Who is EMDR Not Appropriate For? A Therapist's Guide to Understanding Contraindications

As a Licensed Clinical Social Worker with over 25 years of experience, EMDR Certified Therapist and Approved Consultant, and DBT trained clinician, I'm often asked whether EMDR is right for everyone who has experienced trauma. While I've witnessed the profound healing power of Eye Movement Desensitization and Reprocessing (EMDR) throughout my decades of practice, I want to be transparent about the fact that this approach isn't suitable for every client or situation. Understanding contraindications is not only essential for safety—it's part of providing ethical, individualized care.

In my 25+ years of practice, I've integrated multiple therapeutic approaches including EMDR, Dialectical Behavior Therapy (DBT), Cognitive Behavioral Therapy (CBT), and other evidence-based techniques. This extensive experience, combined with my role as current EMDRIA San Diego Regional Co-Coordinator and faculty member at San Diego State University's School of Social Work, allows me to tailor treatment to each client's unique needs and readiness level.

My Approach to EMDR Assessment

In my practice, I conduct thorough assessments before recommending any specific treatment approach to ensure it's the right fit for each client. This isn't about excluding people from treatment—it's about finding the safest and most effective path to healing. Sometimes that means doing preparatory work using DBT skills or CBT techniques first, and sometimes it means utilizing different therapeutic approaches that might be more appropriate for the client's current situation.

When I Typically Don't Recommend EMDR

1. Severe Dissociative Disorders

In my clinical experience, clients with severe dissociative identity disorder (DID) or other complex dissociative conditions require careful consideration before beginning EMDR. Over my 25 years of practice, I've learned that the bilateral stimulation can sometimes trigger dissociative episodes or increase dissociative symptoms. This doesn't mean these clients can't benefit from EMDR eventually, but they typically need extensive preparation and stabilization work first. I often work with these clients using phase-oriented treatment approaches before introducing EMDR protocols.

2. Active Psychosis

I don't recommend EMDR for clients experiencing active psychotic episodes. EMDR requires the ability to distinguish between past traumatic memories and present reality, which can be compromised during psychotic states. For clients with conditions like schizophrenia, I wait until they're stabilized on medication and no longer experiencing active symptoms before considering EMDR.

3. Severe Cognitive Impairment

EMDR requires certain cognitive abilities that some clients may not possess. In my practice, I need clients to be able to hold dual awareness—staying present in the therapy room while accessing difficult memories—and follow multi-step instructions. Clients with severe dementia, significant intellectual disabilities, or other cognitive impairments may struggle with this dual awareness, making EMDR ineffective or potentially destabilizing.

4. Unstable Medical Conditions

I always review medical history before beginning EMDR because certain conditions require medical clearance. EMDR can be emotionally intense and physiologically activating, which may be contraindicated for clients with:

• Recent cardiac events or unstable heart conditions
• Uncontrolled hypertension
• Recent strokes
• Certain neurological conditions affecting eye movement
• Seizure disorders (though this is debated in the field)

I work collaboratively with clients' medical providers to ensure EMDR is safe for them. Just because you may have one of the above conditions, it does not mean that EMDR is out of the question for your treatment.

5. Active Substance Abuse

Active substance abuse significantly interferes with EMDR effectiveness in my experience. Throughout my decades of practice, I've observed that substances impair memory processing, affect emotional regulation, and can interfere with the bilateral stimulation process. I typically work with clients on achieving some sort of stability rather than simply turning them away. If we can use a harm reduction protocol in EMDR first to help with the substance use, I recommend that first before standard reprocessing.

6. Severe Depression with Suicidal Ideation

When clients are experiencing severe depression with active suicidal ideation, I focus on safety and stabilization before introducing EMDR. The initial stages of trauma processing can sometimes intensify emotions, which could be dangerous for someone already at high suicide risk. I use other interventions first to build their emotional resilience and coping skills.

Situations Where I Exercise Caution

Legal Proceedings

When clients are involved in ongoing legal proceedings related to their trauma, I typically recommend speaking with a client’s attorney before beginning EMDR. The memory processing that occurs in EMDR could potentially affect recall and testimony. I discuss this thoroughly with clients and sometimes consult with attorneys to make the best decision for each situation.

My Integrative, Preparation-First Approach

Many conditions that seem like contraindications for EMDR actually just require preparation work using other therapeutic modalities before EMDR can be safely implemented. In my practice, I often spend weeks or months using various techniques, which include:

DBT Skills Training: As a certified DBT therapist, I teach clients:

• Emotional regulation skills to manage intense emotions that may arise during processing
• Distress tolerance techniques to stay present with difficult feelings
• Interpersonal effectiveness to strengthen support systems
• Mindfulness skills to develop present-moment awareness

CBT Techniques: I use cognitive behavioral approaches to:

• Identify and challenge trauma-related thought patterns
• Develop healthy coping mechanisms
• Address current stressors and life challenges
• Build problem-solving skills

Other Therapeutic Approaches: Depending on client needs, I may integrate:

• Somatic awareness techniques for body-based trauma responses
• Parts Work concepts for working with different "parts"
• Mindfulness-based interventions for present-moment awareness

This foundational work creates the stability and skills necessary for successful EMDR processing. Over my 25 years of practice, I've found that clients who initially seem "not ready" for EMDR often become excellent candidates after this integrative preparation work.

My Assessment Process

When someone comes to my practice asking about EMDR, I conduct a comprehensive evaluation that includes:

• Detailed trauma history: Understanding the nature, timing, and impact of traumatic experiences
• Mental health assessment: Current symptoms, previous diagnoses, and treatment history
• Medical history: Any conditions or medications that might affect EMDR safety
• Substance use evaluation: Current and past use patterns
• Support system assessment: Family, friends, and other therapeutic supports
• Coping resources inventory: Current strategies for managing stress and emotions
• Life stability evaluation: Work, housing, relationships, and other current stressors

This assessment typically takes 1-3 sessions and helps me determine not just whether EMDR is appropriate, but what preparation might be needed first.

Alternative Treatment Approaches in My Practice

For clients who aren't appropriate candidates for EMDR, I don't simply postpone treatment. Instead, I utilize other evidence-based approaches that I'm trained in, including:

Dialectical Behavior Therapy (DBT): Having been trained by Marsha Linehan's personal team of clinicians over 20 years ago, I use this approach for clients with:

• Emotional dysregulation
• Borderline personality disorder
• Self-harm behaviors
• Chronic suicidality
• Difficulty tolerating distress

The four core DBT skills modules I teach include mindfulness, distress tolerance, emotion regulation, and interpersonal effectiveness—all crucial foundations for eventual EMDR work.

Cognitive Behavioral Therapy (CBT): I integrate CBT techniques for:

• Depression and anxiety
• Trauma-related cognitive distortions
• Behavioral patterns that interfere with healing
• Skills building and problem-solving

Trauma-Focused CBT: For clients who aren't ready for EMDR, I often use:

• Cognitive processing techniques to address trauma-related thoughts
• Behavioral experiments to reduce avoidance
• Exposure work when appropriate
• Skills-based interventions for managing symptoms

Somatic and Body-Based Approaches: I incorporate techniques such as:

• Body awareness and grounding exercises
• Breathing and relaxation techniques
• Mindfulness-based somatic interventions

Parts Work Concepts: For complex trauma, I integrate:

• Parts work to address internal conflicts
• Self-leadership development
• Healing wounded parts before trauma processing

This integrative approach means that even if EMDR isn't appropriate initially, we can still make significant progress using other modalities. Many clients benefit from this multi-faceted approach, and some eventually progress to EMDR once they've built the necessary foundation.

A Message to Potential Clients

If you're reading this and wondering if EMDR might be right for you, I want you to know that having contraindications doesn't mean you can't heal from trauma. It simply means we might start with a different therapeutic approach and perhaps do some preparation work using DBT skills or CBT techniques first.

In my 25+ years of practice, I've seen countless clients who initially weren't ready for EMDR go on to have profound healing experiences once we addressed the factors that were barriers to treatment using other therapeutic modalities. The goal isn't to exclude anyone from healing—it's to find the safest, most effective path for each individual.

My training in multiple approaches—EMDR (as a Certified Therapist and Approved Consultant), DBT (trained by Linehan's team), CBT, and other evidence-based techniques—means that we can always find a way to work together, regardless of where you're starting from. Whether that's beginning with DBT skills to build emotional regulation, using CBT to address current symptoms, or jumping right into EMDR if you're ready, we'll find the approach that works best for you.

EMDR has been a powerful tool in my practice, but it's just one tool in a comprehensive toolkit. What matters most is finding what works for you at this point in your healing journey.

If you're interested in exploring EMDR or other trauma treatments, I encourage you to reach out for a consultation. Together, we can determine whether EMDR is appropriate now, or if we should start with DBT skills training, CBT techniques, or other approaches to build the foundation for your healing journey.

Ready to Take the Next Step?

If you're considering EMDR therapy or have questions about whether it might be appropriate for you, I'd be happy to discuss your specific situation during a consultation. You can reach me at (619) 743-2879 or use the contact form on this website to schedule an appointment.

Remember, seeking help is a sign of strength, and with my extensive training in multiple therapeutic approaches—including my credentials as an EMDR Certified Therapist and Approved Consultant, and DBT training from Linehan's team—we can always find an effective treatment path, regardless of where you're starting from in your healing journey.