Learning how to select targets for processing with your EMDR clients can be a daunting task especially when things aren’t exactly clear or you’re presented with complex trauma. This is a skill that seasons with experience and becomes stronger as your case conceptualization skills grow. However, if you’re reading this, you may not quite be there yet and maybe even feel a bit lost or stuck with a current client. That’s okay, I’m going to lay it out for you. Here are the three layers of clinical decision making and insight needed in order to make sure you’re picking the right target sequencing for your client.
1) Identifying Themes & Stuck Points for Clients
The first step in the layered approach to target sequencing and processing is figuring out what is “it” that we need to process. We’ll come about this information in a few ways: client self-report, history taking, floatbacks, and–once processing begins–the EMDR processing itself.
Client Self-Report of Themes and Issues
Some clients come in and know exactly what their issues are. They can tell you what their negative core beliefs are, how they developed those beliefs, and what symptoms are keeping them stuck in their day to day lives. These clients have likely had a decent amount of therapy before–though often more cognitive based–and are quite self aware. Their self report is an excellent starting point and more may be revealed once you get into processing and we see what their body has to say.
Other clients may have clear, identifiable traumas. These are traumas that the client specifically sought you out to address. For some clients with a complex trauma history these are the traumas that may need to be processed prior to any other work being done.
History Taking
History taking is actually laid out as the first phase in the eight phase process of EMDR therapy, so it makes sense that we would get a lot of foundational information from it. Taking a thorough history that starts at conception and continues to present day allows you to “zoom in” and “zoom out” on the client’s experiences. We “zoom in” when we ask more clarifying questions surrounding certain events (e.g. How did your parents react when you were angry as a child?) and we “zoom out” when we’re able to connect past and present events through the theme they represent (e.g. Client suppresses anger due to fears of rejection and abandonment if anger is expressed).
Floatback for Identifying Memories
Floatbacks can be a wonderful tool for gathering more specific targets utilizing current presenting issues. There are two main types of floatback that you can do: cognitive and somatic. I prefer the somatic floatback as it connects to the feeling that clients experience.
An example of how to use a somatic floatback includes noticing how the client is physically feeling during a current triggering event (e.g. noticing how their body physically experiences anxiety when their romantic interest doesn’t text back) and using that physical sensation to let their body and mind “float back” to other times that felt very similar (e.g. when their parent was supposed to pick them up for their custody weekend and wouldn’t call or show up). When doing a floatback we’re able to gather several other memories, perhaps 3-6, in a short period of time that all fall under the same theme or neural network.
EMDR Processing: Identifying New Themes
Let’s say you’ve already started processing with a client and oh look, suddenly something gets revealed in processing that changes the conceptualization of what’s happening. That’s okay! This happens for a lot of people, especially when we’re working with complex trauma clients. In this work we are peeling back layers of healing. When this occurs it's important to talk with your client and collaborate on the direction of care. Sometimes this means we’re in the middle of a processing session and need to contain the memory that comes up. Sometimes new information will be presented in processing, but it doesn’t derail their processing experience. In those situations it's important to debrief afterwards and see if perhaps this new thread needs to be explored to further their processing.
2) Deciding on Target Sequence
Once we have an idea of potential themes and targets, we have to decide on how exactly we’re going to structure the order of the targets. This second layer of clinical decision making can often times run simultaneously with the third layer (picking the type of processing).
First, Worst, Last
First, Worst, Last is one of the classic EMDR target sequencing approaches. I find this can often help when we’re dealing with something like panic attacks where the client has very little awareness of what the root cause truly is (spoiler: it usually isn’t the thing they think it is such as driving or medical anxiety). This approach helps us dig in, decrease activation and identify any other targets or themes that need to be worked with.
Traditional Three Prong Approach
The Three Prong Approach is the target sequencing model that you hear the most about and likely learned–perhaps along with the First, Worst, Last–in your basic training. This model states that we should target memories in this order: Past, Present, Future. When we think about it, it does actually make a lot of sense to do so because if we can deactivate the roots then it makes all the other later targets a lot easier to knock down. However, this is likely not going to work for plenty of clients with complex trauma.
Graduated Approach (Present, Past, Future)
A graduated approach is what I use most often in my work with complex trauma clients because it is most tolerable to their system. This is especially important for clients that have a highly protected system and show signs of dissociative disorders, especially dissociative amnesia. This approach has clients beginning their work in the present day and gradually working back to earlier and earlier memories. This titration helps them to build trust and safety in the process, themselves, and their therapist. Doing a graduated approach will often allow past memories and experiences to become clearer as that trust and safety builds.
The “Biggest Bonfires” Approach
I utilize what I term the “Biggest Bonfires” approach when a client has some specific memories that take up all the space in their mind. Emotional targets that “burn so brightly” that they can’t see anything else. This often happens with our clients who we can tell are submerged in the emotion of it all–the stark contrast to our highly protected, dissociated clients. For these clients it is likely that we will need to bring down the distress of these “bonfires” in order to be able to do any of the other underlying work.
Future Template First Approach
Some therapists use the Future Template with clients prior to going into past work in order to instill hope and stabilize the client for further EMDR processing. While this approach can be beneficial for many clients, I find that if we’re doing deep attachment work where they don’t have a secure sense of self identity they may struggle with this type of activity.
3) Pick The Type of Processing
Once we know the core themes that are causing the client’s symptoms and we have an idea of the path we need to take forward in targeting them, then we can look at what type of processing we need to do in order to start taking down the targets.
Minimal Target
I am a huge proponent of doing a minimal target with clients prior to any main theme targets. This is because it helps the client experience EMDR in a low stakes way which builds trust and safety in the process and it helps you assess what their system can tolerate. Minimal targets are typically around a SUD score of 4-5, though this will change if the client represses emotion or if they are more prone to having emotions bubble up. After we’ve processed a minimal target we may have a much better sense of what type of processing we need in order to proceed forward. Below are some of the options to consider.
Flash Technique or Four Blinks
If the client is not able to tolerate emotional distress, but is able to hold positive affect, then Flash Technique or Four Blinks is the way to go. These techniques are particularly effective because they allow the client to decrease activation without having to fully go into the distressing memory. While these techniques are wonderful, I don’t recommend completely foregoing EMDR in place of them.
You can use Flash or Four Blinks with the “Biggest Bonfires” approach to decrease the distress of the most activating memories. This will create a bit more clarity around your target sequencing approach since the “bonfires” are no longer burning as brightly and taking up all the emotional focus for clients. With this approach you would use Flash or Four Blinks on all of the big targets first prior to having any EMDR reprocessing sessions.
You can also use Flash or Four Blinks when planning to work on singular highly distressing targets that have a SUD score of 8+. This strategy is good when we have a selection of targets and we know that a particular target is going to be highly distressing. We can decrease distress in the session prior to going in with EMDR in the next session. This helps make the processing more tolerable for clients.
Deciding Between EMD, EMDr, and EMDR
When talking about EMDR processing the difference between EMD, EMDr, and EMDR is how restricted we are with allowing the client’s brain or body to free associate. For the sake of a simple analogy, I’m comparing what we allow the brain to do with a dog to do in following explanations—no offense to dogs or humans.
EMD (Short leash)
EMD is like having the brain on a very short leash, unable to wander very far at all. This is the most restricted form of EMDR processing. This particular type of processing focuses on desensitization for the client and less on reprocessing work. When doing this type of processing you will do shorter BLS sets and bring the client back to target after every set. This is best for highly sensitive targets where we need to decrease distress and perhaps don’t feel Flash or Four Blinks is appropriate.
EMDr (Fenced in Yard)
EMDr is like a fenced in yard for the mind–it can wander a little bit, but not outside of the specific confines. With this approach you will often do normal BLS sets, but will bring the client back to target more frequently after every few passes. This is a great way to start processing with clients that are still gaining security and trust in the process.
EMDR (Free Range)
Doing full on EMDR is like allowing the mind free range to wander and explore as needed. This is ultimately the type of processing we want to work our clients up to, but for some it takes a bit longer than others. You may need to occasionally bring clients back to target, but for the most part their mind knows exactly where they need to go to relieve the distress.
It’s important to note that you can transition back and forth between the different types of processing within a session if needed. There are times your client may be doing full on EMDR, but it starts getting off track and they need to be stepped down to EMDr. There may be times that you start with EMD, but realize the client can tolerate a bit more and transition to EMDr or from EMDr to EMDR. Our attunement with our clients is our most powerful tool when it comes to making clinical decisions during the session. If we’re appropriately attuned we’ll be able to slow things down when needed and support them in going further in moments where they’re capable.
While this isn’t an exhaustive guide to target sequencing, it’s about all I can write in a blog post. If you’re interested in joining one of my consultation groups where we cover all of this and more with a special emphasis on complex trauma then head here to check out what groups we have coming up next.
