Who Should NOT Do EMDR? A Complete Guide to Client Suitability and Safety

While Eye Movement Desensitization and Reprocessing (EMDR) therapy is highly effective for trauma treatment, it's not suitable for everyone. Understanding client suitability is crucial for ethical practice and optimal outcomes. This comprehensive guide explores who should avoid EMDR, why, and what alternatives to consider, ensuring therapists make informed decisions about treatment approaches.

The Importance of Client Suitability Assessment

Why Suitability Matters

Thorough assessment ensures EMDR suitability and client safety

EMDR's unique mechanism—bilateral stimulation combined with trauma processing—works well for many but can be harmful for others. Proper assessment:

• Protects clients from potential harm or destabilization
• Optimizes outcomes by matching treatment to client needs
• Maintains ethics through informed consent and appropriate care
• Preserves therapeutic alliance by setting realistic expectations

Assessment as Standard Practice

Every potential EMDR client requires comprehensive evaluation before beginning treatment, including:

• Medical history and current health status
• Psychiatric assessment of symptoms and stability
• Trauma history and processing capacity
• Support systems and environmental factors
• Client preferences and treatment goals

Absolute Contraindications: Who Should Never Do EMDR

Severe Medical Conditions

Neurological Disorders

• Uncontrolled epilepsy or seizure disorders: Bilateral stimulation risks triggering seizures
• Recent traumatic brain injury (TBI): Within 3-6 months post-injury
• Active migraines or severe headaches: Can be exacerbated by eye movements
• Retinal detachment or eye conditions: Physical eye movement risks

Cardiovascular Instability

• Unstable angina or recent heart attack: Stress response may be dangerous
• Severe hypertension: Uncontrolled high blood pressure
• Recent cardiac surgery: Within 6-12 months
• Aortic aneurysm: Risk of rupture under emotional stress

Acute Psychiatric Crises

Active Psychosis

• Hallucinations or delusions: EMDR may worsen symptoms
• Acute manic episodes: Bipolar disorder in active mania
• Severe dissociative episodes: Complete disconnection from reality

Immediate Safety Risks

• Active suicidal ideation with plan: Requires immediate stabilization
• Severe self-harm behaviors: High-risk behaviors present
• Violent behaviors: Risk to self or others

Specific Populations

Children Under Age 6

• Cognitive immaturity: Cannot process abstract trauma concepts
• Limited verbal skills: Difficulty articulating experiences
• Attachment disruptions: Severe early neglect or abuse

Severe Cognitive Impairment

• Advanced dementia: Cannot engage in processing
• Severe intellectual disability: Significant cognitive limitations
• Acute delirium: Confusion and disorientation

Relative Contraindications: Proceed with Extreme Caution

Complex Trauma Without Stabilization

Dissociative Disorders

• Dissociative Identity Disorder (DID): Without system integration
• Severe dissociation (DES > 40): High fragmentation risk
• Complex PTSD: Multiple traumas without preparation

Current Life Instability

• Active domestic violence: Ongoing abuse situations
• Homelessness: Unstable living conditions
• Recent major loss: Acute grief reactions
• Financial crisis: Severe external stressors

Mental Health Conditions Requiring Different Approaches

Borderline Personality Disorder

• Severe emotional dysregulation: May destabilize further
• Self-harm behaviors: Risk of increased incidents
• Unstable relationships: Complex transference issues

Substance Use Disorders

• Active addiction: Without concurrent substance treatment
• Recent relapse: Within 3-6 months
• Polysubstance abuse: Multiple substance dependencies

Risk Factor Assessment Framework

Client Vulnerability Factors

Client Suitability Assessment Matrix:
━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━
Factor                | Low Risk                  | Moderate Risk             | High Risk
━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━
Trauma Complexity    | Single incident          | Multiple traumas         | Complex/developmental
Emotional Regulation | Good coping skills       | Moderate difficulties     | Poor/severe dysregulation
Dissociation         | None/mild                | Moderate                 | Severe/fragmented
Support System       | Strong network           | Moderate support         | Isolated/minimal
Current Stressors    | Manageable               | Moderate pressure        | Overwhelming
━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━

Environmental Risk Factors

• Unsafe living environment: High stress or danger
• Lack of social support: Isolation increasing vulnerability
• Cultural stigma: Mental health barriers
• Treatment accessibility: Limited follow-up care

Assessment Tools and Protocols

Pre-Treatment Evaluation Components

Clinical Interview

• Detailed trauma history: Types, timing, severity
• Current symptoms: PTSD, depression, anxiety levels
• Coping resources: Internal and external supports
• Treatment history: Previous therapy experiences

Standardized Measures

• PCL-5: PTSD symptom severity
• DES: Dissociative experiences scale
• PHQ-9: Depression screening
• BAI: Anxiety assessment
• WHO-DAS: Functional impairment

Medical Clearance

• Physician consultation: For medical contraindications
• Medication review: Impact on processing capacity
• Physical health status: Overall medical stability

Alternative Treatment Approaches

When EMDR is Not Recommended

Trauma-Focused Therapies

• Cognitive Processing Therapy (CPT): Cognitive restructuring without bilateral stimulation
• Prolonged Exposure (PE): Gradual exposure techniques
• Trauma-Focused CBT: Skills-based trauma treatment

Stabilizing Approaches

• Dialectical Behavior Therapy (DBT): Emotional regulation skills
• Stabilization techniques: Building coping resources
• Supportive psychotherapy: Non-trauma focused support

Sequential Treatment Planning

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

Special Considerations for Different Populations

Medical Patients

• Modified protocols: Adapted for physical limitations
• Physician collaboration: Coordinated care approach
• Monitoring: Close observation for adverse effects

Forensic and Legal Populations

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

Cultural and Diversity Factors

• Cultural healing models: Respect traditional approaches
• Language barriers: Communication challenges
• Acculturation stress: Immigration-related trauma

Implementation Guidelines

Informed Consent Process

• Clear discussion: Risks, benefits, alternatives
• Client understanding: Ensure comprehension
• Ongoing consent: Re-evaluate throughout treatment

Treatment Planning

• Individualized approach: Match treatment to client needs
• Pacing considerations: Respect client readiness
• Integration with other treatments: Holistic care approach

Monitoring and Adjustment

• Regular assessment: Progress and safety monitoring
• Flexible planning: Adjust based on response
• Exit strategies: Clear plans for treatment changes

Case Studies: Suitability Decisions

Case 1: Medical Contraindication

Client with uncontrolled epilepsy and PTSD.

• Assessment: Identified seizure risk with bilateral stimulation
• Decision: Recommended CPT instead
• Outcome: Successful trauma processing without medical complications

Case 2: Stabilization Needed

Client with severe dissociation and complex trauma.

• Assessment: High DES scores, fragmented identity
• Decision: 6-month stabilization before EMDR consideration
• Outcome: Improved stability, eventual successful EMDR

Case 3: Alternative Recommended

Client with active substance abuse and trauma.

• Assessment: Active addiction destabilizing treatment
• Decision: Substance treatment first, then trauma therapy
• Outcome: Sober client later successfully completed EMDR

Research and Evidence Base

Studies support careful suitability assessment:

• EMDRIA guidelines: Comprehensive pre-treatment evaluation
• Shapiro (2018): Medical clearance essential
• van der Kolk (2014): Individualized trauma treatment
• Bisson et al. (2013): Tailored approaches improve outcomes

Meta-analyses show appropriate client selection improves success rates by 40-60%.

Training and Competence Requirements

Essential Knowledge

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

Professional Development

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

Future Directions

Emerging considerations include:

• Personalized medicine: Genetic factors in treatment response
• Digital assessment: AI-assisted suitability screening
• Cultural adaptations: Globally sensitive contraindications
• Integrated care: Medical-psychological collaboration

Conclusion: Right Treatment, Right Time, Right Client

Determining EMDR suitability is a cornerstone of responsible trauma therapy. While EMDR is powerful and effective for many, recognizing who should not do EMDR protects clients and maximizes healing potential. By conducting thorough assessments and offering appropriate alternatives, therapists ensure that every client receives the safest, most effective care for their unique situation.

The decision to pursue or avoid EMDR should always prioritize client safety, well-being, and optimal therapeutic outcomes.

References

Bisson, J. I., Roberts, N. P., Andrew, M., Cooper, R., & Lewis, C. (2013). Psychological therapies for chronic post-traumatic stress disorder (PTSD) in adults. Cochrane Database of Systematic Reviews.

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

All content designed to promote safe and ethical EMDR practice.