When to Modify the EMDR Standard Protocol (And When NOT To)
A few months ago, a therapist in my consultation group asked a question that gets to the heart of what makes EMDR both powerful and challenging:
"How do I know when I should modify the standard protocol and when I should stick with it?"
It's a question I hear often, and for good reason. We want to be flexible enough to meet our clients' needs, but not so flexible that we drift away from what makes EMDR effective in the first place.
Today, I want to explore this clinical issue and give you a framework for making these decisions confidently.
The Paradox of Protocol Fidelity
Let's start with this:
Francine Shapiro developed the 8-phase protocol for a reason. Research consistently shows that following the standard protocol produces reliable results for many clients.
But the paradox?
Rigid adherence to protocol can sometimes be counterproductive to the very goals the protocol was designed to achieve.
I've observed both extremes in consultation:
The "Protocol Purist" who follows every step exactly as written, even when the client is dissociating, overwhelmed, or clearly not benefiting from the approach.
The "Creative Improviser" who modifies so extensively that what they're doing barely resembles EMDR anymore (thus losing the core mechanisms that make it effective).
The sweet spot lies somewhere in between:
Something we’ll call "principled flexibility".
When Modification Is Clinically Needed
Through years of EMDR supervision and consultation, I've identified several specific scenarios where modification is clinically needed (not just helpful):
1. Significant Dissociative Symptoms
When a client has dissociative tendencies, the standard protocol can sometimes trigger further dissociation and make processing impossible.
Modifications might include:
Shorter processing sets (sometimes as brief as 15-30 seconds)
More frequent check-ins to maintain dual awareness
Greater emphasis on grounding between sets
Starting with peripheral details rather than the most disturbing aspects
Using tactile bilateral stimulation rather than visual
Using the FLASH technique
Struggling to determine which of these situations applies to your case? My EMDR Protocol Modification Decision Tree can help you navigate these complex clinical decisions.
2. Complex Developmental Trauma
Clients with extensive childhood trauma often don't have discrete "worst" memories to target. Their memory networks formed during critical developmental periods and are structured differently.
Helpful modifications include:
Working with "memory clusters" around themes rather than single incidents
Processing emotional states or body sensations rather than narrative memories
Focusing on attachment disruptions that occurred across thousands of interactions
Extended preparation phases to build internal resources
Integrating parts work or ego state interventions with bilateral stimulation
3. Currently Unsafe Life Circumstances
When a client remains in unsafe or highly stressful circumstances, full processing of trauma can sometimes destabilize their functioning when they need it most.
Consider modifications like:
Resource development and installation as a primary focus (an extended preparation phase)
Processing current triggers without addressing historical material until more stability is present
Shorter, more contained processing with clear boundaries
EMD or FLASH to focus on desensitizing
Present-focused safety planning integrated into each session
More emphasis on closure and containment
4. Medical Complications
Clients with conditions like traumatic brain injury, seizure disorders, or severe migraines may need adjustments to the standard bilateral stimulation.
Modifications might include:
Slower eye movements or different bilateral modalities
Shorter processing sets with more breaks
Integrating medical management strategies into the treatment plan
Coordination with medical providers
Helping address their relationship to the medical issues with something like Mark Grants Pain protocol
When to Stick with Standard Protocol
Knowing when to modify the EMDR protocols is important – but just as important to recognize when the standard protocol is likely to be most effective.
Here are four scenarios where I generally recommend sticking with standard protocol:
1. Single-Incident Adult Trauma (in Otherwise Stable Individuals)
For clients with good affect tolerance, minimal dissociation, and discrete traumatic events that occurred in adulthood, the standard protocol often works beautifully.
Modifications may actually slow progress.
2. When Progress Is Obvious (Despite Discomfort)
Sometimes clients experience distress during processing, but the SUD score is decreasing and adaptive information is emerging. This discomfort is part of the processing – and modification might interrupt the natural healing. If they remain in the window of tolerance, keep going.
3. Early in Your EMDR Journey
If you're relatively new to EMDR, mastering the standard protocol before attempting modifications gives you a solid foundation. Many difficulties that seem to require modification actually resolve with proper application of the standard approach.
4. When Previous Modifications Haven't Helped
If you've tried various modifications without success, returning to the standard protocol with careful attention to each element sometimes reveals missed opportunities.
The Decision Framework: Questions to Guide Your Clinical Judgment
When facing the modify-or-not decision with a client, I find these questions helpful for clarifying my thinking:
Is the standard protocol posing a risk to this client? (Safety always comes first)
Is there evidence that this client's information processing system works differently in a way that would benefit from modification?
Will this modification maintain the core elements of EMDR (bilateral stimulation, dual attention, adaptive information processing)?
Is my desire to modify based on the client's needs or my own discomfort with the process?
Have I consulted on this case before making significant modifications?
That last question is especially important.
Consultation provides an essential outside perspective when we're considering departures from standard practice.
If you find yourself regularly wrestling with these questions, you might benefit from a structured approach. I've developed an EMDR Protocol Modification Decision Tree that walks you through this decision-making process step by step.
Ethical Considerations in Protocol Modification
As we adapt our approach to meet client needs, we also need to consider several important ethical aspects of EMDR therapy:
Informed consent: Clients have a right to know when we're modifying standard approaches and why. I explicitly discuss this with clients when making significant changes.
Scope of practice: Modifications should remain within our training and competence. If a client needs an approach we're not trained in, referral, consultation, or pursuit of training is appropriate.
Fidelity to the model: When we modify extensively, are we still doing EMDR? This question matters for both research integrity and honest communication with clients.
Documentation: I document my rationale for modifications, the specific changes made, and the outcomes observed. This creates a clear record of clinical decision-making.
Developing Your Clinical Judgment
Strong clinical judgment around protocol modifications doesn't happen overnight. It develops through intentional practice and ongoing professional development.
Here are four important components of this growth:
Deep understanding of the AIP model: Modifications should serve the core principle of facilitating adaptive information processing
Ongoing consultation: Regular case discussion helps identify blind spots in our clinical reasoning
Continuing education: Advanced training provides structured guidance on evidence-based modifications
Reflective practice: Honest assessment of what's working and what isn't with each modification attempt
Your Clinical Challenge
To deepen your own clinical decision-making, I invite you to reflect on your own practice with these questions:
In which situations do you feel most confident following standard protocol?
When do you find yourself wanting to modify, and what drives that impulse?
How do you balance creativity with fidelity to the model?
What resources do you use to guide your modification decisions?
I'd love to hear your thoughts, too!
In gratitude,
Christopher Brown, LICSW
P.S. If you're looking for more structured guidance on protocol modifications, I've created an EMDR Protocol Modification Decision Tree that many therapists in my consultation groups have found helpful.
