When EMDR Should NOT Be Used: A Complete Guide to Contraindications and Safety

While Eye Movement Desensitization and Reprocessing (EMDR) therapy is highly effective for trauma treatment, it is not appropriate for every client or situation. Understanding contraindications ensures client safety and optimal treatment outcomes. This comprehensive guide explores when EMDR should not be used, risk assessment, and alternative approaches.

The Importance of Contraindication Assessment

Why Contraindications Matter

Assessing brain safety before EMDR trauma processing

EMDR's power lies in its ability to unlock traumatic memories, but this same mechanism can destabilize vulnerable clients. Proper contraindication assessment:

• Prevents harm: Avoids treatment complications
• Ensures safety: Protects clients from overwhelm
• Optimizes outcomes: Matches treatment to client needs
• Maintains ethics: Follows "do no harm" principle

Assessment as Standard Practice

Every EMDR therapist must conduct thorough pre-treatment evaluation to identify:

• Medical conditions: That contraindicate bilateral stimulation
• Psychiatric instability: Requiring stabilization first
• Environmental factors: Affecting treatment safety
• Client readiness: For trauma processing

Absolute Contraindications

Medical Conditions

Neurological Disorders

• Uncontrolled epilepsy: Bilateral stimulation may trigger seizures
• Recent brain injury: Within 3-6 months of concussion/TBI
• Active migraines: Severe, uncontrolled headache disorders
• Retinal detachment: Eye movement risks to vision

Cardiovascular Conditions

• Unstable angina: Risk of cardiac events
• Recent heart surgery: Within 6-12 months
• Severe hypertension: Uncontrolled blood pressure
• Aortic aneurysm: Risk of rupture under stress

Psychiatric Emergencies

Acute Crisis States

• Active psychosis: Hallucinations, delusions requiring immediate intervention
• Acute mania: Severe manic episodes
• Severe depression with suicidality: High imminent risk
• Substance intoxication: Acute substance effects

Relative Contraindications

Requiring Stabilization First

Complex Trauma

• Dissociative Identity Disorder: Without system stabilization
• Severe dissociation: High DES scores (>30)
• Attachment trauma: Unresolved early relational wounds

Current Life Threats

• Domestic violence: Ongoing abuse situations
• Homelessness: Unstable living conditions
• Active addiction: Without concurrent substance treatment

Developmental Considerations

Children Under 6

• Cognitive immaturity: Unable to process abstract concepts
• Limited verbal skills: Difficulty articulating experiences
• Attachment disruptions: Severe early neglect

Severe Cognitive Impairment

• Dementia: Advanced stages affecting memory processing
• Intellectual disability: Significant cognitive limitations
• Brain injury sequelae: Impaired information processing

Risk Factor Assessment

Psychological Risk Factors

Risk Assessment Matrix:
━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━
Factor                | Low Risk                  | High Risk
━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━
Trauma Complexity    | Single incident          | Complex/multiple traumas
Dissociation         | Mild/none                | Severe/compartmentalized
Coping Skills        | Good resources           | Poor/few strategies
Support System       | Strong network           | Isolated/minimal
Current Stressors    | Manageable               | Overwhelming
━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━

Environmental Risk Factors

• Unsafe living situation: High stress environment
• Lack of social support: Isolation increasing vulnerability
• Financial instability: Adding external pressure
• Legal issues: Court involvement affecting stability

Assessment Tools and Protocols

Pre-Treatment Evaluation

Clinical Interview

• Trauma history: Type, severity, chronicity
• Current symptoms: Depression, anxiety, dissociation
• Coping resources: Internal and external supports
• Medical history: Relevant health conditions

Standardized Measures

• CAPS-5: PTSD symptom severity
• DES: Dissociative experiences
• PHQ-9: Depression screening
• BAI: Anxiety assessment

Ongoing Risk Monitoring

• Session-by-session: Check stability before processing
• Crisis indicators: Suicidality, self-harm, decompensation
• Progress tracking: Symptom improvement vs. worsening

When to Pause or Stop EMDR

Immediate Cessation Criteria

• Acute distress: Client unable to continue
• Dissociation increase: Loss of therapeutic contact
• Physical symptoms: Severe headaches, nausea, dizziness
• Client request: "I need to stop"

Temporary Holds

• Life stressors: Major changes requiring adaptation
• Medical issues: Temporary health concerns
• Therapist concerns: Unresolved countertransference

Alternative Treatment Approaches

When EMDR is Contraindicated

Stabilization-Focused Therapies

• DBT: Skills for emotional regulation
• CPT: Cognitive processing without bilateral stimulation
• PE: Prolonged exposure with therapist control

Supportive Therapies

• Psychodynamic therapy: Insight-oriented approach
• Humanistic therapy: Person-centered support
• Supportive counseling: Non-trauma focused

Sequential Treatment

• Stabilize first: Build resources before trauma work
• Medical clearance: Address health issues
• Concurrent treatment: Combine with appropriate therapies

Special Population Considerations

Medical Patients

• Consultation required: Physician clearance for bilateral stimulation
• Modified protocols: Adapted for physical limitations
• Monitoring: Close observation for adverse reactions

Forensic Populations

• Court involvement: May affect treatment process
• Secondary gain: External motivations for "recovery"
• Confidentiality limits: Legal reporting requirements

Cultural Considerations

• Cultural beliefs: Healing concepts affecting treatment fit
• Stigma: Mental health stigma in some cultures
• Language barriers: Communication challenges

Ethical and Legal Considerations

Informed Consent

• Clear discussion: Explain contraindications and alternatives
• Client understanding: Ensure comprehension of risks/benefits
• Ongoing consent: Re-evaluate throughout treatment

Competence and Referral

• Scope of practice: Know when to refer
• Supervisor consultation: Complex cases
• Continuing education: Stay updated on contraindications

Documentation

• Assessment records: Thorough contraindication evaluation
• Clinical reasoning: Document decision-making process
• Outcome tracking: Monitor treatment effects

Case Study: Appropriate Non-Use

Client with uncontrolled epilepsy and complex PTSD.

• Initial assessment: Identified seizure history, current medications
• Medical consultation: Neurologist advised against bilateral stimulation
• Alternative treatment: CPT with stabilization skills
• Outcome: Successful trauma processing without EMDR
• Lesson: Proper contraindication assessment prevented harm

Research on Contraindications

Studies support careful contraindication assessment:

• Shapiro (2018): Medical clearance essential for safe practice
• EMDRIA guidelines: Comprehensive pre-treatment evaluation
• ISP (International Society for Psychological and Social Approaches to Psychosis): Caution with psychosis

Meta-analyses show 10-15% of clients require alternative approaches initially.

Training and Competence

Required Knowledge

• Medical literacy: Understanding contraindications
• Assessment skills: Comprehensive evaluation
• Alternative treatments: Knowledge of other approaches
• Risk management: Crisis intervention skills

Professional Development

• EMDRIA standards: Adhere to professional guidelines
• Continuing education: Updates on contraindications
• Supervision: Regular consultation on complex cases

Future Directions

Emerging considerations include:

• Individualized protocols: Personalized contraindication assessment
• Technology alternatives: Non-bilateral stimulation methods
• Cultural adaptations: Globally sensitive contraindications
• Research updates: New evidence on safety parameters

Conclusion: Safety First in Trauma Treatment

EMDR's effectiveness must be balanced with client safety. Recognizing when not to use EMDR demonstrates clinical wisdom and ethical practice. By thoroughly assessing contraindications and providing appropriate alternatives, therapists ensure that trauma treatment serves healing rather than harm.

The decision to forgo EMDR is not treatment failure—it's responsible practice that prioritizes client well-being above all else.

References

EMDR International Association. (2023). EMDR therapy training manual. Author.

Shapiro, F. (2018). Eye movement desensitization and reprocessing (EMDR) therapy: Basic principles, protocols, and procedures (3rd ed.). Guilford Press.

van der Kolk, B. A. (2014). The body keeps the score: Brain, mind, and body in the healing of trauma. Viking.

This article is for informational purposes only and does not constitute medical advice. EMDR therapy should only be conducted by properly trained and licensed mental health professionals.

Image Credits

• Brain safety assessment illustration: Original image from the EMDR therapy project, used under project license for educational content.
• Risk assessment matrix diagram: Created using ASCII art for clarity and accessibility.

All content designed to promote safe and ethical EMDR practice.