When working with most EMDR clients, especially complex ones, preparation entails more than doing a few relaxation exercises with bilateral stimulation. Preparation is the sum total of clinical activities in which we engage to ensure a client’s safety before proceeding with trauma processing work. Having worked mostly with complicated clients in my time as an EMDR therapist, I have developed the following list of best practices for evaluating the quality of preparation and thus determining whether a client can move into the trauma processing stage:

• Have I assessed for secondary gains? Secondary gains are what a person is “getting” out of staying sick. These gains can be as tangible as procuring a government disability check due to a diagnosis or as subtle as maintaining an excuse for irresponsible behavior because of being “ill.” Shapiro (2001) wrote about the importance of secondary gain assessment. Typically, I am direct with clients about what I mean by secondary gains, and if they are holding on to reasons for staying stuck in maladaptive behavior, I talk about it with them in the context of our therapeutic alliance. In some cases, I use a specialized sequence that I developed for targeting secondary gains, assuming that all of the other preparation steps listed below have seen completed (see inset on Addressing Secondary Gains).

• What is the client’s motivation for wanting to do trauma processing work?  I am reticent to do EMDR with a client, especially a complex one prone to destructive behaviors, when the reason given for seeking treatment is “to find out why I am the way I am.” I am especially reluctant to use EMDR with a client if no effort has been made to embrace lifestyle change (e.g., if the client is in a precontemplative or contemplative stage of change) and he or she feels that a simple explanation for his or her problems lies in the past. Many therapists disagree with me on this one. However, in the spirit of safety, I will not do trauma processing work unless I am reasonably convinced that a client’s motivations for doing so are based on getting well and not ascribing blame to others or finding “magic” answers. EMDR, as well as other trauma work, may reveal some clues from the past, but I make sure a client knows that it’s what they do with those clues that matters.
  

• Does the client understand what may happen if change results and the effects of the trauma on his or her life start to shift?  If EMDR works for the client, there is a very good chance he or she will change and adopt healthier lifestyle patterns. It is important that you discuss this with a client ahead of time to make sure he or she is aware of what’s to come, especially if people in his or her life are used to the client being sick or unhealthy. If a client is in the middle of a legal or court case, it is especially important that he or she knows that the impact on memories of EMDR, especially if he or she is being called to testify against a perpetrator (see inset on EMDR and Legal Issues). One time I did EMDR with woman with a serious history of abuse who was in an emotionally controlling relationship at the time of her treatment. I asked, “If you make these changes, how might that affect your marriage?” Of course, we do not have these conversations with our clients to dissuade change but rather, to ensure that they know what they are potentially getting into with EMDR or any Stage 2 trauma processing intervention. This is why, in my clinical view, orientation to the EMDR process is especially critical (more so before the trauma processing component) as part of preparation.

• Does the client have emotional support resources, including, but not limited to, an A.A. sponsor, home group and support network, a church group, access to healthy and easily accessible friends and family? The essential question is this: If the client has an emotionally draining EMDR session and has some disturbance after he or she goes home, is there someone healthy and supportive, besides you, whom he or she can call? I always encourage clients to let at least one person in their life know they are going through EMDR. The absence of a support system does not necessarily rule out doing EMDR with a client. It does, however, mean that you will need to spend more time bolstering preparation. If the client is genuinely without any positive social support, explore whether there are 24-hour on-call services in your community or ask yourself whether you would be willing to be contacted more regularly via your answering service during this complex client’s trauma processing.

• Is the client able to reasonably calm and/or relax himself or herself when distressed? Of course, the client does not have to be able to perfectly calm himself or herself down when distressed; if he or she could, your services probably would not be necessary. However, as Shapiro (2001) wrote, the client needs some ability for affect regulation. Can he or she use one or more coping skills to self-soothe? Skills can utilize imagery exercises, music, somatic techniques, talking to someone, and others. Practicing these exercises and building up an arsenal of options for self-soothing is critical to EMDR preparation to allow a client to at least return to a state of emotional equilibrium before leaving your office after a difficult session. Moreover, it becomes vital for clients to be able to do these exercises on their own if disturbance from processing emotional material emerges between sessions. I have clients test out, on their own time, the affect regulation exercises on which we have worked together before I am comfortable proceeding with trauma processing.
  

• Is there a sufficient amount of adaptive, healthy material in the client’s life? As Fadalia (see case in Chapter 4) shared with me during her follow-up interview, “It is important that a person who does EMDR isn’t coming emotionally unglued.” This reflection speaks to the importance of stabilization and having an adequate amount of positive material in one’s life so that the negative has something to which it can be linked. Positive material can include everything from acquisition of the basic needs (e.g., food, water, shelter), to work, hobbies, a supportive family, life goals, and healthy friends. The absence of such positive material does not rule out EMDR but does necessitate more advanced preparation in the realm of resource development. The concept of frontloading this positive material is discussed more fully in the next section.

• Am I comfortable working with a specific client and his or her general population group? This is where you must check yourself as part of the preparation process. Shapiro (2001) wisely recommended not doing EMDR with a client whom you wouldn’t treat using other modalities. An essential question you may want to ask yourself is whether you have the clinical skills, especially in the relational realm, to bring clients back to equilibrium without EMDR if the EMDR session takes an unexpected turn. The more carefully you’re prepared, the less complicated such a process becomes. I explain more fully in Chapter 6 how relying on yourself and your own style can be the most effective technique with which to handle troublesome EMDR processing sessions.

These questions can’t be answered with a simple yes or no, and meeting X number of the items on the list does not mean you can automatically proceed with EMDR. It is the quality of your collective answers that should determine if you and your client proceed with trauma processing. Ultimately, proceeding with Stage 2 processing work with EMDR (or any other trauma therapy) is a judgment call that you and the client must make together.

(c) Jamie Marich, 2011