EMDR can be provided through a virtual platform
EMDR therapists, among many others kinds of therapists, have been offering telehealth sessions to their clients far before the current crisis with COVID-19. These EMDR therapists might have been few and far between, but they have been quietly serving rural, disabled, home-bound people who are as deserving of high quality trauma-informed, life-changing therapy like EMDR as more mobile clients. Most of us are now learning from their experience with this medium as well as from our professional organizations and colleagues how to provide EMDR therapy through a virtual platform. For some therapists, it is not the ideal way to receive or provide EMDR therapy, but as highly resilient and creative therapists, we can do this and learn to do it well.
So yes you can provide EMDR to your clients virtually. Even to clients whom you’ve never met before and may have never heard of EMDR.
How to Get Started
1) State Licensing Requirements/Insurance Coverage
First check with your state licensing requirements for telehealth. Certain restrictions from state licensing boards and insurance companies might be lifted for a limited time due to the COVID-19 crisis, so make sure you are up to date with their requirements.
2) Telehealth Education
I recommend taking an online class in teletherapy from your licensing board or professional organization such as NASW for LCSWs, the American Counseling Association for LCMHCs, American Psychological Association for licensed psychologists, etc. A private company that provides training is Telehealth Certification Institute (https://telementalhealthtraining.com/) You will learn the basics of teletherapy, from HIPAA compliance to privacy interruptions to bandwidth requirements.
EMDRIA has provided a comprehensive document for telehealth and EMDR Therapy; it can be found on the EMDRIA website and it well worth reading. The EMDRIA website also has a great page for telehealth ideas and trainings from its members, most of them free.
3) Which Telehealth Platform?
Find an online platform that works for your budget and caseload, including multiple clients at a time if you run groups. The universal requirement is that it is HIPAA compliant, which entails a Business Associate Agreement. Here is the link to the requirements of a BAA: https://www.hhs.gov/hipaa/for-professionals/covered-entities/sample-business-associate-agreement-provisions/index.html. Most platforms have a monthly fee for encryption. Doxy.me has a free HIPAA version for one to one sessions.
Here are some choices in virtual platforms:
Zoom.us VSEE.Com Theranest
Doxy.me NousTalk.com GoToMeeting
Freeconference.com Simple Practice Cisco WebEX
Zoom is $200/month for its HIPAA included service but this arrangement can cover 10 clinicians on the same agreement so if you are part of a group of several therapists who want to share this cost it would cut down the monthly cost quite a bit.
It is always a good idea to test out your platform before your first session, especially if you use a screen-share feature for the application of visual BLS such as remotEMDR: (https://www.remotemdr.com/) or EasyEMDR (https://www.easy-emdr.com/)
Clients may need to download the client version of your platform, especially if they have an assigned client portal. They will receive an email from you with the web link to their session with you and then click on the link at the time of their appointment. They will need to make sure their video camera and computer audio are on.
You will need to be able to send your documents to and from your clients in an encrypted manner. Regular email is not secure enough for these documents. Most therapists already have an electronic office setup like Simple Practice or Theranest through which you can send encrypted documents.
A special Informed Consent form for Telemental Health is a very good idea; most professional organizations have created one for their members.
Psycho/Social Assessments and demographic documents that can be filled out online and then sent back electronically work best. The clients will need to print out documents for themselves such as the consent to treat and disclosure forms. The informed consent form will need to include an amendment that addresses the privacy of the client’s session (no interruptions from family members, cell phone, TV, etc.) as well as plans for what to do with technical and privacy interruptions. It is essential that the therapist have a form with the client’s personal and local hospital/law enforcement emergency contact information.
Treatment plans can be sent directly to the client after they have agreed to the plan.
Diagnostic screenings such as the Impact of Events Scale, PCL, DES II, BEK depression and anxiety tools, suicide assessments and other non-online tests are best given live. If you would like to give them to your clients to fill out then send back to you, you can do this through a portal like Simple Practice.
The MID (Multidimensional Inventory of Dissociation) needs to be administered online. Here is a one page instruction sheet for clients: http://www.mid-assessment.com/wp-content/uploads/2020/04/MID-Directions-03-2020R.pdf
Here is the link for the MID manual: www.mid-assessment.com/mid-and-manual
According to D. Michael McCoy, LICSW, “The most useful version of the MID for a client to complete at home is the MID MS Word version (which is both typeable and printable), which is also available on the MID and Manual page of the MID website. This version makes it easier for you to copy the 218 items from the Word doc and paste into the Questions tab in the MID Analysis once your client has gotten it back to you. (Just be sure to paste ‘Values Only’, by clicking on the down arrow right next to ‘Paste’ in MS Excel. Clicking on that arrow should give you multiple options for what/how to paste.) You can download that version directly http://www.mid-assessment.com/wp-content/uploads/2018/02/MID-for-MS-Word-in-English-01-2018.docx”
Requirements of Your Clients
Even though clients will not need to travel to your office, there are certain things that they will need to do to be able to participate in teletherapy with you. Telehealth clients need to have access to a screen, the internet, and an ability to receive, fill out, sign, print, and send documents back to the therapist. They need to agree to plan ahead for an uninterrupted private time with you at their location, (there will be interruptions) as well as agree to give you their phone number and address each session in the event of a technical interruption or mental health emergency. It is possible that they will be asked to apply bilateral stimulation to themselves so they need to be open to trying that. Parents will need to fill out the documents for their children as well as attend and help structure the session if the child is under 12 years old. Some clients will be accessing their sessions through a phone; they just need to be in one place where they can concentrate on their session.
Requirements of the EMDR Therapist
1) Your Virtual Office Environment: it’s all about consistency and safety
You have already put effort into creating a safe comfortable environment in your office. You will now need to put some effort into creating a setting that is also safe and comfortable, whether that is your real office or your home. If your client was used to your office but is now interacting with you at your home, is there an object like a plant or even coffee/tea mug that you could bring to your virtual sessions? Consider the lighting (lighting is best near the screen, not behind you), art, and other fixtures that contribute to a sense of neutrality and safety. Is there an echo in your room? Is there a land line in the room that could ring during your sessions? Is there street or construction noise near your window? Have you taken precautions to make sure that no one in your location will interrupt you? Are you dressed the same way as you used to dress in your ‘real’ office? Even this last question is important to address as it affects the client’s need for consistency and comfort based on the physical cues of the virtual environment.
It’s a good idea to sit back a bit from the screen so the client can see most of your torso. This is so they can see your gestures as well as to maintain good eye contact. Remember that the client can hear almost any noise coming from your space including typing on your keyboard.
When interruptions occur on your end, you can quickly unmute and un-video them on your screen, then talk about it after the fact.
2) The Therapeutic Relationship: it’s all about an intentional connection
Therapeutic attunement is one of the most important aspects of EMDR Therapy, whether you are with your client in your office or interacting through a computer screen. Even if your client has had a long therapeutic relationship with you and switches to online only, you will have to put a little more work into creating that therapeutic connection. Think about it – neither of you can see the other’s entire body to be able to ‘read’ and adjust to each other’s comfort level on a micro, non-verbal level (where 70 to 80 percent of interpersonal communication takes place) Other cues such as the prosody (tone) of the therapist’s voice, direct eye contact, gestures, and the visual background become extra important for the therapist to utilize with all of their clients. The therapist will also have to track their client in a more vigilant manner so as to keep them in the room and not ‘drift off,’ especially during phase 4. (see below for some specific ideas on how to contain the safety of comfort of the therapeutic relationship).
It’s a good idea to talk openly with your client about what it’s like for them to see you through their screen if they have switched from your office to the computer platform. Even if you have a new client who you haven’t met before beginning teletherapy, you can ask about their experience of meeting a new therapist online, including sharing what it’s like for you. Talking about these seemingly mundane subjects become important now that we need to build the therapeutic relationship through our computer screens.
3) Need to Address Current Concerns: It’s all about flexibility
Whether your client has been with you for a long time or is brand new, it is important to address current concerns that your client may be experiencing, due especially to the many
levels of stress connected to the COVID-19 situation. Depending on the specific concerns that your client presents, these levels of stress can trigger abandonment issues, safety issues, control issues, and loss and grief. The demands of social distancing, loss of income, staying at home with a dysfunctional family or living situation including domestic violence, loss of child care and school for children, among others, can combine to overwhelm our clients with an ’off the charts’ stress level.
As EMDR therapists, we will need to be extra aware of how our clients are coping with the COVID-19 stress as well as other sources of environmental stress and how they might be influencing their overall treatment goals. You may find that you need to use variations of the 8-phase protocol such as the Crisis Intervention Desensitization (CID) procedure, EMD Prime, EMDr, and the A-TIP protocol (see emdrconsulting.com), and/or the Self-Care Procedure for Coronavirus (SPC-C) Worksheet for Clients offered by Gary Quinn, M.D.: (http://www.emdr-israel.org/) Ignacio Jarero has created recent protocols such as the EMDR-Preci and ASSYST protocols as well as Elan Shapiro’s R-TEP protocol.
4) Commitment to the Treatment Plan – it’s all about steady guidance
When the therapist has assessed the client is ready to begin processing their target memories based on the completion of phases one and two and the establishment of comfortable applications of BLS, it is time to dive into the desensitization and reprocessing phase. You will need to hold steady with your client’s treatment goals, showing that you are committed to helping them desensitize and reprocess their traumatic memories. Just be extra watchful for keeping your clients in their windows of tolerance and use variations of EMD and grounding skills to keep them present in the room. If you are ready and confident in your ability to perform phases 3 through 7 via telehealth, your client will be ready too.
If a client is highly dissociative and is not able to practice dual attention, the EMDR therapist would apply the same precautions as they would in their office – don’t start processing a traumatic memory until they are more stabilized and able to remain grounded in the present.
Practical Suggestions for EMDR and Telehealth
1) Ideas for Establishment and Maintenance of the Therapeutic Relationship
1) Develop a ritual at the beginning and end of every session that grounds both of you in real time in the same space. Ideas for this ritual include a breathing exercise in which you both breathe in for _ counts, then breathe out for _ counts. These breathing sets can continue for as many sets as you think helps. A positive affirmation such as “I breathe in, knowing that I am breathing in, I breathe out, knowing that I am breathing out,” could accompany this exercise.
2) When your client is tapping on themselves either for installation of positive resources or when reprocessing a target memory, the therapist can tap on themselves at the same time, using the same rhythm and location of the taps. The therapist can set a faster pace for phases 4 and 5, and a slower pace for installing resources. It is recommended to use the Butterfly hug only for installation of positive resources, and another form of BLS for reprocessing traumas, but you can assess which procedure is best for your client.
3) Teach the client to be good at reporting on their body sensations. Since the therapist can’t see the client’s body, the client will need to learn to report on what they are sensing in their body, e.g., if their legs, hands, posture, etc., are moving or changing in real time. This extra work by the client is actually a good way to build the therapist/client attunement as it creates a solid team of the two of you working together toward the client’s goals. And of course that is always the case no matter where you are located; the co-creation of the therapeutic environment is a two-way street.
2) Ideas for Grounding and Reducing Hyperarousal
1) Help the client create a grounding box or container of some kind. This container can hold soothing objects such as favorite essential oils or scents, rocks, shells, stuffed animals, pillows, photos or pictures of animals, rosary, or other objects that have the ability to help the client feel grounded and oriented to the present. This is a good idea for children as well as adults.
2) Roy Kiessling of EMDRConsulting.com, suggested an exercise called ‘Securing Your Space,’ in which the client describes what he/she has done to make their space safe and secure. These actions might be closing or locking the door to their room, having pleasant pictures or photos on their wall, even parking in a secluded parking lot if they are on their phone and in their car. The therapist can then encourage the client to feel the positive feelings that come from securing their space and install these positive feelings with slow tapping. This really helps the client build confidence in their ability to take control of their physical and emotional space.
3) Jim Knipe has many good ideas to ground clients especially if they start to dissociate. CIPOS, or the Constant Installation of Present Orientation and Safety, is a go-to for these situations. Chapter 13 in Jim Knipe’s book, EMDR Toolbox, Theory and Treatment of Complex PTSD and Dissociation describes this skill in detail.
3) Ideas for EMDR via telehealth and children/adolescents
1) EMDR therapy can take place with children and adolescents through computer screens. With children 12 and under, I suggest that the parent be in the session to help structure the child and to help the child with exercises that the therapist will use in their therapy. The parent can help the child collect art materials, grounding objects, dolls and/or animals and other figures that the therapist would use in their office to create their therapeutic interventions.
Adolescents in particular have needs for privacy and need accommodations from EMDR therapists to honor those needs. This may entail communicating on your phones through Facetime or Hangouts.
2) Carolyn Settle and Ana Gomez among others have created webinars for working with children and adolescents online. Check out their websites for their ideas or find the links to them on the EMDRIA COVID-19 page.
EMDR Therapy has always been Psychotherapy
From the non-verbal to the verbal aspects of therapy, EMDR therapy has always followed the basics of phase-based, client-centered psychotherapy. You all know this and have this knowledge installed in your bones. This means you can relax and focus on what you know best – paying attention to the client in the present moment in the therapy session. Don’t forget to pay attention to your own reactions, such as body sensations, thoughts and images that spontaneously arise during the session as they might yield valuable information that could help your client. In other words, continue being the highly trained, competent therapist you’ve always been. Being an excellent EMDR therapist doesn’t go away just because you are now conducting your sessions via telehealth. This unfamiliar way of providing EMDR therapy may even prove to have benefits over in-person therapy according to reports from many EMDR therapists, such as clients feeling more comfortable revealing themselves in their own environment and therapists becoming more finely tuned to the therapeutic relationship.
So I strongly encourage you to apply EMDR therapy with your clients through a virtual means. Your clients will adapt because they trust you and believe in your empathic guidance in reaching their goals. The more you believe in yourself and your abilities to provide EMDR therapy in general, the more they will benefit from these abilities whether you are in your office or online. You can do this.