherapy is challenging. With instability of the child’s placement often impacting the child’s consistency of attendance for psychotherapy, the EMDR protocol needs to be titrated in episodes of care. These episodes of care often include case conceptualization in EMDR with each session considered as the one session and only session or the last session for the child. This type of realistic case conceptualization does not prevent the use of EMDR in psychotherapy, but just an adjustment in case conceptualization with consideration of the possibility of targets of opportunity with children and unique case conceptualization rotating between installation of mastery along with trauma reprocessing focused on those targets of opportunity.

Targets of Opportunity
Targets of opportunity are those with which the child presents in therapy. The therapist can reprocess the target identified by the child while also taking the adaptive resolution to present and future events in the child’s life. Each target can be reprocessed through the three pronged approach of EMDR where one target is the focus of treatment – past, present, and future. The goal is one target at time through the three pronged approach. This allows the therapist to conceptualize each session of therapy as a microcosm of the entire therapy process.

Session Case Conceptualization
The flow of a typical 50 minute session starts with review of progress and identification of successes the child has accomplished since the last session. Then installation of mastery for approximately 10 minutes followed by trauma reprocessing through phases 3-6 of the EMDR protocol through past, present, and future triggers fill the majority of the session. Sessions end with review of work accomplished and plans for between sessions.

Because of environmental instability, case conceptualization for children in the child welfare system is paced through episodes of care with EMDR. Each session has to be conceptualized as potentially the child's one and only session. The plan for each session must take into consideration the amount of psychotherapeutic work that can realistically be completed for the child's best interest. The session should start with a brief check in with the child about the time since the last session and a review of any previous treatment. This is followed by probing for successes and mastery experiences that can be installed. This mastery installation provides a foundation to support the child in reprocessing a target of opportunity (the target that appears to be the most salient for the child), and then reprocessing through the 3 pronged approach – past/present/future. The session ends with the therapist enacting closure skills for stabilization between sessions. This can be done in 50 minutes once you know the EMDR protocol.

When probing for successes and mastery experiences, the therapist may ask the child, “Tell me something that made you feel good or that you felt proud of that you did this week.” The child may need assistance in identifying positive symptoms, and the therapist needs to listen closely for any positives that can be utilized to improve self-esteem, confidence, and feelings of competency for the child. Unfortunately, children in the child welfare system often feel unwanted and unimportant; therefore, the review of successes is even more important for this population. Once a specific event has been identified, the therapist can instruct the child, “Notice the positive or good feelings you get from being successful and where you feel those good feelings in your body.” The therapist can instruct the child to do a butterfly hug or the therapist can implement 2-3 saccades of bilateral stimulation for installation of a positive experience for the child. After several sets of saccades, the therapist can then proceed with the trauma reprocessing phases of EMDR. It is important for the therapist to keep a list of mastery experiences for future reference to remind the client of the positive and success the client has experienced. With this structure for psychotherapy, even if the child does not return to your office, the child is more likely to realize the benefits of participating in therapy and more likely to engage with the next therapist.

If the child who comes to your office has previously participated in EMDR and can recall any work from the previous sessions, the therapist can continue with the next phase of the EMDR protocol indicated in the child’s process. If the child has not previously identified any targets, the therapist can ask the child to identify a target. Targets of opportunity are often most helpful to the child and engage the child in the EMDR process by providing the child with the feeling of power from treatment.

The therapy sessions continues for as much time as is available with the therapist allowing 5-10 minutes for closure at the end of each session. On-going therapy continues to focus on reprocessing as much trauma as is possible given the client’s stability and time available for psychotherapy services.
-------------------------------

This section from my chapter was intended to give you a few additional tools on managing the EMDR process in your office. Let me know if you have questions.

Happy New Year!