Clinician Experiences With EMDR: Factors Influencing Continued Use

Therapist Pretraining Factors

Therapist pretraining factors pertain to preconceptions about EMDR, therapeutic abilities in the area of trauma treatment, and original theoretical orientation, to name a few. Lipke (1995) wondered if there might be a relationship between work in private practice and clinicians’ “willingness to investigate innovative treatment” (p. 378). He created a measure to survey the first 1,200 clinicians trained in EMDR and their experience of using it with some 10,000 clients. The majority of his participants were psychologists in private practice. Most clinicians had experience treating at least 10 patients with EMDR at the time of completing the survey. Of 342 responses, 239 (69%) reported comfort in using EMDR at a level comparable to comfort using other treatment modalities. A reduction of suicidal ideation or activity, fewer cancellations, and less violence were all perceived as benefits by the respondents. Additionally, 86% of clinicians reported their clients experienced the emergence of repressed material more often than with alternate therapies.

Lipke (1995) also sought answers regarding possible problems using EMDR. Of interest, when asked about “extreme agitation or panic,” 31% of clinicians reported their clients experienced this more often than with other therapeutic modalities, 31% stated as often, and 34% reported less often. The question of clinicians’ perceptions of EMDR within the therapy session and how uncomfortable they are with witnessing an increase in negative affect within the context of the therapy session arose in the wake of this finding.

The results of Lipke’s survey (1995) suggested psychologist respondents overwhelmingly supported PTSD symptom alleviation with EMDR. Results were positive when comparing EMDR to exposure treatments. EMDR was rated as being more effective than exposure therapy by 57% of the respondents. EMDR was also rated as being less stressful to the client (59%) and less stressful to the therapist (47%).

Finally, Lipke (1995) asked clinicians to discuss their decreasing use of EMDR through an open-ended format. The primary reason provided for decreased use was a change in client load or work situation. Other reasons offered were “preference of other procedures owing to their success or EMDR failure, need for more training to feel comfortable using EMDR, client rejection of the procedure, and lack of supervision” (p. 384).

Loyalty to Other Treatment Methods

Cook, Schnurr, et al. (2009) reported that despite interest in new techniques, practitioners tend to remain loyal to the approach they learned early in their training. Based on this finding, it may be inferred that even though a clinician engages in training of a new method, he or she may resume practicing the approach with which he or she was familiar. Although it is not clear how many new EMDR clinicians avoid or stop using the method or why, the presented literature suggests some do (Cook, Schnurr, et al, 2009).

The likelihood of adopting a new approach is increased if it is suggested by a personal acquaintance and if it is clear how to integrate and synthesize new techniques with existing modalities in the clinician’s repertoire (Cook, Schnurr, et al., 2009). EMDR is described as an “integrative, comprehensive treatment approach that contains many elements of effective psychodynamic, cognitive-behavioral, experiential, interpersonal, and physiological therapies” (Schubert & Lee, 2009, p. 120); thus, it may be assumed to be easily integrated into existing practice.

Cook, Schnurr, et al. (2009) found clinicians to be less concerned about empirical validation of a therapeutic modality when making treatment decisions despite the efforts of others to validate EMDR in the research community. Although the research community is invested in evidence-based therapies, this interest does not translate with ease to the clinical practitioners to whom the community wishes to disseminate. Social factors played a much more significant role than evidence-based therapies in training decisions. Clinicians were found to pay heed to supervisors and colleagues whom they respected more than research evidence supporting various modalities. Remarkably, the study yielded a difference between new and seasoned clinicians in terms of adoption of new techniques. New therapists were more likely to adopt an approach if they read or learned about it in graduate school at the beginning of their career. Seasoned clinicians were responsive to respected clinicians when considering a new approach (Cook, Schnurr, et al., 2009). The authors also suggested retention of the new technique may be achieved by focusing on confidence building and mastery of the new therapy. This applied to new and seasoned clinicians, alike.

Becker et al. (2007) and Tarrier et al. (2006) described investigator biases against EMDR, which potentially influenced the outcomes of their studies. Such bias in the literature could be influential when dealing with decisions to pursue EMDR training and whether or not clinicians continue to use it. Of interest is whether clinicians undergoing EMDR training approach the training with the same bias and if the bias is overcome through training and subsequent use of the treatment.

Lack of Comfort With Trauma

Greenwald (2006) reported many experiences of EMDR-trained clinicians not using EMDR. His article presented issues pertaining to retention of learned concepts. Greenwald highlighted many training issues that he attributed to both discontinuation and dilution of EMDR treatment. He expressed concerns about clinicians not necessarily being familiar with trauma concepts prior to training. It may, therefore, be premature to teach a trauma treatment without an adequate foundation of knowledge. This perceived lack of knowledge or proficiency may affect the clinician’s confidence in using EMDR. Greenwald conjectured that clinicians’ fear of using EMDR following initial training would contribute to discontinued use. Lack of experience with trauma treatment may also cause therapists to experience discomfort with the intensity of their clients’ emotions during recall and treatment. Tarrier et al. (2006) and Becker et al. (2007) suggested that therapists may avoid exposing their clients to perceived discomfort, regardless of empirical support. Interestingly, clients in these studies were more willing to consider potential discomfort because of perceived benefit. Both Tarrier et al. (2006) and Becker et al. (2007) discussed the discrepancy between patient preference and therapist preference with other treatment modalities. Exposure therapies appear to be resisted despite heavy support in the literature (Becker et al., 2007).

Foa, Riggs, Massie, and Yarczower (1995) discussed the importance of fear activation during the treatment process and how this promotes successful outcome in exposure therapy. Given the inherent distress that traumatized patients bring to the therapy arena, outlined by the findings of Tarrier et al. (2006) and Becker et al. (2007) regarding therapist avoidance of discomfort, clinician anxiety within the context of EMDR treatment may be an important topic to include in the training process.

The Training Itself

Greenwald (2006) elaborated on issues pertaining to the training delivery format and warned that trainees who did not use EMDR soon enough after training developed bad habits. This has implications for treatment fidelity because a lack of memory of the protocol is likely to result in modifications, whether intentional or not. Lipke (1995) discussed the discomfort shared by his respondents that necessary skills were lacking and that further consultation was required to increase their confidence in using EMDR. Farrell and Keenan (2013) discussed their primary finding that clinicians in their study were no longer using EMDR because of feeling that the training they undertook did not instill the confidence required to engage in its continued use.

Clients’ Experiences Before and During EMDR Treatment

Becker et al. (2007) found that clients lacked awareness of and familiarity with EMDR. This would suggest the need for the therapist to initiate a discussion of EMDR as a treatment option rather than the client requesting it. With such large numbers of clinicians being trained each year, it is unclear why consumers lack awareness of EMDR (Tarrier et al, 2006).

Many of the studies previously mentioned have discussed the discomfort that can arise on behalf of both the therapist and client during an EMDR session, with Lipke (1995) reporting 31% of clinicians in his study reporting their clients to be more agitated or panicked than those who engage in other therapies. There is a lack of research outlining specific patterns of overall client experiences, but a general theme of fear and discomfort is evident within the findings of Lipke (1995) and Greenwald (2006) and is indicative of this phenomenon in EMDR treatment.

Posttraining Skill Development

The EMDR International Association (EMDRIA) instituted a posttraining consultation requirement for EMDR basic training in 2008. Prior to that time, many informal study groups were in operation, and there was an apparent need for ongoing support and consultation. Again, Lipke (1995) and Greenwald (2006) discussed the perception of an insufficient training structure because of the large amount of information presented in the weekend training format. Ten hours of consultation are now factored into the training structure, with ongoing consultation and peer support encouraged after that. It remains to be seen how this impacts EMDR retention.

Socioenvironmental Factors

With many clinicians being trained in EMDR each year, the appeal of EMDR is not disputed. However, from the information distributed by Cook, Biyanova, and Coyne (2009) and Cook, Schnurr, et al., 2009, the vulnerability of the newly trained EMDR therapist is evident. There are clearly additional influencing factors that render both newly trained and seasoned clinicians vulnerable (Cook, Schnurr, et al., 2009). As described, collegial support, having a resident “champion,” and funding for continuing education all affect the likelihood of pursuit or adoption of new techniques.

As can be observed from the earlier information, the literature offers much in the way of therapist pretraining factors, with less data available on the other factors influencing clinician use or discontinuation of EMDR. This study aimed to explore the extraneous factors that remain elusive but are very impactful to the development and continued use of EMDR.

Although EMDR has been shown to be a robust therapeutic treatment (Maxfield & Hyer, 2002), there is likely a level of reduction in its use by practitioners consistent with the research on adoption of other therapeutic modalities (Cook, Schnurr, et al., 2009). EMDR requires a high level of commitment from the clinician because of the extensive training program, and the therapy would be expected to retain therapist adherents well as a result. EMDR is not perceived to be taken on a whim because the requirements for basic training add up to approximately 50 hours of invested time with a significant financial commitment. The reasons for discontinuation are largely unclear. Studies exploring clinician experiences are either dated or focus on a specific clinical setting (Cook, Biyanova, et al. 2009; cf., Farrell & Keenan, 2013; Lipke, 1995).

This investigation aimed to quantify clinician experiences with EMDR and explore the reasons that clinicians choose either to commit to EMDR or return to their previous modality of choice. This will serve as a foundation to expand or refine current training practices or offer validity to existing practices that contribute to retention. Although some clinicians may use EMDR as an adjunct therapy, the focus of this study was to distinguish between those who continued using it as opposed to those who did not adopt the treatment in their practice.

The impetus for conducting this investigation was an original study carried out by Cook, Biyanova, et al. (2009). Clinicians from two U.S. Department of Veterans Affairs treatment sites were interviewed to investigate adoption or rejection of EMDR. In total, 29 clinicians were surveyed. One site had a resident champion of EMDR, thus encouraging its use as a treatment option. At the second site, there was a general lack of support, starting at the management level, with subsequent discontinuation, or avoidance of, EMDR practice. The National Institute of Mental Health (1998) reviewed the difficulties in getting practitioners to use evidence-based psychotherapies, but there is a distinct lack of understanding of the phenomenon (Cook, Biyanova, et al., 2009). The findings presented by Cook, Biyanova, et al. (2009) motivated a quest for a deeper understanding of the unique experiences of clinicians trained in EMDR.

The assertions posited by Lipke (1995) were based on a survey conducted almost 25 years ago with existing EMDR practitioners. Cook, Biyanova, et al. (2009) included a small sample derived from a limited clinical setting. The intention of this study was to dig below the surface by quantitatively and qualitatively investigating the reasons for the occurrence of EMDR clinicians discontinuing their use of such a robust treatment method in a large and varied sample.

The purpose of this study was to determine if a clear pattern would emerge to illuminate the reasons for EMDR-trained clinicians continuing to use the therapy or not. As such, several questions regarding use surfaced and were used as a means to guide the objectives of the survey instrument and subsequent interpretation of data. For each factor, scores on various items were compared for use or discontinuation of EMDR:

Additional analyses were conducted to examine the relationships between various factors—for example, if employment setting influenced participation in posttraining consultation.

Method

Results

Responses provided by the 239 clinicians who completed the survey were analyzed to reveal patterns differentiating those clinicians still using EMDR from those no longer using it and to identify the factors contributing to its continued use. As previously stated, not all respondents answered all questions, and percentages reflect the number of analyzable responses obtained. The survey was initially sent to clinicians in five states in the United States. The momentum of the participants expanded the scope to include 37 states and 14 countries, with most respondents being private practitioners (78%).

Thirty-three percent of the sample had used EMDR with their clients on more than 100 occasions. A further 15% had used it on zero to nine clients. Of the clinicians surveyed, 37.5% were using EMDR daily, 35% weekly, 12.5% monthly, and 15% too infrequently to track. In the sample as a whole, only 12% had stopped using EMDR. Preferring other methods, needing more consultation, and not feeling prepared were prevalent reasons provided for discontinuing use.

Reasons for Discontinued and Continued Use of EMDR

In summary, there were no statistically significant relationships between the factors investigated. However, the primary reasons that emerged for not using EMDR were preferring a previous modality (no treatment surfaced as generally preferred), not feeling competent, client refusal, and discomfort suggesting it. Of those clinicians still using EMDR, 25% stated rapid results as the primary reason. Other reasons for retaining EMDR were feeling more effective as a clinician and an increase in referrals because of using EMDR. Five respondents stated their practice was enhanced either because their clients experienced less distress, were able to do deeper work, achieved their treatment goals, or because the therapist experienced more success in treating patients with PTSD. Table 7 includes a tabulation of negative experiences, both from clinicians still using EMDR and those who were no longer using it.

Discussion

In applying these findings to the literature previously presented, several conclusions can be made that complement existing research. The primary (most endorsed) reason given for discontinuing use of EMDR in this study was preferring another modality (pretraining factor); either the one previously used or a new one that the participant considered to be more efficacious. Needing increased training to feel more comfortable using EMDR (training and posttraining skill development), client rejection (client factor), and a lack of supervision (posttraining skill development) all featured prominently in this study despite the gains that have been made in improving the basic training over the last two decades. Farrell and Keenan (2013) noted similar findings, with lack of funding being the primary reason provided in their study for not completing EMDR training, followed by lack of EMDR clinical supervision and lack of confidence using EMDR.

Limitations

The primary limitation of this study was that clinicians who no longer using EMDR were underrepresented. As a result, the obtained results may not be fully representative of the population sampled. Although there was convergence of results with prior research conducted in the field, questions arise regarding the representativeness of the sample caused by a lack of random sampling in the methodology. The second limitation of this study was sample composition. Although 239 people completed the survey, which did allow for meaningful interpretation of the results, there was an overrepresentation of private practitioners compared to agency clinicians. As such, it would have been preferable to increase the sample size and obtain greater representation of agency clinicians.

A further limitation of the study was not having a random sample of participants, thus limiting the extent to which the results are generalizable. Given the scope of the study, participants were recruited purposefully, and the original five states were selected because of the volume of EMDR clinicians in those geographical areas. Participation in the survey was entirely voluntary and relied on the willingness of clinicians to respond to solicitations. This may have created a response bias in the sample, thus not being an accurate representation of the population at large. As previously stated, however, the results of this study did converge with previous research findings, and although restraint should be exercised when generalizing the findings of this study, it is presumed to be representative to the greatest extent possible.

A further limitation associated with using an online survey pertains to missing data. As previously reported, not all respondents answered all questions. The survey format allowed for respondents to answer those questions that were pertinent to them. Some respondents also skipped questions that did pertain to them, creating a gap in the data that may have yielded more useful information.

Training Recommendations

Not having a background in trauma treatment (pretraining factor), not using EMDR soon enough after training, and a subsequent lack of confidence (posttraining skill development factors) arose as prominent issues pertaining to discontinued use of EMDR. These factors likely considerably influence the clinician’s ability to suggest the treatment to the patient or to work proficiently with client refusal (client experiences/training factor).

Proposing EMDR to a client came up across various questions as being an issue for clinicians. This highlights the need for trainers to be more aware of this issue and perhaps to incorporate a structured discussion during the trainings (training factor). If a clinician is unaware of how EMDR works, he or she is not going to feel comfortable explaining it to a client. Advances have been made in identifying some neurophysiological processes that EMDR impacts. Incorporating this information may help train new therapists in presenting EMDR to potential clients. Setting standards for applicants’ study of EMDR—prior to and after basic training—would probably also help with therapists’ comfort in presenting the method to clients.

When addressing discomfort with proposing EMDR as a treatment option, or a general lack of confidence in using the treatment, a natural connection between this issue and the idea of receiving consultation and ongoing support after completion of training arises (training and posttraining skill development factors). Although the introduction of the consultation requirement was not driven by research, most respondents felt it was a crucial element to success and ongoing use of EMDR. This gives support to the training changes that occurred in 2008. This speaks to the complex nature of the therapy and also highlights some potential inconsistencies in training delivery (training factor). Consultation beyond the initial training requirement is elective and cost-prohibitive to many, especially private practitioners, who are responsible for paying for their own posttraining support.

With 40% of respondents reporting that basic training was inadequate (training factor) and that they had sought posttraining supervision and skill development, it is interesting to observe that consultation was made a training requirement in 2008. Participants in this study suggested that trainers emphasize that Parts 1 and 2 constitute only a basic training, and advanced trainings are required for addressing specific disorders and situations. Opinions pertaining to normalizing anxiety and having realistic expectations were prevalent, suggesting that current trainings overlook these aspects. Remarkably, some practitioners stopped using EMDR despite having had from 24 to 40 hours of EMDR consultation. Those clinicians nevertheless reported finding EMDR to be ineffective, not knowing how it works, and not being comfortable with client abreaction. A recommendation is that all such topics should be addressed during the course of consultation. Such may imply a need to structure basic training consultation more uniformly, at least initially, to address each of these factors early on in the training process.

Because EMDR addresses trauma, and the most severe trauma disorder, PTSD, is highly comorbid, clinicians lacking certain skills will often have difficulty applying EMDR (pretraining and training factors). Having the ability to integrate EMDR with other modalities to optimize treatment for the patient is crucial when EMDR alone is not sufficient in reaching treatment goals (pretraining and training factors).

Implications for Practice

Some respondents stated they were no longer using EMDR because of either lack of client interest or client refusal (training and client factors). This is an intriguing response that suggests the responsibility of treatment choice lies with the client. This pattern would require a very informed consumer be able to ask for what he or she needs. As Becker et al. (2007) discussed, the client is initially generally unaware of or unfamiliar with EMDR. As professionals, the change in focus to bearing the burden of informing the client regarding what is available may reduce this scenario significantly. Mental health practitioners may be in the minority with this expectation when considering how treatment is offered in parallel professions. Placing the responsibility of being informed of treatment options on the patient reflects a lack of effort on the clinician who will contribute to the resistance with which the EMDR community has already been faced.

The fact that EMDR works has been established (Foa, Keane, Friedman, & Cohen, 2009; Schubert & Lee, 2009). Its efficacy is strongly supported by those respondents who continued to endorse using EMDR despite negative experiences with it. Given the support that EMDR receives from those who firmly believe in it, it is unclear why others lack such enthusiasm (socioenvironmental contributors). It has gone from being a treatment for PTSD to being a comprehensive treatment. Perhaps some enthusiasm has distorted the views of those being trained, as they approach the training expecting miraculous outcomes. Much of EMDR success was driven by the results of single incident trauma. Complex PTSD requires far more clinical skill and judgment than a single incident trauma. The question of for whom it works best remains. Maybe managing these expectations differently (training and socioenvironmental factors) will offer a more realistic expectation for the new EMDR clinician and encourage him or her to persevere when the results require more arduous EMDR work than might have been expected.

Recommendations for Future Research

It would be helpful to know how long since completion of their degree that each clinician was trained in EMDR. Such information may shed more light on therapist attrition with regard to being set in their ways and having developed significant loyalty for another modality and should be included in any follow-up study.

Summary

This study yielded findings related to the previously outlined themes. With regard to pretraining factors, not having general clinical skills or knowledge of trauma treatment were provided as reasons for discontinued use. Similarly, possessing unrealistic expectations was offered as a reason contributing to discontinuing the use of EMDR. Continued use of the method was seen as a result of ability to integrate therapies and participate in EMDR support activities, as indicated by a large but nonsignificant number of respondents.

Training factors indicative of discontinued use were feeling that training was inadequate, not conforming to treatment fidelity, difficulty understanding EMDR well enough to suggest it posttraining, and lack of ability to integrate new concepts with previously learned modalities. A factor contributing to continued use was seeking additional training and increased comfort in suggesting EMDR to a prospective or current client.

Negative client experiences before and during EMDR included lack of awareness of the treatment, outright refusal to participate in the EMDR treatment, and poor EMDR outcomes probably as a result of fidelity drift on behalf of the clinician all offered as reasons clinicians were less likely to continue using EMDR. Continued use was more likely when the client had not had a previous negative experience with EMDR and, therefore, did not refuse it.

Posttraining factors lending themselves to discontinuing use were needing more training, consultation, and/or supervision, not using the method enough following training, and not engaging in EMDR support activities in general. Although not statistically significant, continued use was reported to be enhanced by ongoing support, including individual and/or group consultation and/or participation in the EMDR LISTSERV.

Finally, few general socioenvironmental factors were identified. Needing a champion was not endorsed as necessary, although the sample consisted primarily of private practitioners, an environment in which having a champion is irrelevant. However, many respondents reported positive collegial experiences, including their peers using EMDR, which resulted in positive outcomes for those clinicians. Maintaining unrealistic expectations following training and closing one’s practice because of life circumstances were the most commonly featured explanations pertaining to this factor.

Consequently, this study appears to lend support to the following: Continuing to use EMDR in clinical practice would be enhanced by having a strong clinical background to tolerate the additional demand of treating trauma (pretraining factor); more attention to developing comfort with the treatment to allow for comfort in proposing EMDR to clients, sufficient practice, and exiting training with realistic expectations (training factors); and an increase in consultation (posttraining skill development). It may be beneficial for trainers to consider the structure of their trainings to ensure adequate practice is attained upon completion of their Part 1 training and in the time between trainings in order to ensure readiness to proceed with more in-depth instruction and advanced practice in Part 2. Reasons for discontinued use by clinicians in agency settings should be further explored to identify if it is a general avoidance of risk (as Lipke [1995] asserted), a lack of support in their vocational setting (as suggested by Cook, Biyanova, et al. (2009), or other factors yet to be determined.

Refinements in training will likely result in a more confident clinician and, subsequently, a more informed client. This will ultimately help with continuing to promote EMDR as an empirically validated and efficacious therapy.