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Unread January 24th, 2007, 03:36 PM
emdrhypno emdrhypno is offline
Join Date: Jan 2007
Location: Boulder, Colorado
Posts: 30
Default How to skillfully work with "overeager" clients?

I am running into a fairly recurrent challenge in my practice: Clients who somehow have the impression that they can just come in for a session or two of EMDR, I'll do something magical to them, and they'll be done. These clients tend to be fairly unstable people (people who could really benefit from some trauma work). Invariably, these clients get frustrated with the (minimum) three or four sessions of rapport building,psycho-ed, screening for dissociative tendencies,history-taking&trauma ranking, safe-place&containment building, and Resource development. Often there's a subtle or not so subtle accusation that I'm stringing them along to make money---that I could just "fix" them in a session or two, but that I want to squeeze them for more sessions, and hence, more money.
Of course, this is not the case.
I am simply doing my best to be an effective and ethical therapist, and to follow the guidelines I've been very clearly taught.
Apparently, according to some of my clients, there are therapists out there willing to give them the speedy treatment they want. There are, it seems, a lot of practitioners out there saying they do EMDR, but scrapping all protocol except for the BLS aspect. I tell clients that I am doing what EMDR governing bodies require me to do, that history taking and the trust built between us actually constitute a very important and potentially healing part of treatment, and that if they want to go to a therapist that will skip those steps, that is their choice. I also add that those therapists, if they are giving them EMDR on the first session, are practicing questionable ethics in my opinion.
I have lost a few clients by setting this boundary, though I have done it very gently, respectfully, and professionally.
I'm fairly new to the field and am this just par for the course? Or is there something I can do to salvage these clients, reframe the situation for them, and get to the point where we get to do some real work before they bail?
It's happened three times in the last three months!!
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Unread January 24th, 2007, 04:35 PM
Sandra Paulsen Sandra Paulsen is offline
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Join Date: Jul 2004
Location: Bainbridge Island WA
Posts: 207
Default Re: How to skillfully work with "overeager" clients?

You have well described a big problem in the field. Lots of people say they do EMDR but only do BLS. The approach you are using is the right one.

You might also direct people to this website so they know the things that can go wrong.

I say to clients, "what would you think of a surgeon who makes an incision where the patient demands without getting xrays and confirming a diagnosis?"

I also say, "EMDR is a power tool and so it can cause harm if not done properly. I want your EMDR experience to be successful and efficient."

It may also be that in your town someone is creating a particular expectation that EMDR is invariably fast. I'd check where the clients are getting their ideas.

Doing the right thing is often hard, but is never a mistake.

Last edited by Sandra Paulsen; February 4th, 2007 at 02:37 AM.
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Unread January 25th, 2007, 12:31 PM
Sandra Paulsen Sandra Paulsen is offline
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Location: Bainbridge Island WA
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Default Re: How to skillfully work with "overeager" clients?

I just reread your original post, because I thought perhaps I should add something about how there are a few people who CAN begin EMDR early on, like second session or second half of a long initial session.

But I see you said those people were fairly unstable people, so by all means you are right to make sure everything is in place.

Let me describe a scenario where it may go fast: On the initial phone contact the client says she has had a history of therapy that was highly successful, and she has previously had EMDR and it was helpful. She is seeking to work on a specific thing, and she obviously knows how it all works. In your initial interview (when you DO get a history because we can't delegate our own assessment/diagnostic process to the client) you not only see she's right but it is clear she has tons of resources. She has a range of coping strategies she successfully uses commonly. She takes the DES in the waiting room (NOT taking it home, since it wasn't normed for that) and the score is low, which is consistent with your clinical findings.

Next appointment you can do EMDR.

Now another client isn't so clear, there's more symptoms and diagnostically there is more going on. There's no evidence of a dissociative disorder on DES or clinically. She responds well to safe place. That client may not need RDI. Francine Shapiro has recently reminded us that not everyone needs Resource Development before EMDR.

Another client has a 24 on the DES (not DID) but you can see she is quite labile and overwhelmed. She'd benefit from RDI or other ego strengthening methods before EMDR.

Another client is not overwhelmed but seems rather flat. Low DES but you sense she's overcontrolled. As you proceed cautiously you see she is affect avoidant, doesn't think its okay to have needs and feelings, so the brakes are on. In no way should that person's EMDR begin yet.

So as usual, EMDR is not a cookie cutter, we have to use clinical judgment. But client urgency should not move us if we see signs that cautious forward movement is the responsible thing to do.
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Unread January 25th, 2007, 03:22 PM
Carol Ann Rowland Carol Ann Rowland is offline
Join Date: Jul 2004
Location: Ontario
Posts: 31
Default Re: How to skillfully work with "overeager" clients?

I've had this experience a number of times and think that the suggestions Sandra has given you are excellent.

I generally simply tell people some of the things I have heard of that have gone wrong, and explain that I understand their urgency because they've heard about how powerful EMDR can be and I affirm that YES EMDR is extremely powerful but if used at the wrong time, with the wrong person, in the wrong situation, or without putting adequate resources in place, that it can also do powerful harm, and lead to people feeling much worse rather than better.

Sometimes it is very helpful to explain to people - especially those with complex trauma or who have significant levels of dissociation - that sometimes going more slowly helps to move things more quickly.

If you go too fast, then you end up in the long run needing to do more work, have more sessions, have extra emergency sessions, etc... because you keep having to do repair work and to try to fix that problems that were being created by rushing in - as well as the cost in their personal and even professional life if things felt very destabilized.

If you take things more slowly and do the proper assessment and get to know each other so you know what is helpful for them and they feel comfortable enough to communicate that for you AND you have the positive resources installed, etc... then it can go smoothly without so many bumps and bruises and their personal lives and professional lives should remain relatively undisturbed during the healing process.

I have not thought of this before but some kind of construction work might be a good analogy - building the foundation of a house maybe? You want to make sure the foundation is good and strong and has all the chinks patched up and reinforced and is nice and solid before you put up the rest of the house - because later if the foundation crumbles and falls apart the rest of the house may follow suit.

I have, by the way, encountered the same kind of pressure even when I worked in a setting in which there was no cost to clients. The implication that I was doing it for my own benefit was not necessarily there but there was at times very heavy pressure, anger and even overt harrassment.

Sometimes those clients who really push can end up being very enjoyable to work with, and it can help a great deal to try to get inside the reasons for the pushing which is invariably that they want to feel better as of yesterday, and they have read about EMDR or it's been recommended to them as a cure all, so it's a very good place to start and look at and talk about expectations.

And you do not ever want to go against what your own clinical judgement is because ultimately if they DO have fallout and a hard time, you will know that you had concerns about it but let them persuade you (they don't know the risks in an experiential way), and you ultimately have to watch and clean up the mess that ensues afterwards, which is NOT fun.

Sooner or later you will start having people come to you with stories of their EMDR that went bad with therapists who didn't think they needed to do all that pesky prep work, and you'll feel much more confident and strong in maintaining your boundaries in this area.

In the big scheme of things, it seems to me that there are potential liability issues and certainly ethical concerns when therapists rush in without doing the adequate groundwork first.
Carol Ann Rowland, MSW, RSW

Last edited by Carol Ann Rowland; January 26th, 2007 at 08:54 AM. Reason: oops
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Unread January 25th, 2007, 08:58 PM
Sandra Paulsen Sandra Paulsen is offline
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Join Date: Jul 2004
Location: Bainbridge Island WA
Posts: 207
Default Re: How to skillfully work with "overeager" clients?

Perfectly stated!!
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