Target lists, treatment plans, and the three pronged protocol
A three part series
One of the most challenging aspects facing newly trained EMDR clinicians is how to organize the information they learn in phase one of the EMDR 8-Phase protocol — history taking. To help, this three part series looks at how to coordinate target lists, treatment plans, and the three pronged protocol.
Part Two: Treatment Plans
The first part in this series looked at the nuts and bolts of how to create symptom informed target lists. Now, in part two, we will examine some of the key points in designing a treatment plan that best meets the needs of our client.
When creating a treatment plan, it is important to consider a few elements:
- Symptom relief
The client sets the pace
While EMDR can be an efficient therapy that moves a client toward symptom relief at a productive pace, it is important for EMDR therapists to monitor the process, and to proceed at a pace that works best for the individual client. From the very onset of therapy, how fast or slow we go in the work is largely determined by the client’s ability to 1) stay within the window of tolerance during history taking, and 2) engage in containment, self-regulation, and affect-tolerance practices, both in and outside of sessions.
Because each situation is unique, we should only go as fast, or as slow, as indicated by what we learn at each step. This is as true in the beginning of the work, as it is later on when we begin reprocessing. One way to gauge pace is to have each session begin with a phase 8 re-evaluation of the client’s symptoms and their responses to the work, both in and out of session. If symptoms are improving, or at the very least ‘stable’, we have a strong indication that the pace is good and the treatment plan is effective. If the opposite is true, we need to consider which adjustments are necessary to better serve our client — sometimes this is an indication that we need to not only slow down, but also (re)consider the order in which we are working.
Order is not always orderly
The 8-phase standard protocol for EMDR therapy places history taking as phase one and preparation work as phase two. While this may work for many of our clients, the standard protocol is not a one-size-fits-all order of therapeutic operation. From the moment we begin with a new client, it is important to be aware of how they are tolerating the order of the work, and make adjustments accordingly.
For example, we can begin to imagine that the process will move at a steady clip if, during our initial session(s), the client is able to share information about their goals for therapy, relay information about their past (childhood history, past experiences, and the like), and tolerate the emerging therapeutic relationship. In this example, we can integrate preparation work into history taking, as items such as psychoeducation about EMDR, teaching BLS, the Calm Place, and the Container will serve the client from the onset of treatment.
Conversely, if a client is unable to tolerate history taking without becoming dysregulated, dissociative, or generally overwhelmed, this is a strong indication that the pace needs to slow dramatically. In this instance, we would postpone history taking and shift the focus of our work toward building the client’s self-capacities of containment, grounding & presentification, affect tolerance, emotional regulation, and (if appropriate) daily living. By prioritizing phase two (preparation) over phase one (history taking), we are adapting our treatment plan to the immediate needs of the client and, simultaneously, doing the crucial work of developing and strengthening the therapeutic alliance.
Are they ready?
Because every client is unique, in terms of their past experiences and current capacities, we need to use clinical judgement to determine their readiness for reprocessing. Some clients, even those with complex trauma histories, may meet readiness criteria early on in treatment. Others may take longer to get to the stage where we feel it will be beneficial to begin reprocessing. Just as we tell our clients, there are no right or wrong answers — only information to consider.
With that in mind, the following is a non-exhaustive list of areas to examine when assessing a client’s readiness for EMDR reprocessing:
- Ability to tolerate the therapeutic relationship
- Ability to self-regulate
- Ability to tolerate positive and negative emotions
- Ability to tolerate positive and negative physical sensations
- Ability to tolerate memories, past experiences, and perceptions
- Ability to practice and benefit from therapeutic exercises, such as Container, Calm Place, and Resource Development and Installation (RDI)
- Ability to consistently engage in self-care
- Adequate functioning in daily life
- Has some social support system
- Secondary gain and/or loss issues have been addressed
This is really where the ‘art’ of EMDR therapy comes to play — a person does not necessarily need to meet all of the above elements with flying colors of stability and containment to be a good and ready candidate for reprocessing. In fact, many of these items won’t come to fruition UNTIL we’ve reprocessed past traumas that negatively impact current functioning.
To determine the appropriate course of action with each client, we have to use our best clinical judgement and consider a few key questions:
- Given what I know about this individual, would reprocessing at this moment destabilize the client? If so, my treatment plan needs to focus on stabilization and readying the client for future reprocessing.
- Given what I know, would reprocessing benefit the client, by giving them relief of symptoms directly related to the target memory? If so, my treatment plan can shift to reprocessing memories on the target list, while continuing to assess client symptoms during and between sessions.
A note on countertransference
When answering these questions, it is important for EMDR clinicians to also address their own feelings about the client, the target memories, and the work ahead. If we are postponing or delaying reprocessing with a client who otherwise meets readiness criteria, we need to seek consultation and/or our own EMDR therapy to ensure that our own phobias and feelings are not inhibiting the healing process for our clients.
Go toward the greatest symptom relief!
Once we’ve determined that a client meets readiness criteria for reprocessing, our task will then be to determine in which order to begin the reprocessing work — for not all symptoms and their accompanying target lists hold equal weight, urgency, and importance in the lives of our clients.
To understand this better, let’s look back at the example we used in part one of this series — a client who comes to therapy with the following symptoms:
- social anxiety
- feelings of worthlessness and the negative belief “I’m not good enough”
- fear of authority figures
- phobia of dogs
During the history taking process, and in working with the client to organize their symptoms, triggers, and past experiences, we created two separate target lists: 1) the feeling of worthlessness, and 2) the fear of dogs.
Symptom Informed Target List — worthlessness
|Date or age||Memory||Other information|
|3 y/o||Dad spanking me in public for wetting pants||Shame and self blame|
|5 y/o||First day of kindergarten — left on my own||Anxiety and feeling I didn’t belong|
|9 y/o||Little league tryouts — dad screams in the car, then hits me at home||Fear, shame, I’m not good enough|
|13 y/o||Bullied on playground at school||First time bullied — it happened for two years|
|17 y/o||Dad gets drunk and gives me a black eye||**worst memory|
|24 y/o||Can’t apply for the ‘good’ job — take the lesser one instead||I’m not good enough|
|26 y/o||Tried to ask for a raise — chickened out||Not good enough and fear of what boss will say|
|30 y/o||Passed for promotion because I didn’t step up||** most recent memory|
- Social gatherings with unfamiliar people
- Seeing groups of teenagers (especially males) gathered together in public
- Presenting at meetings, especially if C-level people are present
- Speaking to boss one-on-one or in a group
- Thinking about applying for a promotion or better job
Symptom Informed Target List — dog phobia
|Date or age||Memory||Other information|
|5 y/o||Bitten by neighbor’s dog at birthday party||Didn’t see it coming|
|10 y/o||Chased by dog in park – ran on top of parked car||* worst memory *|
|11 y/o||Dogs running off leash at campground||Fear and out of control — not safe!|
|17 y/o||Backyard neighbor’s dog snarling through the fence||Fear, not safe|
|22 y/o||Girlfriend brought dog to sleep over — I didn’t sleep at all — the dog hates me||Fear and confusion|
|27 y/o||German Shepard jumped up at me||Out of the blue — no control, not safe|
- Hearing a dog bark (especially if can’t see the dog)
- Seeing unfamiliar dog in public, especially big ones
- When girlfriend brings her dog over
- Seeing dogs off leash
Once this information is organized, we have an open, ’cards on the table’ conversation with the client about where to begin. As a general rule, we begin reprocessing the memories related to the most severe symptoms. Why? Because resolving those memories would, most likely, give the client the greatest symptom relief.
Using the client example, we can imagine that working the list of ‘worthlessness’ would have a greater positive impact in the client’s life, then would resolving the fear of dogs. That being said, until we verify this hypothesis with our client, we can never be certain.
Conversely, we may consider beginning with the dog phobia target list — not because it would give the client the greatest symptom relief, but because of other important and relevant factors, such as the client’s hesitation about reprocessing childhood memories, or our own concerns that the client might not be ready to go fully into the work of reprocessing attachment traumas. With these in mind, it might make sense to both client and clinician to start with the ‘low hanging fruit’, if you will, and place the dog phobia list at the top of our treatment plan.
Stay in touch!
We hope this has given you some useful guidance for your treatment planning work. Please do get in touch if you’ve any questions or comments. We are always happy to hear from you!