Using EMDR With Autistic Clients: How Do Therapists Adapt?

We have used “identity-first” language (i.e., autistic person) through this article. This is following the UK National Autistic Society guidance whose recommendations are based on the preferences of some autistic people National Autistic Society (2022). In line with these guidelines, we have avoided use of terms such as “high functioning” and “low functioning” as these can be stigmatizing.

Literature Review

Eye movement desensitization and reprocessing (EMDR) is an evidence-based psychological therapy, developed by Francine Shapiro. It was first described as an effective brief intervention for resolving symptoms of post-traumatic stress disorder (PTSD) in adults (Shapiro, 1989) and since then has developed into a well-established and effective full scale treatment for trauma (Shapiro, 2018). It is recommended by the World Health Organization (WHO, 2013), the International Society for Traumatic Stress Studies (ISTSS, 2020) and the UK’s National Institute for Health and Care Excellence (NICE, 2018) as a treatment for PTSD. It is increasingly used for problems beyond PTSD, including depression, phobias, anxiety, psychosis, pain, eating disorders, and attachment-based conditions (Valiente-Gómez et al., 2017) and has been shown to be cost-effective when compared to other treatments for PTSD (Mavranezouli et al., 2020).

Shapiro developed the Adaptive Information Processing (AIP) model as a theory of trauma processing that underpins EMDR. This posits that all humans are naturally predisposed to psychologically heal themselves from adverse events (Shapiro, 2018). Briefly, we have a knowledge base (held generally in a narrative form), that informs us about life around us (who, where, and what to expect). Adverse events are part of normal life; when processed adaptively, we add to or update these memory stores to direct and prepare us further. When healing is interrupted or inhibited, this processing is not achieved, and the events or memories are stored in different form (with thoughts, feelings, and body sensations frozen in time or experienced as they were at the time of the event). These memories are locked within the nervous system and may become activated through daily life and influence current daily experiences in a distressing and unpleasant manner. This can be seen through an individual’s fixed negative thinking patterns, emotional/arousal responses or symptoms of continuous unsuccessful attempts to process information, as indicated by flashbacks, intrusions, nightmares, and rumination, all of which are symptoms of PTSD (APA, 2013).

EMDR therapists conceptualize their client’s difficulties using the AIP model. Sharing this with the individual can be helpful in reducing shame and enhancing a sense of hope, as they are able to see their emotional reactions as a understandable response to their traumatic experiences. Additionally, it helps to direct the therapy. Therapists support the client to facilitate the reprocessing of adverse/traumatic events through EMDR, which involves an emotional activation of the memory paired with bilateral stimulation (BLS). The goal of therapy is to enable the individual to be able to recall experiences as past events and respond to life now, without the influence of unprocessed memories. Negative beliefs about self and associated somatic experiences can also be targeted during EMDR.

Autism spectrum disorder (henceforth, referred to as autism) is a neurodevelopmental condition, diagnosed by assessing social interaction/communication impairments (e.g., difficulties knowing how to engage reciprocally in social interactions and form and maintain friendships and relationships; difficulties both expressing thoughts and feelings, and interpreting others’ thoughts, feelings, and behaviors); hypo- and hyper-sensory sensitivities (e.g., to sound, light, taste, and touch); and restricted interests and patterns of behavior (e.g., having highly focused and narrow interests, repetitive motor movements, engaging in rituals and routines, and experiencing difficulty managing change and ambiguity; APA, 2013). Autism is a spectrum condition and varies in severity between individuals. It is of childhood onset and lifelong. However, characteristics may not always manifest until social demands exceed capacity; for some, this may only be in adulthood. To meet diagnostic criteria, characteristics need to be clinically significant and contribute to impairment in social, educational, and occupational contexts, as well as other areas of the person’s life. Autism can be present with or without learning disabilities, and with or without language impairment (APA, 2013). Many autistic characteristics (such as the tendency to dive deeply into interests or an attention to detail) can be adaptive and useful in the right contexts.

Autistic people commonly experience co-occurring mental health conditions, including depression, anxiety disorders, obsessive compulsive disorder, psychosis, PTSD, and eating disorders (Lai et al., 2019). Emotion dysregulation is also a common experience (Keluskar et al., 2021). Recent research has found that autistic people may be more at risk of self-harm and suicide than non-autistic individuals (Blanchard et al., 2021). Others have written about the way in which many autistic people camouflage or “mask” their anxieties, hiding very significant levels of distress, confusion, and isolation (Cook et al., 2021). Lobregt-van Buuren et al. (2021) reported on adverse experiences and trauma being difficult to recognize in autistic clients, leading to diagnostic overshadowing. Signs of trauma can be misinterpreted as signs of autism, leading to autistic clients not being offered appropriate evidence-based interventions for trauma. They emphasize the need for increased recognition and for treatment models to be individually adapted.

There has been burgeoning interest in using EMDR with autistic clients. This could be due to several factors. There has been a huge increase in autism diagnoses over the last 30 years (Russell et al., 2021), meaning that many more therapists (and clients) are aware of autism. Online information and support groups have made it easier for people to find information about autism, and may also have contributed to the increase in demand for diagnosis, and there is increasing mainstream press coverage of adults being diagnosed with autism in later life.

The interest in EMDR for autistic clients may also be attributed to the fact that autistic people represent a client group who may experience more trauma than non-autistic people (Kerns et al., 2015) and experience their lives as more traumatic. This can be due to information and sensory processing differences as well as social-emotional difficulties, which can lead to shame, anxiety, and social isolation. There is some suggestion in the research (and much clinical anecdotal evidence) that adverse events that are seen to be mildly annoying by many people can be perceived as extremely distressing or traumatic by autistic people (Taylor & Gotham, 2016).

There is very little research to date on how EMDR is actually used with autistic people, leading many clinicians to develop their ideas “on the go,” often in isolation and without much discussion with other EMDR therapists working with autistic clients. What literature is available to therapists is usually based on the clinical experience of one or two experts, rather than on research. However, it is clear that EMDR is being used and there are some studies that indicate it can be effective with certain modifications.

The earliest work in this area consisted of case studies demonstrating that EMDR can be effective with individuals with intellectual and developmental disabilities, four of whom were autistic (Barol & Seubert, 2010). They described several adaptations, including being more directive than is typical and taking more preparation time to work on self-soothing skills and resources. They checked on progress more during the processing and they were more interventionist in bringing in positive resources and titrating the painful event by breaking it down. They used a technique to check the outcome where they asked clients to imagine a “movie” of the event, so as to see if there was any remaining disturbance. In two cases, they focused on the here-and-now and emotional and somatic experiences only, as the clients were unable to make the link between their present-day distress and past traumas.

Kosatka and Ona (2014) reported using intensive EMDR with a 21-year-old female with a diagnosis of Asperger’s Syndrome (a subtype of autism spectrum disorder in former diagnostic manuals which was given to people without an intellectual disability), who had been physically abused by her peers at school. She did not have an intellectual disability and they reported using only minor modifications, such as taking longer to help her to formulate her negative beliefs about herself. The therapist also allowed for a longer period than usual between eye movements in order to accommodate her difficulties in expressing her emotions.

The first larger scale study of EMDR with autistic people was published in 2019 (Lobregt-van Buuren et al., 2019). This study used the Dutch EMDR protocol for children and did not include any additional stabilization techniques. Study authors found a significant reduction in PTSD symptoms, psychological distress, and also in difficulties with social motivation and communication. Participants were reported to be less impaired in their daily lives after EMDR therapy. These results were maintained over 6–8 weeks of follow-up.

EMDR is clearly being used with autistic clients, potentially with adaptations, but as yet there is no consensus about which adaptations may be important, or why and how they are incorporated into therapy. The present paper describes the modifications made to the standard EMDR protocol by a group of 103 EMDR therapists who have worked with autistic people. The therapists were asked to describe the adaptations they had made. This survey was then used as part of a three-round Delphi survey, which has been reported elsewhere (Fisher et al., 2022). The survey, was written by the authors, following the structure of the EMDR protocol. This present study used a qualitative analysis to draw out themes in participants’ responses, which could help EMDR therapists to improve the quality of their work with this client group. It is therefore a practical clinical paper based on research.

Methodology

Findings

In this section, we will summarize the main themes and will then go through the eight phases of the EMDR protocol, discussing themes which arose from each section. We will end by discussing our findings about clinical supervision.

All of the EMDR therapists in our sample were positive about using EMDR with autistic clients. No one reported avoiding work with this client group, although this may reflect the way in which we recruited our sample: we sought therapists who had worked with autistic clients and so those who avoid the work were unlikely to participate.

Discussion

This is the first research study to examine the adaptations made to EMDR by therapists working with autistic clients. Previous studies have made modifications based on the clinical experience and judgement of a few expert therapists. Here, we have drawn on the experience of a sample of 103 therapists. This gives our findings a depth and breadth that so far has been missing in the literature on EMDR and autism. These therapists spanned a wide range of experience, both in EMDR and working with autistic clients. They ranged from EMDR trainers to those who had completed their basic training, and their level of experience with autism ranged from occasional to daily. Our findings therefore reflect EMDR as it is being carried out “on the ground” by therapists, both expert and less expert. There is little written about EMDR and autism, and so therapists are often in the position of trying to work things out as they go along. This study was an attempt to look at what they do as a result of this process.

The implications for clinical practice are many. This is a highly heterogenous client group which has become more so since the autism diagnostic criteria changed in 2013. This means that earlier research may not in fact be reflective of the characteristics of the group who are currently being diagnosed. This is at the point where well-respected autism researchers are arguing that the diagnosis itself now tells us very little about a person’s difficulties and needs (Gallagher, 2021). The autism spectrum now ranges from severely disabled to exceptionally high achieving individuals. An “autism EMDR protocol” or even a list of “autism-specific adaptations” may therefore not be as useful as it initially seems, as it may narrow the perspective of the therapists. However, a need for a better understanding of the autistic spectrum and how autistic characteristics can interact with the EMDR protocol, particularly among EMDR supervisors, was a strong theme. There is clearly a need for greater awareness in the EMDR community of the ways in which autism can affect a person’s ability to engage in EMDR and therapy in general.

Flexibility and responding to the individual were the key themes mentioned by therapists, across all stages of the protocol. This flexibility included using aspects of adaptations usually made for young people, varying how sessions were run, using a variety of ways to establish a safe space and resources and even suggesting that clients lie on the floor if they felt overwhelmed. These adaptations were made in response to common autistic characteristics, such as perseveration, a need for expectations to be made explicit, sensitivity to emotional and somatic stimuli, and a need to feel in control where possible. These changes were made to reduce anxiety and thus to facilitate the ease of EMDR processing. Therapists need to be creative and ready to make changes during the course of the session.

Within the question of flexibility, some themes emerged that therapists should consider. A lack of generalization was mentioned by many, as was the need to consider sensory and attentional issues. Some said they were more directive and structured to the point of telling clients in advance what to expect in each session, whilst others said they gave more control to their autistic clients, allowing them to decide the length of sets and when to stop.

Any discussion of adaptations poses the question of what changes are possible whilst preserving the integrity of the EMDR protocol, and what adaptations should not be made as they will compromise the effectiveness of the adaptive information processing. This may be particularly difficult for novice therapists to discern. For example, as Morris-Smith and Silvestre say in their book on using EMDR with children (Morris-Smith & Silvestre, 2014), sometimes therapists make “adaptations” which are in fact errors, such as not returning to target to take a SUDs but instead asking at the end of the channel. Perhaps reflecting their uncertainty about what changes they can make, therapists often said that they used EMDR adaptations which they had learnt in relationship to working with children. Some of them said that they changed how they presented particular parts of the protocol (such as the PC and VOC) if a client struggled with it, as is sometimes suggested for younger children (Morris-Smith & Silvestre, 2014). Others referred to the introduction of visual scales, using concrete examples of the safe space or resources, working with emotions in the moment, using drawing and techniques such as story-telling (Logie et al., 2020). These variations are usually only taught in relation to working with children, meaning that those who work only with adults are less likely to have experience of this sort of flexibility. Therapists reported making these adaptations in a flexible way, responding to the characteristics of an individual client, rather than simply adopting an approach they would use with children. Autistic people vary greatly in their levels of ability as well as their neurocognitive profile, and therapists will need to be aware of this and ready to adapt accordingly. This research suggests that the adaptations usually thought of as for children only may have a wider application and perhaps should be introduced to all EMDR therapists.

Autism-specific knowledge was said to be important, particularly by clinical supervisors. Therapists mentioned differences in sensory experiences and introspection, and the need for supervisors to have ideas about how to accommodate these within the EMDR therapy. They discussed the importance of an awareness of the difficulties that living an autistic life can involve, and the ways in which people have had to adapt to live in a world that they often experience as uncomfortable and alienating. Autistic people are more likely to experience trauma as well as more likely to experiences daily events as traumatic, both of which can lead to an accumulation of trauma symptoms. They are also very likely to experience shame, particularly given their frequent experiences of being repeatedly misunderstood by others and socially isolated. The importance of getting alongside the client and being ready to adapt to their needs was emphasized.

Several therapists mentioned that as they have become more aware of neurodiversity, they have started to be aware that some of their clients, both past and present, may have unrecognized autism. This raises an interesting issue, since if many therapists are working with undiagnosed autistic clients, they may not be aware of the need to seek extra supervision. This suggests that perhaps an awareness of neurodiversity and the many ways in which autism can present would be useful for EMDR supervisors, even those who do not see themselves as specialists in this area.

Disclosure

The authors have no relevant financial interest or affiliations with any commercial interests related to the subjects discussed within this article.

Funding

The author(s) received no specific grant or financial support for the research, authorship, and/or publication of this article.