Phase One: Getting Grounded in History Taking with EMDR

Listen in to hear Jen, Melissa, and Bridger pick back up their journey through Francine Shapiro’s Eye Movement Desensitization and Reprocessing (EMDR) Therapy (3rd ed.). In this episode, the hosts begin in chapter four of the book, Client History.

Narrative Summary

So, we’re returning to Francie Shapiro’s foundational EMDR textbook, resuming from where we previously concluded Chapter Three in our last recording, resulting in a two-month gap. However, we’re now starting Chapter Four, titled “Phase One: Client History.” This is our focus for today’s discussion, at least in part. It’s unlikely that we’ll cover the entire chapter. Similar to our previous episodes, our approach involves acknowledging segments of the text while also incorporating our interpretations, modifications, and insights derived from our experience with EMDR. Additionally, we aim to integrate significant updates and advancements in the field of traumatology that weren’t available when the text was originally written, especially regarding safety considerations. This includes incorporating the wisdom and research accumulated since then, offering a broader understanding of what we now know compared to the time of the book’s publication.

How do we get started with EMDR?

When we graduate from basic training, there’s an overflow of information swirling in our minds—everything from the comprehensive book content presented through PowerPoint slides by our instructors to the influx of clinical hours with our clients. It becomes a daunting task to figure out where to even begin. Within the framework of EMDR’s basic training, the main takeaway often seems to be the directive to simply start applying it in practice. The instructions suggest initiating EMDR with clients we’re already working with or taking on new clients specifically for EMDR therapy. However, this approach can be quite confusing and unclear.

I’m relieved that we have this space to dissect and methodically explore what it truly entails to begin EMDR therapy with someone, especially during Phase One, which focuses on the client’s history. The concept of client history encompasses a wide spectrum of possibilities, ranging from inheriting extensive documentation containing previous clinical notes, additional diagnoses, and medication histories, to the gradual establishment of a personal connection and rapport with the client. It’s like merging these two aspects together—a union of sorts.

I’m currently recollecting whether we’ve discussed this particular aspect on this podcast or in various other forums. We’ve pondered over whether Phases One and Two follow as linear a progression as the other phases outlined in the methodology. In reality, the experience of these two phases doesn’t always unfold in such a linear fashion. In practice, Phases One and Two tend to blend together. Relationship-building occurs both through the process of gathering history and by experiencing resources together, all while preparing the client for what EMDR therapy entails.

The complexity of each case dictates that we can’t rigidly stick to a fixed sequence of collecting a complete history before initiating preparation, or vice versa. Sometimes, we might delve into preparation before even delving deeply into the client’s history. The intricacies of these phases are vast and varied.

One aspect that often causes confusion is labeling all the stages as “phases,” which implies they’re markedly distinct from one another. Consider the process involved in conducting a phase three assessment—a discrete worksheet with a set of questions—as compared to the intricate nature of something like gathering a client’s history, which might unfold gradually over several years. An assessment worksheet, if done efficiently, might only take a couple of minutes. By categorizing them under the same term, it creates an impression for clinicians that these phases should somehow be similar experientially, when in reality, they’re not. It’s akin to equating a marriage with the specific moment of exchanging wedding vows. While they are connected, it’s challenging to discuss them as if they offer the same experience.

When attempting to discuss these phases, visual aids and representations have been helpful due to their complexity. I view the initial two phases as broad, expansive, and extended experiences over time, whereas the subsequent phases are more defined, almost black and white in some respects. Mentally distinguishing between these two sets of experiences can be beneficial—recognizing that phases one and two are not necessarily tied to a particular target, while phases three through seven involve precise and intentional work on specific memories or processing channels. They entail working discreetly within a memory or series of memories before zooming out to grasp the larger ongoing process.

There’s an assumption in the language of a phased treatment approach that each phase exhibits consistency, even concerning our relationship with time. However, attempting to treat an assessment phase as identical to preparation or history-taking phases would lead to significant oversights and force an overly objective approach.

As both of you were discussing the overarching categories of phase one and two, I found it interesting because within these categories, they encompass specific, even target-specific elements, yet they go beyond that. These phases are notably broad, fluid, and relational. For instance, consider a technique like the “float back” method, a particular tool used in history-taking that directs us toward the specific target we’re about to work on. It involves a step-by-step process or specific resourcing for a particular schema or realm before diving into the work. While these phases can contain these specific components, they transcend mere specificity. They unfold over an extended period, more like a continuous process.

One way to visualize this intertwining is to perceive phases one and two as the foundational bedrock upon which everything else in the therapy process rests. They remain constant and ever-present, requiring continuous attention and additions. Nothing in the therapeutic journey moves forward without this foundational support. This understanding offers a more grounded perspective on what we aim to accomplish in these initial phases—they form the groundwork for the entire therapeutic experience. Therefore, it’s crucial to invest as much time as necessary in building and nurturing this foundation.

Sometimes there’s a discussion about switching phase one and phase two, which may hold some truth. However, it might be more accurate to consider them as ongoing and concurrent processes. Even when we used to discuss switching between the two, the intention was to emphasize their essential parallel nature rather than strictly adhering to a numerical sequence. Placing client history before preparation seems somewhat restrictive to me. It creates a funnel-like structure rather than acknowledging the intricate complexity inherent in the therapeutic relationship. This approach might understate one of the fundamental catalysts for change in EMDR—the profound relationship between the therapist and the client. When we refer to phases one and two, it signifies establishing the broader context within which the entire therapeutic journey will unfold. These phases form the foundational base upon which the therapeutic relationship thrives and develops.

When do we modify the basic protocol?

Okay, so we’ve discussed this topic before, and I’m revisiting instances where we’ve imagined conversations with Francine posthumously, considering what she might say now that she couldn’t express back then. There are moments while reading these chapters where I feel she hinted at critical caveats to the broader discussion. Usually, it revolves around the need to modify the basic protocol in cases involving complex presentations, severe abuse, dissociation, etc. However, this is conveyed in a way that suggests, to me at least, that modification might not be the norm. The underlying premise of the book seems to emphasize adhering to the standard protocol without alterations. Yet, there are chapters and references hinting that modifications might indeed be necessary and offering guidance for such situations.

In light of current knowledge and research in the field, a necessary update to this understanding is that modification is more common than originally conveyed. These small cautionary statements, such as the one found towards the bottom of page 87, where she mentions considering clients with severe abuse backgrounds before proceeding with treatment, leave therapists in a challenging position. Therapists regularly encounter severe abuse situations and need more than just a suggestion to carefully consider before proceeding. There’s a need for guidance on what consideration entails, what factors to consider, and what alternate paths to take. These situations raise numerous questions that demand more detailed guidance.

A general update that we should emphasize is the recognition that regular modifications are not a deviation but rather a common aspect of EMDR practice. Even for clients who might seem suited for a straightforward standard experience, certain modifications can benefit both the client and the therapist, hence warranting their implementation.

From personal experience, the absence of explicit acknowledgment for modifications in the basic training material can lead to feelings of inadequacy or questioning one’s ability, especially when working with challenging populations. Acknowledging and starting from the premise that modifications are commonplace because of our individual and nuanced humanity is vital. We are attempting to tailor a standardized approach to fit the unique individuals we treat.

There’s a stark contrast between the textbook’s categorical, objective language and the nuanced, humanized approach needed in practice. The textbook lists various domains to assess for client readiness in a quantitative, evidence-based manner. However, it lacks the emphasis on humanizing these standards in clinical work. The basic training might convey these standards as rigid requirements for doing EMDR, yet it’s crucial to realize that humanizing the approach and considering the individuality of each client is what breathes life into this otherwise objective and reductionist methodology.

I’ve come to grasp the reasoning behind why basic training is structured the way it is, particularly as we’re engaged in writing our own training. Condensing everything we’ve learned and experienced over more than a decade into a mere five days, though it might seem like an extensive training, makes it implausible to comprehend all components thoroughly until one has actually utilized the most fundamental aspects. It’s akin to a student in grad school—grasping something as intricate as complex dissociation is beyond their reach when they’re still in the initial phases of learning basic helping skills.

Reflecting on this perspective, the primary takeaway I hope listeners glean from this discussion is not that they must comprehend every nuanced adaptation or creative approach immediately, but rather, to recognize the potential within themselves to do so over time. Trusting both their instincts and the protocol, seeing these elements merge alongside their clinical skills and natural intuition, can lead to something truly remarkable. They needn’t feel restricted or as though they lack permission to make these adaptations.

There’s a quote by Picasso that I’ve been using quite frequently—it’s become somewhat of a motto for us, especially in certification groups. The quote is “learn the rules like a master so you can break them like an artist.” While the “break them like an artist” part may seem more appealing, I stress the importance of living by the first part of the quote. It’s about dedicating oneself to understanding the rules, not because rules are to be followed without question, but because they provide a foundation. They’re the framework upon which our practice stands. Before we venture into the artistic freedom of breaking these rules, there’s a crucial need to deeply comprehend them. They offer us support, clarity, and stability as therapists.

Long before embracing the flamboyance of rule-breaking, there’s an initial phase dedicated to understanding these rules. However, part of comprehending these rules involves recognizing when they might not fit a particular situation or client. This is where the conversation initially fell short in terms of nuanced understanding. The asterisk indicating exceptions or nuances is often missing in the portrayal of EMDR, even in books like this one. The caveats we’ve discussed thus far appear towards the end of paragraphs, rather than prominently at the beginning and end of chapters.

For me personally, it’s about acknowledging, before delving into the objective, left-brained material of EMDR, that this approach requires a relational connection and an understanding that it evolves uniquely for each client. It needs to resonate with the therapist’s genuine feelings and authenticity. Once we establish this relational connection, we can transition into the more technical aspects, exploring how these rules resonate and apply to each therapist and their clients, facilitating a deeper understanding and effective application of the modality.

Assessing for Reprocessing Readiness

We’ve affectionately renamed many aspects of EMDR within our approach, and we’ve done the same with what’s commonly referred to as the traditional readiness checklist. We’ve termed it as “assessment for reprocessing readiness.” The adjustment we’re making internally is that when we talk about readiness, we’re not indicating readiness for preparation and resourcing, as everyone is generally prepared for that phase. Even in severe and acute cases, that’s the starting point. What we’re truly examining in terms of risk and readiness is whether individuals are prepared for the work required in phases three and four. This involves selecting a specific target, activating it intentionally, and aiming to reprocess and alleviate distress related to that target. The shift in perspective here is different from the conventional teaching, where the danger lies in assessing readiness solely for EMDR as a whole. This can result in people missing out on the assistance offered in other phases because they might be deemed not ready for phase four. This holds significant importance in practical application.

If we view EMDR as more than just a tool or intervention, then indeed, assessing this type of readiness might be appropriate. However, when we consider EMDR’s objectives from a nervous system-informed perspective, it’s not about whether clients are suitable for healing, but rather, do they possess the necessary components for the targeted processing that occurs in phases three and beyond. We have a general list of considerations that we take into account. Some are straightforward, while others require more nuanced examination. However, it’s essential to underscore that these considerations are not disqualifiers but rather elements for assessment. For instance, we consider past mental health diagnoses, current medications, physical health conditions, overall life stability, safety within the clinical relationship, internal and external resources available to the clients, risk factors like suicidal ideation, and the degree of known dissociation. However, known dissociation shouldn’t be assumed as fully comprehensive from an initial assessment. Oftentimes, new manifestations or expressions might emerge as we progress through the subsequent phases.

It’s the collective evaluation of these factors that provides a sense of readiness, but it’s not a simple checkbox. It’s more analogous to determining how much acceleration we apply—how swiftly or deeply we move into the subsequent phases or what preparatory steps might be necessary beforehand. It’s not about a hard switch; rather, it’s about gauging how fast and how deeply we can proceed at a particular moment.

To humanize our approach, we utilize various indicators to gauge a client’s capacity to connect with their internal experiences and effectively delve into a memory or a specific moment from their past that holds present relevance. This isn’t something objectively quantifiable, but we aim to understand if they’re prepared in their current life circumstances to address the issues they’ve brought to work on. It might require us to identify necessary resources to establish, perhaps forming a support team or determining who they’ll engage with outside our sessions, individuals who support and foster their healing journey. Additionally, it involves safeguarding the vulnerability that emerges during our work together. It’s about their ability to navigate emotions internally and engage in the processes expected in EMDR—letting a memory surface, feeling its impact in the body, opening the reconsolidation window, and ideally achieving reprocessing. These assumptions within the EMDR process often lack sufficient discussion or nuanced exploration.

There’s a list in the text that I’d like to discuss from a slightly different perspective. Francine highlighted the necessity for clients to tolerate high vulnerability, lack of control, intense physical sensations, and complete honesty with the therapist to proceed with reprocessing. However, approaching it in such a stringent manner seems impractical for most individuals—it feels almost intolerable just articulating it. Especially at the initial stages, presenting these requirements might dissuade anyone from considering EMDR or engaging in a therapeutic relationship.

I understand the intent behind each of these requirements, yet what’s important to soften about this approach is that they aren’t disqualifiers. Instead of viewing them as all-or-nothing prerequisites, we can explore the strategies clients employ when these conditions aren’t fully present. For instance, if they struggle with high vulnerability, they might resort to humor, laughter, or avoidance. Identifying these strategies allows us to work alongside them, either preceding the processing or concurrently with it. Take sarcasm or humor in vulnerable moments as an example—it doesn’t necessarily halt the process but signifies a coping strategy that requires acknowledgment. Similarly, verbal processing amid intensity could be observed as a strategy to manage discomfort. It’s an area where we’ve adopted a more flexible stance, recognizing these factors as vital for holistic processing without considering them as definitive disqualifiers. There are numerous adaptations and modifications available to honor each of these elements while proceeding with therapy.

Recognizing these strategies provides a great illustration of how extensive and thorough history taking provides valuable hints and cues for modifications. Let me share an example that I encounter frequently with my client demographic. Sometimes, I let go of the expectation to completely clear a target, aiming for a perfect zero. For instance, there are cases where the client can manage various emotions but hasn’t yet experienced and processed big expressions of rage or intense anger. I’m currently working with three clients who’ve revisited previous targets because they’re now ready to confront and express their rage about those experiences. We’ve prepared for this, taking careful steps to access their rage and create a safe space for them to express it. For one client, we’re planning a session in a nearby wooded area because they feel unable to express rage in the office. It’s an adjustment we’re making based on the thorough history taking that indicates readiness for many emotions but a significant difficulty with anger. So, we’re addressing what we can and planning to revisit when the situation shifts. We’ve been using preparation techniques like Ego State work, resourcing, and more to prepare for expressing rage while continuing phase four processing on emotions like shame and anxiety. This is just one example of the modifications we’re exploring.

The discussion about modifications is crucial. Although we won’t delve deeply into the exhaustive list of modifications, subsequent chapters will consistently intertwine this theme throughout. It’s about considering modifications based on the relationship, historical understanding, and the progress made in the preparation phase. We need to reconnect with our intuitive understanding, emphasizing that modifications are context-driven and don’t necessarily demand referring to specific guidelines or lists.

I often find in consultations that I end up asking more questions than the consultees do. That’s because I don’t know their clients as well as they do. The key to modifications lies in developing a sensitivity toward ourselves and our clients’ needs. It’s a therapist-dependent process too, considering what therapeutic skills and methods resonate with us and align with our comfort and expertise. Basic training traditionally provides a list of possible interweaves, but there’s a vast array of modifications that are as diverse as the populations we work with.

To provide an overview of potential modifications for those wondering what these might entail, they could encompass a variety of strategies. For instance, revisiting the preparation phase and crafting unique and inventive resources tailored to each client’s needs. It might involve altering the sequence of targets, opting for a less emotionally charged target or exploring a different aspect of memory networks in some way. Take interweaves for instance, interweaves, which involve incorporating content or process-based interweaves. Yet, what I consider most crucial is emphasizing the therapeutic relationship. This involves creating a secure and attuned environment that caters to the depth of material we’re addressing, molded by each client’s individual attachment experiences.

The modifications also extend to how we select and sequence targets, allowing ourselves to imagine targeting distressing material through unconventional avenues apart from explicit memories. Sometimes, it’s impractical or unnecessary to focus solely on explicit memories that represent what we seek to change. For instance, when dealing with conditions like DID or severe dissociation, it’s entirely possible to engage in EMDR. It’s about knowing how to target sensations, dreams, or fragmented flashbacks, even when their reality is uncertain. Navigating these unconventional targets within memory networks marks a significant modification when explicit memory retrieval isn’t feasible.

What do modifications look like?

Personally, I favor symbolic targeting in certain situations and often integrate it between traditional preparation and the explicit memory-focused phases. This phase of symbolic processing offers tremendous learning opportunities, although I don’t use it universally. It aligns with what feels right for my practice and benefits the therapeutic process. Broadening our perception of what constitutes a target is a fundamental modification zone in EMDR practice.

My primary method involves reprocessing trauma through resourcing, using resource building as a gateway to access the trauma network. This concept may require further elaboration, and we’ll likely discuss how to implement this approach later. Essentially, we have two choices: we can directly target a specific memory for processing, or we can enter through resourcing, allowing it to organically unfold. An example might involve ego state work, focusing on unmet developmental needs within certain parts and resourcing to address those needs rather than immediately delving into the trauma memory itself.

For me, this approach stands as the most common modification, although it’s challenging to precisely categorize. Essentially, it’s about exercising patience in allowing the relational aspect of the process to evolve. I acknowledge that each client’s ability to experience vulnerability, lack of control, physical sensations, etc., particularly in the presence of another person, is distinct. Hence, I ground the anchor of our work in the understanding that this process will take time to deepen and unfold. It’s not about expecting clients to pour out everything or conform to what I’m doing; it’s about experiencing and discovering together, fostering post-traumatic growth, resilience, and authenticity.

Similar to your method, Jen, I employ a consistent resourcing process that guides how I approach, work within, and exit from targets—it’s about resourcing consistently. Moreover, I aim to extend these resources into the client’s external world. While this might not be an initial modification, I’m always considering how to apply these resources presently and in the future, not just focused on looking back at the past.

Indeed, discussing modifications could take a significant amount of time because no amount of documentation can encompass all potential modifications. Yet, my intention is for individuals to feel liberated to engage differently with their clients, fostering a more collaborative and creative environment in these interactions. I advocate for broadening our definitions and approaches to EMDR beyond what manuals dictate, urging therapists to be fully present in understanding what we aim to achieve and finding innovative ways to accomplish it together. While scripts can be helpful, I encourage the confidence to improvise and create together in the therapeutic process, recognizing that doing so constitutes good therapy.

The book delves into various domains like neurological impairment, epilepsy, eye problems, drug and alcohol abuse, particularly on pages 90 and 91. For me, there’s a specific way of interpreting these categories that’s crucial. I often get asked if EMDR can be done with individuals having conditions like a traumatic brain injury (TBI) or other neurological disorders, seen as potential hindrances to EMDR. I focus on three key aspects irrespective of the specific condition. Firstly, I assess their ability to detect sensations internally and externally. Secondly, I look at how they regulate their emotions, observing their responses when they’re highly aroused or hypo aroused. Lastly, I consider their access to internal processing, whether it’s related to memory or emotions. Evaluating these components patiently guides how I modify and tailor the process for the client based on where they stand concerning these three aspects.

Collaborative common sense plays a role here. For medical concerns, I advocate a collaborative common-sense approach: ask the client how they feel about trying EMDR given the situation, and seek clearance from a doctor if needed. For instance, in the case of pregnancy, it’s essential to consider the client’s feelings, my own feelings, and obtain approval from their doctor. If everyone agrees, then we proceed; if not, then we don’t. However, for some non-medical matters, common sense might not offer a clear-cut yes or no. In such cases, it’s about trying it out together, taking a cautious step-by-step approach, assessing how the client feels during a bit of processing, and deciding together whether to continue.

Rigidly adhering to a binary approach, as if there’s an EMDR rulebook from above to follow, doesn’t align with my collaborative practice. I encourage therapists to work collaboratively with clients, conduct experiments, and gather their own data to determine what works best for them. It’s about being flexible, experimental, and running trials to truly understand if EMDR is suitable for their clients’ specific situations.

There’s a particular case where a client had heart arrhythmia, and both the therapist and the doctor were worried about any physical exertion triggering irregular heartbeats. This concern raised a dilemma as seeking therapy was potentially distressing, leaving them with no viable help. The restrictive standards posed a challenge. However, through a careful, sensitive assessment, we managed to understand the situation better and establish protocols for handling potential issues. We ensured a plan was in place should anything untoward happen during therapy, with a clear agreement to halt EMDR if needed, with both client and therapist feeling comfortable and attuned to each other before starting.

Considering all these factors, the main takeaway is that EMDR is a relational process that unfolds over time. While the basic protocol serves as a solid foundation, it’s not rigidly adhered to; instead, it’s about being adaptive and creative. Being a good EMDR clinician involves employing your creativity to tailor the process to each client’s needs. There isn’t a comprehensive list of interweaves that cover every scenario, so it’s crucial to permit yourself to incorporate your creativity in therapy sessions and collaborate with the client to find what works best for them. It’s absolutely okay if certain techniques or resources don’t yield the expected results; it’s all part of the learning process for both the therapist and the client. We’re not hastening to confront distressing experiences, but we’re also not shying away from them due to potential risks, acknowledging that there are implications to consider in the process.

Transcript

Bridger
0:01:43
We’re back.

Jen
0:01:44
We’re back, finally.

Bridger
0:01:46
The three of us.

Melissa
0:01:47
Where have we been?

Bridger
0:01:48
Where have we been? I’m sure a lot of you are wondering that. Where have you been? Two months and no episode? What is this? How rude, we’ve left him hanging.

Jen
0:01:58
Has anyone reached out? I haven’t gotten any like, messages about it…

Melissa

0:02:01

Oh there’s been plenty of conversations. Yes.

Jen
0:02:04
OK.

Bridger
0:02:05
Melissa’s in the know on people wanting more.

Melissa
0:02:08
Like, is everybody OK? I’ve had, you know, loving comments. Just curiosity.

Bridger
0:02:13
Just curiosity.

Jen
0:02:15
Well, maybe we should give our listeners a little bit of context as to why…One reason why…

Bridger
0:02:22
Yes, one reason why.

Jen

0:02:23

There’s been multiple reasons why if we’re going to be real about it, but one really big, special, adorable, cute, snuggly reason why we’ve been gone.

 

Bridger
0:02:34
There’s another human in the world now…

Jen
0:02:35
A little Bridger.

Bridger
0:02:36
… and that’s very cool.

Bridger
0:02:37
A little, well, a little Olivia. I don’t know. A little Bridger Olivia.

Jen
0:02:41
Yeah.

Bridger
0:02:42
She’s a girl. So, I don’t know. Bridger? I don’t know.

Bridger
0:02:45
I don’t know. But yes, there is a now nine pound, two ounce, small human with no teeth living in my house named Goldie Rose Falkenstien. And so that’s very cool. But it has been a journey. We got COVID in the hospital, which was not what we expected. We had an open plan as far as how we were going to give birth, but that wasn’t on it.

Melissa
0:03:15
In all of the creative renditions of how will birth go, you forgot to put code on it.

Bridger
0:03:22
Didn’t even think about that. Yeah, so perhaps we should have, I can hear many voices in my head saying, you should have thought of that, that’s why you don’t go to hospitals. Okay, well, I’m not trying to get into this whole thing right now. We had a lovely experience. We’re good. Yes, we had a lovely experience aside from getting COVID. But about a week after we brought her home, everybody kind of got back to normal, whatever that means now.

Jen

0:03:53

Yeah, a new normal.

Bridger

0:03:53

A new normal… I was talking with Caleb and the best metaphor or analogy I can use is that I feel like I’m a resident now of two parallel universes that I’m perpetually late to transport between. Like I’m just, I like show up to the one I’m supposed to be in quote unquote, and it’s like I’m late and I have to like orient to where I am. And then at some point I’m like sucked back into the other one of work. And yeah, it feels very disorienting and when you time travel sleep is a bad thing I guess so… really not getting much of that… can’t afford it.

 

Jen
0:04:33
Bridger, that visualization explains some of the facial expressions that you’ve jumped onto zoom with

Bridger

0:04:43

yeah exactly

 

Jen
0:04:42
you just look like really disoriented…

 

Bridger

0:04:45

yeah because I’m like where am I? What time is it?

 

Melissa

0:04:48

What meeting am I in?

 

Bridger

0:04:49

what version of myself was I just before this?

 

Jen
0:04:53
Yeah.

Bridger
0:04:53
It’s very disorienting… and I thankfully have so much, like so many people have been really understanding from clients and consultees. It’s interesting to work with so many people internationally because they’re like, so you’re like off for like a while, right?

Melissa
0:05:10
Oh, yeah.

Bridger
0:05:11
Like, no. There is no governmental support for this.

Melissa
0:05:17
Yes.

Jen
0:05:20
So wild.

Bridger
0:05:22
It’s been interesting, but she is lovely and beautiful and wonderful. She makes amazing faces. Her eyebrows are unbelievable.

Jen
0:05:34
Well, if you ended up making a photo of her, the cover image for this episode, I wouldn’t be opposed to that. I think there’s a few questioners out there that would be thrilled to see her face.

Bridger
0:05:46
There is one that isn’t particularly like cute because her face is like so scrunched, but she’s given the peace sign. That’s my favorite photo of her. And it was caught perfectly where it looks like very intentional, like peace sign.

Melissa
0:05:58
Yeah, I have one like that of a Nora at about a month old. She was doing the thinker face right. She had this serious like, you know, hand on chin like there’s something very, very serious happening in there.

Bridger
0:06:12
There’s another picture of Goldie where she’s laying down and she’s like, posing like she’s like full on like arms crossed one hand up like just so beautiful.

Melissa
0:06:23
The serene baby pose.

Bridger

0:06:25

Serene baby. Yeah, that’s what it would be called if it were curated. Serene baby.

 

Melissa

0:06:31

Well, it’s an excellent reason that we have been delinquent in episodes.

 

Bridger
0:06:36
And I have to say, like, I have definitely missed you guys in this space. I miss you guys just in general, but like in this space as well. This is my first episode, like recorded being back. And it’s just a different space that no other social space offers where we just get to kind of dive in and have fun and know that we’re speaking about something really important and that hopefully a lot of people will benefit from and we’ll get a lot out of it too just in this time together. So I’m really excited to be back.

Jen
0:07:11
Glad to have you back and for us to be back too. Melissa and I were, didn’t tend to our recording as well as we could have maybe with…

Melissa

0:07:22

We’ve been using our time very well though, I promise.

 

Jen
0:07:24
Yes we have.

 

Melissa
0:07:25
We’re busy.

 

Bridger
0:07:26
So we’re back…

 

Melissa
0:07:29
We are.

 

Bridger
0:07:30
… into Francie Shapiro’s EMDR seminal textbook… and we’re picking up where we left off, which we finished chapter three in our last recording, so you’ll see a two month gap there, but we’re right back to where we were starting chapter four, entitled Phase One, Client History. That’s what we’re gonna talk about today, in part, at least. I don’t think we’re gonna get through the chapter, but.

 

Melissa

0:07:59

We’re gonna get through at least half of it. That’s our goal.

 

Bridger
0:08:01
That’s our commitment. We’re going to try.

Melissa

0:08:03

Yeah, yeah.

 

Jen

0:08:05

And I think similar to our other episodes, we’re looking to follow that same process of acknowledging pieces of the text. There’s going to be much more than what we get to speak to, but then also offering some of our own interpretation or modifications or insight that we have found through experience of EMDR to kind of fold into some of the material that’s in the text.

 

Melissa

0:08:32

Along with some pretty important kind of updates to the way it was written back then and all the intervening wisdom and research of the field as a whole. What we know now that we didn’t know in terms of safety and updates to traumatology that are very relevant for these spaces.

 

Melissa
0:08:53
So where do you guys want to begin? How do we get started with EMDR?

 

Bridger
0:08:57
Yeah, I think that is a great place to begin. And speaking to my time traveling self, this is helpful for me as well, just getting back into this conversation of… I feel like when we leave basic training, there’s so much in our head, like, you know, this whole book in whatever PowerPoint form it was presented from the presenters and now we’ve got all this clinical hours going on and the clients that we’re seeing, where do you begin? I think within EMDR’s basic training, like what you leave with is that, well, we just start doing it. We start with clients that we’re already seeing or, you know, we take on new clients and start doing EMDR. I think a lot of that is really muddy. So I’m glad that we have this space to kind of parse out and go segmented or just kind of patiently through what it means to start EMDR with somebody. But in phase one, when it says client history, I think there’s a large spectrum of what that could look like from just inheriting a bunch of documentation that has long histories on it, previous clinical notes, additional diagnoses, medications, whatever. And then you’ve got your personal relational connection being built with your client. So it’s like a wedding of the two.

 

Jen
0:10:23
I’m trying to remember right now if we’ve spoken to this on this podcast, we’ve talked about it in so many other places, but I think maybe it’s been on here too, just our conceptualization of “are phase one and two as linear as the other phases?”, or can we really acknowledge, like, the, the real life experience of those experience of those 2 phases is not necessarily like as linear as what it’s written as. And so practically speaking, phase one and two kind of flow, ebb and flow together. And like relationship is being built through history taking and relationship is being built through experiencing resources together and preparing them for what does EMDR even look like and what does that mean. And so depending on the complexity of the case, we can’t say we’re going to collect a full history before we start preparation, or maybe we start with preparing before we even ask any history. There’s so many nuances to those two phases.

Melissa
0:11:25

I think one thing that I think is pretty confusing is the fact that we call them all phases gives this feeling that they’re remarkably different. You know, the process of doing a phase three assessment, which is a very discrete worksheet with a set of questions, and this is what we’re doing, is vastly different to the complex nature of something like a history-taking phase, which could roll out over years, where an assessment worksheet, if done well, is a two-minute experience, right? So even calling them the same thing creates a sensation for our clinicians that somehow they should be kind of similar to each other experientially and they’re not. It’s sort of like if you were to say that a marriage is the same thing as the moment of wedding vows. Well, I mean, I guess sort of, but like you can barely talk about the two as if you’re having the same experience, and yet they’re very linked to each other, right? They’re in the same category of marital experience, right? Things that we do is marry people, but it’s not real useful, I think, to label them as if they’re the same kind of thing. And so when we try to talk about these, and you know, we’ve been working on like creating images and visuals to try to represent this in some way, because it is complex. I think that imagining the first two phases as these very kind of broad and wide open experiential encounters that we have over long lengths of time, and the later phases are much more discrete and black and white in some ways. And so just to kind of mentally separate those two and say these are very different experiences that we’re gonna have.

Bridger
0:13:14
Yeah, the way I think about it is that phase one and two aren’t necessarily specific to a target, whereas the later you go, you know, phase three and on, with some, you know, reevaluation bringing us back to the larger picture, but those phases three through seven, you’re working very, very discreetly in a memory likely or a series of memories, a channel of processing, like you’re doing some very specific and intentional work and then zooming back out into this larger unfolding process that’s kind of just continually going. I love, Melissa, you just noting that one of the assumptions even in the language of a phasic treatment approach is an assumed consistency across each of these phases, even in our relationship to time. Like if assessment phase is going to be the same as our preparation or our history taking phase, you’re gonna be in a world of hurt. You’re gonna miss so many things and have to objectify. Yeah.

Jen
0:14:20
You know, as you were saying that, both of you talking about the broad categories of phase one and two, it’s interesting because they each hold some pretty specific, even target specific pieces, but they’re more than that. So they are very broad, fluid, relational, but then there’s like to identify like a say float back technique, for instance, is a specific history taking tool that gets us to the target we’re going to be working on. And it is more of a step-by-step process or specific, like, target resourcing. We know what schema we’re working on. We know what target realm we’re going to be in. Let’s do specific resourcing for that before moving in. So I think they each can hold those specific components, but it’s also so much more broad than that. And it is something that unfolds over a long span of time.

Melissa
0:15:19

I think that like one sort of image that we could use to imagine it together is that phase one and phase two are a foundation that everything else sits on, and they’re always there, and we’re always tending to them. You know, they’re constantly getting added to. We don’t do anything without that foundation underneath us. And I think that that sort of creates a more situated feeling of what we’re actually trying to achieve in those first two phases of this is the foundation we’re going to be on for the rest of this experience. And so we’re going to have to tend to it with that kind of thoughtfulness and carefulness and spend as much time there as we need to in order to really get that foundation well-laid. So, you know, sometimes we talk about switching phase one and phase two, which I think is probably more true than not, but also I think it’s maybe even better to say we do them both together and forever.

 

Bridger
0:16:21
Yes, yes, that is, yeah, I think that’s, even when we used to use the language of switching, I think that’s what we always meant, is that we see these things as occurring so importantly in tandem that to delineate numerically points us in a direction that we don’t need to go. That client history coming before preparation, it feels very “funnely” to me, as opposed to acknowledging or embracing the complexity that is in the relationship and under emphasizing one of the causal mechanisms of change in EMDR, which is the relationship between the therapist and the client. Like that to me is where when we say one and two, we’re meaning we’re establishing the context that this whole thing is going to unfold. Just like you said, Melissa, the foundation on which we stand and the relationship being such a such a primary part of that.

 

Melissa

0:17:17

Yeah, absolutely. So I feel like maybe I have a relatively good bridge into maybe our next point. Do we feel ready?

 

Bridger

0:17:26

I’m in.

 

Melissa

0:17:28

Okay, so I know that we have said this before and so I’m hearkening back to moments where we have posthumously had a conversation with Francine about what maybe she would have said now that she didn’t get to say back then. And so we’re going to do that again. Because I like… several times since I’m reading these chapters, I have this feeling of like, oh, she said it like she said that really important caveat to the big conversation. And usually it’s something around the concept of you’re going to have to make modifications to this basic protocol in the case of things like complex presentations and serious abuse and, you know,

 

Bridger
0:18:13
dissociation…

Melissa
0:18:14
dissociation, this and that. But it’s always done in this way that at least to me, it has this feeling of, but it’s more common that you’re not going to have to modify, right? Because that’s what the whole book is about, is the not modifying. And then there are some chapters in the back, and there’s a lot of allusions forward to, you know, you’re going to have to modify sometimes, and here’s what to do if that happens. And so I think the update that we would want to make, and I think based on, you know, what we know now and where research is in the field, is that actually modification is more common than not. And so these little caveats that she tends to make, like, you know, there’s one towards the bottom of page 87, where she says, clients with severe abuse background should be given careful consideration before proceeding with treatment…. Please say more, Francine. Because, like, this is the world that therapists live in, is severe abuse situations. Like, we need a lot more than, before you proceed with treatment, give it careful consideration. Like, how do we carefully consider? What are we considering? And when we do consider, what should we do instead? Like, there’s so many questions, right? And so I think that one of the general updates that we would make is that we want everyone to really feel that if you’re having to modify regularly… exactly. You know, this is where we’re all at, is realizing that a pure basic protocol is going to be less common than having to make some modifications. The other thing that I think is true is that even for clients that could benefit from just a very straightforward basic experience, there are some modifications that are potentially beneficial for everybody. And they’re really supportive to both client and therapist, so maybe we should just go ahead and do them.

Jen

0:20:03

Yeah, I would say in my experience that feels so true. And having a template from a basic training that doesn’t necessarily speak to that explicitly leaves you feeling like, “am I doing something wrong?” Or feeling like, gosh, “I must just work with the hardest population ever that’s barely ever going to be able to be able to use EMDR”. So I love just like starting from that point of the reason it’s going to be modified regularly is because we’re all individual nuanced humans. Like it’s, we’re taking something standard and trying to say, how do we make this fit the person that we’re trying to treat.

 

Bridger

0:20:49

Yeah, there’s a lot of writing, a lot of research on this idea of humanizing theory and intervention. And that to me is what we’re speaking to or how I understand it. Because if you look at the textbook, it comes across very categorical, objective, even listing out different domains that you should assess to determine client readiness. That language is very quantitative, like very evidence-based quote-unquote. And what I mean by that isn’t necessarily that it isn’t at all related to if you don’t do these things you’re not doing EMDR. But it’s saying in the way EMDR was developed to satisfy evidence-based assessment standards, it had to be explained in these very specific categories. Like when you say client readiness, what do you mean? And when you list out stability, life supports, general physical health, office consultations, like all this stuff, it comes across, I think, in a basic training to somebody who doesn’t know that, “oh, you’re gonna humanize all of this in your work”. It comes across as, these are these standards, and if you don’t do these things, you’re not doing EMDR. And so I think that’s a really intentional process of bringing your humanity and the humanity of your client into this thing and making it come alive, what was really objective and like reductionary.

 

Jen
0:22:23
And I feel like I am understanding why the basic training is taught the way it is more now than ever, like as we’re working to write ourselves on this. The impossibility of fitting all that we’ve learned and experienced through now more than a decade of doing this into five days, which is like a really long training, but into five days, it’s there’s no…

Bridger
0:22:51
Impossibly short.

Jen
0:22:52
And it’s impossible to understand all of the components until you have yet used the most basic components. Like you can’t quite get it. Like a student in grad school, there’s no way they’re going to fully be able to understand something as advanced as complex dissociation when they’re first learning, you know, basic helping skills. And so I think when we look at it like that, Melissa, you and I were just talking about this this morning of like the biggest thing I hope listeners take from this as they’re hearing it is not that you have to know all of those ways of nuancing it, all of the ways of adapting it and making it this creative process, but just know that you can. And that over time and trusting your instinct along with trusting the protocol, seeing those two come together and all of the clinical skills that you have and the human instinct that you have, that will become something that is really beautiful. any kind of changing as though they don’t have permission to make those modifications.

Melissa

0:24:04

I know that I’ve been using this quote and kind of constantly, maybe it’s like our quote for the year, the Picasso quote of learn the rules like a master so you can break them like an artist. And I was talking to I think it was a certification group recently, which certification is really where the “break the rules like an artist” part comes in. Yeah. But really, really considering that when I say that, I think people hear me emphasizing the “break the rules like an artist” because frankly that’s the sexier portion of the quote. But I actually live my life in deep dedication to the first part of the quote… you know, that we all are devoted to the rules, not because we think that rules are made to follow but because there’s some wisdom in the rules that give us a firm foundation. Right. They are the skeleton of what we’re doing. And as long as we understand them that way, they give us tremendous support and clarity and solidity and all things that we need as therapists. So well before we’re in the, you know, flamboyant lifestyle of breaking them like an artist, there is this need to study and commit to knowing the why of the rules, so that you also know when the rule isn’t helping, why it makes sense. Because those are the moments where then we need to learn a new rule and break that first rule artistically and creatively with our clients so that it can actually work for them and they can benefit. And so in the initial learning of EMDR, it really is a time for the rules. But part of the rules includes knowing when the rule doesn’t apply. and I think that’s where the original conversation just didn’t know how to nuance enough.

 

Bridger
0:25:54
I think it’s that asterisk that is missing a lot of times in the way EMDR is described, even in this book. Those caveats that we’ve talked about thus far come at the end of paragraphs, not at the beginning and end of chapters. To me, that’s the, again, my standards don’t mean anything to Francine. She is who she is. But for me, just naming that before we get into any of the objective left brain material of learning this stuff, I want you to just connect with it relationally and understand that this is going to take on a life of its own and needs to be individualized to the clients that you see and the different feelings and authenticity that you yourself as the therapist have. Once we get to connect on that, now let’s transition into this, you know, left brain. Here’s the specific rules, quote-unquote, of EMDR. How do those feel to you? What does that look like for your client? What’s coming up then as you start to as you start to apply this modality?

Melissa
0:27:10
Yeah. So speaking of the more left-brain rules, do you guys want to hop over to the actual readiness checklist and have a peek at that?

Bridger
0:27:17
Let’s do it.

Melissa
0:27:20
Okay. So we have lovingly, we rename a lot of things and we’ve done it to this too. So what we call the traditional readiness checklist, we call it assessment for reprocessing readiness because I think one of the first kind of internal adjustments we can make is that when we’re talking about readiness, we’re not talking about readiness for preparation and resourcing. Everybody is ready for that phase, right? That’s what we do in the most severe and acute cases. So when we’re talking about risk and readiness, we’re really looking at risk and readiness around are they ready to do the work of phase three and phase four where we’re selecting a specific target, we’re intentionally activating it for the express intention of trying to reprocess and clear the distress there. Are they ready for that? Can they tolerate that particular part of the EMDR process? And that’s a bit of a shift from the way that it’s usually taught, because the danger of imagining that we’re assessing readiness just for EMDR as a whole is that there’s a lot of people that miss out on help of the other phases, just because we are assessing them out as not ready for phase four.

Jen

0:28:29

Yeah, that feels so, so important to me in the actual application. If we’re talking about EMDR being more than just a tool or an intervention, like if you’re going to use it in that way, then then, yes, that might be we’re assessing that kind of readiness. But if we’re talking about really understanding what EMDR is attempting to do from a, you know, nervous system informed perspective and be able to say like, gosh, even the roots of memory consolidation and all that we’ll get into in that to come. This is not about clients “are you a fit for healing or not?” It’s do they have what they need? Do they have access to the components that are really necessary for this targeted processing, which is what comes in in that phase three and on.

 

Melissa

0:29:25

So we, you know, have a general list of things that we like to consider. So I’m going to just kind of say these, and then we can talk about whatever stands out to us. Some of them are obvious and then some need a little more nuancing. But things that probably need to be considered are things like, you know, what diagnoses are they coming in with, whether we agree with them or not. The fact that they’re coming in with them means something.

 

Bridger

0:29:52

Did you, Melissa, did you already read the second half of that qualifier for the assessment?

 

Melissa

0:29:59

No, I was going to read it and then say that, but we can do that first.

 

Bridger

0:30:02

Okay. Yeah for me, it’s just an important thing because even the assumptions that we’ve spoken to in the traditional sense of assessing readiness, you’re looking for disqualification… and that’s not what we’re talking about. We’re talking about considerations based on Assessment; there is no disqualifying in the way we’re conceptualizing what’s to come, like what you’re about to read.

 

Melissa
0:30:27
Yeah, yeah, so with that in mind, that these are things that we consider, but none of them are disqualifiers. We consider past mental health diagnoses. We consider what are the medications that they’re currently on, any physical and medical situations that they’re experiencing. Another big one that we consider is just the general life stability, like how intense and stressful is their current life, whether it’s connected to past trauma or not, what’s up in their day to day is a big consideration of how they’re going to do in a phase three and phase four process. Another thing that we really spend a lot of time highlighting is the level of safety and rapport in the clinical relationship. How much can our relationship hold and contain is really going to influence the kind of material that we can tackle together and have that go well and be successful. Internal and external resources for the clients, some of these they’re going to come in with already, others we’re considering what might we be able to develop and how quickly might those actually be developed for them. Definitely considering kind of the normal risk factors like suicidal ideation plans, attempts, and things like that. And then the last one is the degree of known dissociation, which I use that language very deliberately because we will initially assess for dissociation whether we’re doing it relationally, whether we’re using the DES or something else, but never assume that after you go through that process, you have a perfectly clear and accurate picture of what dissociation may be present for the client. Oftentimes, as we move into those other phases, we find new manifestations or other expressions of dissociation that maybe we didn’t catch initially. But the degree of known dissociation, does the client know that they do that? What are we observing? What are their family members and other practitioners observed? all of that is going to be considered. And it’s kind of in the big constellation and collection of all those factors that we get the sense of how ready we are. But it’s not a box that we check. It’s not like the light turns from red to green. It’s more like how much gas do we put on the accelerator, right? Like how quickly are we going to move into those deeper phases, or what might we need to do ahead of time to get ready for that. So it’s not a hard switch. It’s really a feeling for how fast can we go and how deep can we go at this point.

Bridger

0:33:05

For me, in a way of humanizing this for myself, I use these different indicators as a means of understanding how able is this client to connect with their internal experience and work meaningfully in a memory or in a specific moment or experience from the past as it is currently relevant. Again, that’s not something that you can objectively assess for. But I’m looking for, are you in a situation in life where you’re ready to work on some of the things that you’re coming to work on? Because there might need to be some things that and this is part of the consideration element, but there might need to be some things that we name as needed resources to create now, even if that’s a care team, like who are you going to go out into the world and be with in this way that is open to and encouraging of your healing process and how do we protect the work and the vulnerability that we’re going to unfold in our time together and within that process can you work internally with emotions and actually do what we hope EMDR does in letting a memory wake up and feel in the body and actually be able to open that reconsolidation window and hopefully achieve reprocessing. Because those are assumptions in the EMDR process that I don’t think we talk about enough, or give space for nuance with.

 

Jen
0:34:51
I would like to read a little list that is in the text and talk about how we maybe look at it slightly differently. And Melissa, you and I got to have a conversation on this already, but Francine had acknowledged for clients to be able to move forward with reprocessing, there must be a tolerance for experiencing high levels of vulnerability, lack of control, and high levels of physical sensation or any type of physical sensation that’s associated with the targeted memory, and then the ability to completely tell the truth about their experience with the therapist. And when we looked at that list, it was like, okay, that that would disqualify like 97% of all human beings, right? Like that list feels intolerable to my body, as I say it. And And especially to do that, starting out, we’re talking about the earliest phase. Maybe you first meet a client and say, I have to be willing to feel high levels of vulnerability with you, lack of control, complete honesty about what I’m experiencing, and be open to any physical sensation from my trauma. No, thank you.

Bridger
0:36:22
Jen, you don’t give that as like an assessment to people and say unless you answer yes to all those things you don’t see them?

Jen
0:36:32
Who would want to do EMDR?

Bridger

0:36:35

Who would want to be in relationship with someone else period?

 

Jen

0:36: 39

Yes! Well and I guess I think I get what she’s looking for in each one of these. I really do. But what I want to just like soften about all of it is it’s not, as you guys already mentioned, disqualifying. And then also, what if we look at each one of these and say, instead of it either has to exist or not exist, what are the strategies the clients are using when that doesn’t exist yet? So if they can’t tolerate high levels of vulnerability, what’s showing up in that? Is it humor? Is it laughter? Is it some avoidance? Is it, you know, like, what’s the strategy that shows up when it feels like maybe they’re not quite ready for the high levels of vulnerability? And how do we work with it instead? And it might be we work with it before we proceed, or it might be we work with it alongside the process. And we kind of partner, I’m gonna use the example of sarcasm or humor in vulnerable moments. That doesn’t mean we can’t move forward with it, but it says that might be a strategy or talking, verbal processing, I see that all the time between sets. They can’t tolerate the intensity, so they start talking about it, maybe we work with it. Maybe we allow that alongside the processing while we stay aware of it. So I think that’s kind of an area that we’ve softened a lot to say, like, hey, those are important factors to really be able to holistically process something. But they’re not disqualifiers, and there’s so many modifications that we can make to really honor each one of those.

 

Melissa

0:38:27

Yeah, I think that’s such a good example of how history taking and really thorough and relational history taking, then gives us a lot of hints and clues about how to do modification. So just as like a brief example of a version of this that I feel like I encounter kind of constantly with the types of clients that I tend to work with, is there’s often the modification of I let go of trying to, quote unquote, clear a target, as in get a perfect zero. There’s some situations where I really push for zeros, and also their history and what, you know, we’ve discovered together, they can tolerate a lot of different emotions, but they have yet to have an experience where they can actually tolerate big anger, big expressions of rage. Things like “I hate him”, right? Like we’re not there yet. But we could do a lot, right? We could work with the fear, we could work with anxiety, we could work with shame, we could work with so much. But I’m not going to expect it to get totally clear because I know that there’s a pretty big affect phobia around rage, and we’re just not there. So I can think of three clients off the top of my head, where we’re currently in a phase of revisiting targets that we’ve already done in the past, because they’re ready to rage about it. We have we have done that work that careful process of like accessing their rage and getting them ready to tap into that and speak it and feel it with me in the room, right. And I you know, I have somebody we’re getting ready to go to a town nearby to be in 60 acres of woods, because she’s told me, I can’t do rage here in your office. Right. So we’re going to modify protocol and go into the woods because that’s where we’re at. So we’re going to revisit a target that she knows she needs to do that with. And that’s a modification we made based on this really like careful and thorough history taking that says, OK, we’re pretty good, but I can’t touch anger. I just am not there yet. So let’s do what we can and come back when that has shifted somehow. And we’ve been resourcing and doing Ego State and doing all kinds of prep to get ready for rage the whole time, but we’re still doing phase four processing on shame, anxiety, etc. Just an example. So I’m sure that people are curious in general about modifications, because that’s, that’s the part that like, we keep hinting at, of like, we’re going to have to modify, be ready to modify. And so I don’t think that we’re going to go into a ton of detail about all the different modifications. But I think in all of the subsequent chapters, we’re going to weave that in and throughout this conversation about, like, how might we modify? about some of this based on our relationship, the history taking that we’ve done, and how preparation has gone.

 

Bridger
0:41:39
Yeah, this is a moment where we need to swing back into the right brain and connect a little bit where we just said that this is going to need to be modified. There are considerations to be made. That doesn’t mean flip to page 94 for the exhaustive list of modifications and considerations. Like, we just need to take a second, that’s why I said like swing over to the right brain, that doesn’t mean, oh, go over to this other spreadsheet. It means tune in to yourself and to the client and really think and feel from the bottom up about what is going on in my, in the sense I’m making or the meaning that we’re making together of this assessment process because that’s going to hold the key for whatever modification and consideration you need to make with your client. I’m not going to be able to tell you that as a consultant because it’s your client and you’re you. I don’t know them, you know them. That’s one of the hallmarks for me that I consistently hear in consultation is that I ask more questions than the consultee does and that’s because I have no idea what you’re experiencing. I can go off of templates that I’ve experienced and try and make projective identifications of you know here’s where it might be coming from and sometimes we’re correct. We have a whole case conceptualization model that helps with that. But the whole purpose to me is tuning or cultivating a posture of sensitivity toward ourselves and our clients. That’s where we’re going to find the modifications.

 

Melissa
0:43:26

Yeah. I think it’s also therapist dependent. Like, you know, considering what other things are you well versed in? What other kinds of, you know, therapeutic skills do you have and ways of working do you enjoy that feel good in your body? And that element gets to count, right? So traditionally in basic training, we’re given a list of possible interweaves, but there isn’t really an extended conversation about these are really just possibilities and really a drop in the bucket of possibilities. And so, I mean, that’s what you’re highlighting Bridger is that it’s not, oh, I’m going to need an interweave. No, the modifications could be as diverse as the populations that we work with.

 

Jen

0:44:10

Yeah, and to give some like general categories of modifications in case anyone’s like, what does that even mean? Like, what could that possibly be? Yeah, it can be going back into preparation and really uniquely and creatively preparing and offering resources for that client. It might be around changing your sequence of targets, selecting a lower impact target or a different memory network or kind of changing that process in some way. Melissa, you mentioned interweaves, determining interweaves that could be brought in and utilized either content interweaves or process interweaves. And then even to me, the most important one is really leaning into the therapeutic relationship. When modifications need to be made, how do we really lean into that and start to build security, safety, attunement to the degree that is needed for the type of material that we’re working on, and it is needed based on their own attachment experiences. And that will look so different from client to client. I have some clients that like me, like coming to me, but literally really don’t care that much that I think they’re important and that I care about them. They have humans in their life that give them that message. And then I have others that like wait for that hour every week to feel that I care about them. And it is so important to them and their work. And so that is, you know, uniquely, uniquely shows up for each client.

 

Melissa

0:45:50

I think the other modification in that realm of target selection and sequencing is letting ourselves imagine how we could target distressing material through a different door than an explicit memory. It’s just not always essential or even possible to get an explicit memory that’s going to be a great representative of what we’re trying to change. You know, for instance, there’s a lot of conversation around like, can you do EMDR with DID? Can you do EMDR with heavy dissociation? And my answer to that is absolutely. Do you know how to target things that aren’t there an explicit story form? Do you know how to target? sensation and dreams and fragments of Flashbacks when the client doesn’t even know if they’re real or not, right? Do you do you feel comfortable navigating the murky waters of targets that don’t look like the usual targets? And if we know how to do that, we can work with all kinds of stuff. But that’s one of the big modifications that we make when there’s something funky happening within the memory networks themselves, and we can’t get explicit memory in the same way. I mean, honestly, I have a preference for that kind of symbolic targeting, like I will almost choose to do it if I have an option, because I actually find it tremendously beneficial at certain stages in treatment. And one of the spots that I use it is between what we would call traditional preparation and resourcing and traditional phase three and phase four of explicit memory. I like to go through a phase of kind of symbolic processing because I feel like we learn a lot. But that’s a modification. And I have my reasons for doing it. And I don’t do it with every client and I do it with a lot. It also feels good to my body. I think that gets to count. And so I think in that realm of targeting things, like broadening our definition and understanding of what gets to count as a target is one of the big modification zones.

 

Melissa
0:47:52
I’m curious, can you guys think of what are your most common modifications? I really want to say mods because I have a weird gaming history. This phrase keeps coming over my head. So now that I said it, I won’t have to say it again, but just everyone can join me if that’s happening in your head, if you’re a gamer out there.

Jen
0:48:18
I think mine is reprocessing trauma through resourcing. So letting resourcing be the door into the trauma network. And that’s a whole long explanation, and I’m sure we’ll get to a point of explaining in some ways of how to do that. But we can either select the memory we’re working on and really go straight at it and very direct targeted processing, open that memory network directly, or we can start in through an avenue of resourcing and allow that to kind of come alive. An example of this could even be like some ego state work, like building and the developmental needs meeting strategies of identifying the parts that have a need that wasn’t met and resourcing it to get that need met. We may not start in identifying the trauma memories where their needs weren’t met, but we’re working on having that part get its needs met. So that is probably my most common modification.

Bridger
0:49:30
It’s hard to even label it, but for me it’s the patience given to the relational unfolding of this process, knowing that, you know, those things that you listed, Jen, from the textbook about ability to experience high levels of vulnerability, lack of control, physical sensation, etc. That all of that is potentially unique in the client’s experience in the presence of another person. And so for me, what I just ground as the anchor for the work that we’re going to do is that this is going to take time to deepen and unfold and we’ll get better at connecting, we’ll get better at making meaning together of what we’re doing in session, and that I don’t expect you to just come in and spill your guts all over the place and just be fine with whatever I’m gonna do and say, because ultimately I’m not here to fix you. We’re here to experience something together and find a more authentic expression of yourself in time as it is now, having lived through what you have, using and discovering post-traumatic growth and that resourcing that can create resilience and grit and all of these things that we wanna see in our clients, that that’s discovered relationally. I use, very similar to you, Jen, a very thorough and consistent resourcing process. That’s for me how I get into targets and work in targets and get out of targets. It’s resourcing all the time. And then generalizing those resources out into the world. That for me, while it’s not a modification that I make on the front end, it’s definitely something I’m thinking about in the later stages of I always wanna be able to link, how can we make use of this today? How can we make use of this in what you’re experiencing now and what you might be wanting to do moving forward, not just looking backwards?

Melissa
0:51:54
I feel like we could talk about different modifications for a very long time.

Bridger
0:51:59
Yeah, because there is no amount of paper that can hold like all the modifications, no spreadsheet cells.

Melissa
0:52:03
You know, we could talk for an hour about each one of what we’ve said and you know, give examples of details of how that looks. But I think my hope is that people feel be set free a little bit to be with their clients differently in how this unfolds and more collaborative and creative in those encounters of what gets to count as EMDR. And really broadening definitions and ways of doing this so that we’re not so attached to what a manual is telling us to do. And we can be really present to what is, you know, what are we trying to do? And then what is the way that we could accomplish this together as two humans in this moment? And if we have a script that could be helpful for that, please use it. They’re great. But if we don’t, could we make it up? Right. Could we, you know, create together on the fly and know how to do that with confidence and with full permission that that is good therapy, that we have to do that.

Bridger
0:53:15
Yeah, there’s, and I’m just looking through what I’ve written in the margins of the textbook, but there’s several of these domains that the book goes through, like on page 90 and 91, neurological impairment, epilepsy, eye problems, drug and alcohol abuse. The posture in which you interpret these categories and what’s written there is really important to me. I get a question a lot of, you know, within a TBI, for example, like, can you do EMDR with a, you know, with a person who has a TBI or who has a neurological disorder, some limitation that they see and have detected through their assessment up front that they’re seeing as this could be a big problem for us doing EMDR. And for me, I talk about three components that it doesn’t matter what you put into the scene. I’m looking for these three components. Do they have ability to detect sensation internally and externally? That’s number one. And what does that look like for them? Number two is how do they regulate their affect? So when they get hyper aroused, what does that look like? When they get hypo aroused, what does that look like? Is there any fluidity in there? And then the third is access to internal processing. That could be memory, that could be feeling, I know what I’m feeling, et cetera. But if those three things, if we can be patient in our assessment of those three things, it doesn’t matter what impairment, injury, addiction, whatever, we’re going to learn how to modify and augment our process to suit the client because of where they’re showing up on those three things. And that’s just me personally, of what I’m looking for.

Melissa
0:55:06
I also think there’s a common sense element to this. I would like to identify this as collaborative common sense. If there’s like some sort of medical thing going on and you’re wondering can we do EMDR with this medical thing going on, right? The common sense, the collaborative common sense is ask the client how they feel, right, about trying EMDR given this consideration and then common sense is get clearance from a doctor. If this, you know, if this thing is under the purview of a medical professional in any way, like it’s just safer to check. Can we do it with pregnancy? Does the client feel safe too? Do I feel safe too? And does their doctor say yes? That’s common sense. If everybody says yes, then yes, right? If anybody says no, then no. And I think we can keep this simpler for ourselves. Same thing with a TBI. Do they want to try? Do I want to try? And does the doctor say yes? And there’s some things that are not medical and common sense is not a yes or no. It’s well, let’s try and see. Right? Take a breath. Yeah, feel it out. Well, we’ll toe dip in, we’ll try a little processing, see how you feel, and then we’ll decide together, right? So this rigid binary is if there’s like an EMDR God in the sky that’s judging us and determining if we’re doing it right. And you know, get that out of the room and be collaborative with your client and run experiments and get your own data on whether or not this is going to work for them.

Bridger
0:56:34
Yeah. Yeah. There’s so much nuance because I’m thinking of a client that or a consultee that was working with a client of theirs heart arrhythmia and was really concerned and had the doctor was very concerned that they can’t do any physical exertion because it could throw their their heart rate into an irregularity and the doctor had reservations about them going to therapy because it could be potentially distressing and the the consultee was like well that puts them in in an impossible scenario where they don’t have any way of seeking help at all. Like, you know, the standards, yeah, the standards that were put there were so limiting. But in, again, that careful, feel it out assessment, we were able to learn like, what’s really going on and what are we going to do if anything starts to happen? Like, how are we gonna know, similar to like the raise your hand, let’s stop EMDR, like with the client’s consent and we both feel good and attuned to one another, we know how it’s gonna go when we start this whole thing, that’s what to me I’m really looking for.

Melissa
0:57:50
Yeah, absolutely. Yeah, so I think with all those considerations in mind, like what we really want everybody to kind of take away from this is, this is a relational unfolding, right? We’re meant to be creative and adaptive. The basic protocol is meant to be the sturdy skeleton that we rely on, but not that we feel devoted to and nothing else. Right. And that in order to be a good EMDR clinician, we do have to use our own creative skill. Right. There is no exhaustive interweave list that is going to give you everything you need to adapt to all the different situations with your clients. So give yourself permission. And even beyond that, make it an imperative that you are including your own creativity in the room and be collaborative with your client to figure out what’s going to work for them. And it is OK to try and have it not work. Like nothing went wrong. If you try and interweave and it flops. Or if you try a resource and it’s kind of meh, right? Like you didn’t hurt the client by giving them a container that they’re never going to use again. You learned something, right? You and your client learned that that’s not their jam, which means don’t rely on that. If it didn’t click for them, move on to something else. Keep developing resources until you find something that really feels resonant and personal and powerful and all of that process is incredibly potent for their healing overall. We’re not rushing to face horror but neither are we afraid of it just because there’s potential risks and implications to consider. Yes. How’s that feel for a rousing summary of the conversation?

Bridger

0:59:28

A rousing summary and go and do EMDR.

 

Melissa
0:59:38

Oh my preachy side occasionally comes out. I hope everybody’s okay with it.

 

Bridger
0:59:39
It was good. I felt encouraged. I felt uplifted. I feel uplifted and empowered.

Melissa
0:59:44
I will not use it as an alter call.

Bridger
0:59:47
Yes. As always, stay in tune with the website. Our course calendar is going to have all kinds of ways to stay involved. We’ve got several free things coming up as well with our, what is SIP? I don’t have the dates in front of me for what that is. Does one of you have that?

Jen

1:00:06

That’s October 5th.

 

Melissa
1:00:08
Mm-hmm.

Bridger
1:00:09
Do you have the time?

Jen
1:00:10
It’s 1:30 to 2:30 Central Time on Zoom. And you can find that on the website, but also if you’re part of the Beyond Healing community, that will be listed there. It’s just a space to come and hear Melissa and I say all the things of what is SIP, how does case conceptualization influence your practice, and then you guys get to ask questions about it to see if it’s something that you feel like you’d be interested in.

Melissa

1:00:40

Yeah, so you can come to that free event and you know we’ll help you determine if the full training feels like the right next step for you. And you guys have another one coming up for those that have already taken one and you’re dabbling in the idea of doing some of our advanced trainings. There’s an option on the website for that as well. You’ll be getting an email about it so that’s coming. Yes, and then if you guys are feeling, you know tantalized about learning the “how to break the rules like an artist”, Beyond’s approach the EMDR. That’s right. Our continual options for that are EMDR certification. All three of us offer cohorts for that consistently. So you can get on our website and look at continuing education. And we have each of our dates listed for the rest of the year. So you’ll be able to see those and into 24, too. So you can start planning your calendar for next year. And for those of you that have already certified and you’re wondering about next steps and how to continue your learning, another great option is to become a consultant. Doing consultation work is a great way to diversify. You don’t have to want to be a trainer. You don’t have to want to even do certification. There’s lots of different reasons why being a consultant can add to your work in a really way.

Bridger
1:01:56
And grow you as a clinician and the learning in general, like, you know, you get access to so many different cases and being able to walk with people through the EMDR certification process. Yeah, amazing.

Melissa
1:02:14
Yeah, so we run those cohorts consistently. If you’re interested in those, you can send us an email through the website, or if you’re on the community, you can send me or Jen or Bridger an email through there and we’ll let you know about what’s coming up. We would love to have you in any or all of those.

Bridger
1:02:32
That’s right.

Melissa
1:02:33
All right, guys, thanks for being with us today.

Bridger
1:02:36
Take care.

…

Did you know?  After full completion of Beyond Healing Institute’s Somatic Integration and Processing training, each participant can receive 21 NBCC hours.

Contact BHC

• Our Website
• Contact us about retreats and thera
• Contact us about training and consultation
• Request to join the Beyond Healing Community here!
• Check out the EMDR Supplement and other resources here!

Think Beyond Podcasts:

• Patreon
• Don’t forget to check out the past two seasons of Notice That!

• Evidence-Based Therapist – where we read so you don’t have to!
• Beyond Trauma – geared towards clients
• Burnt Out Educator – An interview-style podcast for educators and students
• Patreon

Support a Child with a Donation Today!

• Donate here!
• 100% of the proceeds donated to the Burntout Educator will provide high quality therapy for a child in the public school system.

Connect with us on social media: Facebook & Instagram 

Credits

Executive Directors: Jennifer and Ryan Savage, Melissa Bentinnedi, Bridger Falkenstien

Hosts: Jennifer Savage, Melissa Benintendi, and Bridger Falkenstien

Podcast Producer: Bridger Falkenstien

Original Music Composers: Bridger Falkenstein and Caleb Boston