14 Phases Seven–Eight:
Closure and Reevaluation
PHASE SEVEN: CLOSURE
During the course of EMDR therapy, a reprocessing session might end due to time constraints after completing the reprocessing of a target memory, although there are other target memories remaining in the treatment plan, or without completing a particular phase for a specific target memory such as reprocessing, installation, or the body scan. Phase Seven provides the therapist-structured guidance on how to close both types of sessions, as well as how to safely prepare clients for transitioning from the reprocessing session back to the military environment.
Managing the Clock
Whether EMDR sessions are 50 minutes in duration, 90 minutes, or somewhere in-between, it’s incumbent upon therapists to remain cognizant of where they are in the session in relation to the amount of time remaining. This split in the therapist’s attention can cause considerable stress for the therapist who also wants to be attuned with the client during the reprocessing session while simultaneously using clinical judgment about the optimal time to sensitively close down the reprocessing and prepare the client for debriefing. Some therapists profess an aversion to watching the time feeling it conveys an impersonal message to the client. However, abruptly stopping reprocessing in less-than-opportune moments, or apologetically ushering the client out of the office is also clearly problematic. Therapists having trouble managing the clock will finding the closure phase to be particularly uncomfortable for themselves and their clients. Given the premium on trust and safety in the therapeutic alliance, especially in trauma-focused work, structuring the therapeutic frame is best for all.
When Should the Therapist Stop EMDR Reprocessing?
Before actually starting the meeting, the therapist should calculate what time specifically they should be shutting down EMDR reprocessing using one of the below configurations: (a) Therapists will want to finish the EMDR reprocessing within at least 10 minutes (15 minutes maximum) before the end of 50-minute appointment to allow time for a short debriefing period and a stress-reduction exercise—if warranted. (b) For 90-minute sessions, leaving the last 15-minutes is adequate for debriefing and stress-reduction exercise if needed. (c) Therapists are encouraged to write down the stop time on a note pad before starting the meeting to prevent confusion at the end.
Looking for Appropriate Times to Finish EMDR Reprocessing
As the session nears the desired stopping time, the therapist should close (a) at a natural pause or plateau after reprocessing, (b) when the client reports positive reshifting of information or insight, (c) after coming down from an abreaction, (d) upon completion of the reprocessing phase, (e) upon completion of the installation phase, (f) after a shift to a positive memory, or (g) after reevaluating the target memory.
Procedure for Closing a Complete Session
An EMDR reprocessing session is considered complete with a SUDS of “0” (or “1” if ecologically valid), a VOC of “7” (or “6” if ecologically valid), and a body scan clear of any residual negative physical sensations associated with a target memory. Within 10 minutes (of a 50-minute session) to the end of the meeting, the therapist should inform the client that “We are almost out of time, is it okay to stop here?” The therapist then offers encouragement to the client: “You have really done some good work today. How are you feeling?” or words to that effect. A completed EMDR reprocessing session does not mean completion of treatment, which is determined by reprocessing the three-pronged protocol consisting of all of the selected targeted memories in the past, the current triggers, and future template, as well as other disturbing memories in the maladaptive neural network.
Procedure for Closing an Incomplete Session
In an incomplete EMDR reprocessing session, the target memory has not been fully reprocessed. This is exemplified by a SUDS rating of the target memory as above a “1,” an incomplete installation phase with a VOC below a “6,” or of an incomplete body scan that registers on client reports of unpleasant, negative-valence physical sensations associated with the target memory. When shutting down an incomplete reprocessing session, the therapists is recommended to provide the client sufficient time to debrief with the therapist about the experience in the session, and to ensure that the client has adequate time to prepare to safely leave the office. Below is the suggested framework for therapists to use for closing down an incomplete session:
1. Respectfully explain to the client that “We are almost out of time, is it okay to stop here?” If on the off chance that the client does not respond or communicates an unwillingness to stop, using a sensitive but firm voice, say, “I’m really sorry about that, but we have to end now, and we can pick things up again next week.”
2. Re-assess the target memory. “Ok, I’d like you to please go back to the memory of the __incident…. What do you notice now?” Write down the client’s responses. Obtain a SUDS rating: “As you are thinking about the __incident now, on a scale of 0–10, how distressed do you feel now?” Write down the client’s response. The therapist should understand that by returning to and re-accessing the target memory, there is a possibility for negative associations to emerge. If that happens, respectfully say, “Ok … well how about we pick this up again next week; does that sound all right to you?”
Clinical note. Shapiro (2001) posits that returning the client to the target memory during an incomplete reprocessing session will reactivate the target memory. That is true. The issue is whether this will unnecessarily distress or destabilize the client. The client is not being redirected to a picture or image of the original target memory, just the memory itself. The SUDS rating taken does not include the negative cognition, emotions, or physical sensations associated with the target memory. There is no empirical support one way or the other, but clinically it has proven useful to recheck the target memory and obtain a SUDS measure at the end of every session. Here’s why: (a) It provides feedback to the client and the therapist about treatment progress. (b) When progress is made, either by a decrease in SUDS, or new, sometimes adaptive information associated with the target memory—in either case it may help inspire the client and motivate him or her to continue. (c) It allows the therapist to record treatment progress in the clinical notes. (d) If little to no progress is reported, the SUDS provides input to the therapist to check for possible blocking beliefs, alter speed, direction, or type of bilateral stimulation, or other mid-course corrections. (e) It offers information on progress or lack of progress to be debriefed at the end of the session. (f) Military culture is extremely results-oriented, even small shifts in target memory, or new negative associations that may arise, but can be reinforced as evidence of shifting or changing that may motivate a return visit. (g) After having the occasional client never return to therapy, call, or answer calls to explain, it seems best to create the opportunity for upfront talk on the client’s progress or lack thereof. (h) The author (Mark Russell) has never had a military client require further intervention for being re-triggered by the brief access and rating taking.
3. If the therapist believes the client is too fragile and/or needs to avoid returning to and re-accessing the target memory and the maladaptive neural network it is linked to, the therapist can just ask for a generalized rating of the level of the client’s distress without returning to the target memory: “On a scale of 0–10, how distressed do you feel now?”
4. Stabilization. If the therapist observes or the client discloses that he or she is still fixed to negative material, the therapist can redirect the client’s attentional focus to the adaptive neural network by implementing a brief stress-reduction technique such as calm/safe place, combat/tactical breathing, or other containment exercise.
Debriefing the Experience
Francine Shapiro (2001) developed a script for therapists to use for debriefing their clients about the possible residual effects of continued reprocessing: “Processing may continue after our session. You may or may not notice new insights, thoughts, memories, physical sensations or dreams. Please make a note in your log of whatever you notice. Then do a Calm/Safe Place or [Combat/Tactical Breathing—added by Mark Russell] exercise to rid yourself of the disturbance. We will talk about that at our next session. If you feel it is necessary, call me” (p. 429). Therapists can develop their own debriefing statement that better suits them and their clients; however, they should preserve the key messages: (a) reprocessing may continue after the session; (b) new memories, feelings, insights, dreams may arise; (c) suggest clients write down any changes and bring to next session; (d) if distressed, remind clients to utilize a stress-reduction technique; and (e) review the safety plan if clients are having dangerous thoughts.
Keeping a TICES Log
Maintaining a brief TICES (Trigger, Image, Cognition, Emotion, and Sensation) log or other self-monitoring tool as events arise has been a staple recommendation in EMDR circles for years. If therapists ask clients to keep a log, they should ask about it at the beginning of a session. The therapist’s failure to follow through communicates that either the task itself was not really important, or the client’s time and effort to comply was inconsequential. Albeit a minor issue, it can lead the client to question the sincerity or legitimacy of other communications from the therapist. So if you ask—you check.
PHASE EIGHT: REEVALUATION
The reevaluation phase of EMDR treatment occurs at the beginning of every EMDR session after the initial meeting. The main purpose is to assess the client’s condition in relation to the extent of integration of reprocessed information as well as check for the emergence of new information that may have been stimulated by the previous reprocessing session.
Transitioning from Welcoming to EMDR Reevaluation
After warmly greeting their client, therapists often start a session with a general question as to the client’s welfare (e.g., “So, how have you been __?”). The client’s response may or may not refer specifically to EMDR treatment or its effects. Therapists working with a 50-minute framework need to closely monitor the amount of time the client uses to bring the therapist up to speed. Obviously, if the client is reporting personally significant or meaningful events, or is in crisis, then that needs to be taken into consideration. Some clients have a lot to say, and others barely whisper. At this juncture, the therapist has not inquired about any EMDR-specific changes. Therapists will want to pay attention to their client’s particular pattern during this re-capping and reevaluation phase and to make adjustments if needed to curtail. It has been estimated that, in a given 50-minute session, actual time allotted for reprocessing is around 30 minutes when sessions are well structured (e.g., Leeds, 2009). That’s not a lot of time.
Conducting the EMDR Reevaluation
There are essentially four ways the therapist might reevaluate their EMDR work with clients:
1. Reevaluate Between-Session Changes:
• Consequently, therapists might want to consider altering their opening remark by combining their welcoming greeting and initiating the EMDR reevaluation: “Hi, how are you __?” Immediately afterward: “What have you noticed since our last session? Has anything changed?” or words to that effect.
• If the client launches into a general review of events from the past week, the therapist should look for the first break or pause and redirect the client’s attention to any residual effects from the previous reprocessing session, “Wow, a lot’s happened with you! By the way, speaking of happening, what have you noticed after our last EMDR sessions? Has anything changed?”
• Therapist should take note of the client’s self-report of changes within the memory, new associations, insights, thoughts, images, feelings, and dreams. If clinically salient, the client might include any new associations as past events, current triggers, or future desired behavior to be added to the treatment plan.
• Next, the therapist should ask if the client kept a log or wrote down any observations since the last session?
• If so, ask if it’s all right for you to see the log (or whatever term the client uses). If they are not comfortable with the therapist having the entire log, ask if the client would please read it or a portion of it.
• If the client is embarrassed or uncomfortable with sharing the log contents, or the more likely scenario, that the client did not keep or bring a written record, simply ask “What have you noticed since our last session? What’s changed?”
• One of the important pieces of information that can often be glossed over is to ask the client whether anyone at work, home, or friends had commented about changes in the client, or had behaved differently towards the client because of the changes that have occurred?
Adopting a systems-lens, we might anticipate that if changes are becoming evident in the client’s behavior, that the client’s subsystems (e.g., partner, co-workers, family members, etc.) may respond positively or negatively to support or negate those changes. Sometimes clients harbor ambivalence about their own change and the prospects of becoming healthier through therapy. Some may fear that “getting better” may have an unpleasant side-effect. Therefore, when clients report observable change in their own behavior, it’s often fruitful for the therapist to inquire about how others may have responded to those positive changes. Another reason this is an important question during the reevaluation is that it provides the therapist valuable information about the client’s perceived level of social support and recovery environment that we know is vital for sustaining improvement or relapse.
Transitioning to EMDR Reprocessing
Once the therapist has welcomed the client, reviewed the client’s log (if applicable), and inquired about any possible changes that she or others may have noticed since the last meeting, the therapist will ask the client to re-access the target memory in preparation for continued EMDR processing.
2. Reevaluate Target Memory from Previous Sessions:
• Therapists should be comfortable with rechecking their work. If the last meeting resulted in an incomplete session, we check the target memory. And, if the previous session ended as a complete session, meaning the client’s SUDS was “0,” VOC was “7,” and the body scan was clear of negative residual symptoms—we check the target memory.
• Because of the brain’s plasticity and how information can be shifted, or re-organized, we always want to check to be certain if those adaptive changes have continued or even strengthened, or conversely, that new negative associations may have emerged.
• The therapist would say “Bring up the incident of __________that we worked on last session (try to name the incident; e.g., “Mess tent bombing” to ensure client is recalling the correct target memory). What image comes up? What thoughts about it come up? What thoughts about yourself? What emotions? What sensations? And, on a scale of 0–10 (SUDS), how disturbing does this memory/trigger feel to you now?
3. Reprocessing the Target Memory from an Incomplete Session
If the previous session was an incomplete session, then upon re-accessing and re-assessing (SUDS) the target memory, the therapist transitions right into reprocessing the target memory (Phase Four).
4. Reevaluating the Target Memory from a Complete Session
• When reevaluating a targeted memory for completeness of its resolution, all of the following are evaluated for any indication of dysfunction:
a. Resolution of primary issue—a SUDS of “0,” VOC of “7,” and body scan clear of any residual negative physical sensations.
b. Ecological validity—a SUDS of “1” or VOC of “6” is reported and appears valid given the client’s combat buddy died and no other blocking beliefs were identified.
c. Has associated material been activated that must be addressed? When re-accessing the target memory, any new negative associations need to be reprocessed until resolution.
d. Resistance—if the therapist suspects the client is still ambivalent about changing their condition, he might ask, “What would happen if you were successful? And reprocess either the client’s overt response or just tell the client “to think about it” and add BLS.
• Any negative associations that arise in the reevaluation will become the focus of reprocessing before moving on. Continue reprocessing and reassess the original target memory until the target is completely resolved (SUDS = “0,” VOC = “7,” Body Scan = clear).
• If the client reports a new current trigger emerged between sessions and requests to reprocess the triggering event, instead of an incomplete target from the previous session, the therapist can agree but must ensure that they return to and reassess the incomplete target and reprocess accordingly.
• Reprocessing continues until completion of the session and, ultimately, of the treatment plan.
• The final reevaluation session will occur after completion of the treatment plan that includes the three-pronged protocol of the past, present, and future targets. If the last target memory reveals negative associations have emerged, those are reprocessed until the last target memory is complete upon assessment (SUDS = “0/1”; VOC = “7/6”; and Body Scan = clear), at which time client is ready to terminate EMDR treatment.
Once the therapist and client have completed processing all the target memories on the EMDR treatment plan and the positive effects have held at reevaluation, the therapist and client are ready to discuss termination of treatment. To assist the therapist and client in making a determination about the readiness for termination, Shapiro (2001) invites therapists to review the following four treatment goals:
1. Have all the necessary targets been reprocessed to allow the client to feel at peace with the past, empowered in the present, and able to make choices in the future? Has adequate assimilation been made with a healthy social system?
2. Has associated material been activated that must be addressed?
3. Have all the necessary targets been reprocessed to allow the client to feel at peace with the past, empowered in the present, and able to make choices in the future?
4. Has adequate assimilation been made with a healthy social system?
The Follow-up Session
Whenever practicable, it would be prudent to invite the client back after 1 month or so to check if the treatment effects have sustained over time. The therapist can repeat the reevaluation steps above. In addition to the SUDS and VOC baseline measures, therapists should ask the client to complete any previously used standardized symptom measures (e.g., PCL, BDI, IES, etc.). If any new negative associations arise, the therapist can discuss with the client about targeting those for reprocessing and so on. Should the therapist want to write a case study for a professional article, he or she should discuss such intentions with the client and explain how the client’s identity and other healthcare information will be protected. When possible, the therapist should obtain the client’s consent. The therapist can schedule additional in-person or phone check-ups if desired. For research purposes, follow-ups of 3, 6, and 12 months are not unusual but may not be practical or desired by clients or therapists.