Hey there,

We’ve all had therapy sessions go sideways.

Maybe a veteran's target selection kept unraveling as you got deeper in, or a pregnant client's activation climbed higher than you'd planned for.

When this happens, it’s easy to feel like the standard protocol has failed us.

Most of us EMDR therapists (and likely you too) learned about special populations one hard case at a time. The issue is, basic training only gives us a protocol, but not a lot of nuance about when to adapt it, and for whom. So when a case doesn't “fit” what you’ve been taught, the fallback is usually to adapt on the fly and hope you catch on quickly enough to avoid doing any harm.

I want to spend some time today on a few populations where the standard protocol, in my clinical experience, tends to fall short without extra consideration.

I won’t walk you through modified protocols (that's what specialized training and consultation is for), but this will be a good starting point to help you make sense of what's going on when these cases don't respond as expected.

(Note: If you're navigating one of these cases now and want another set of eyes, our Helicon platform will be a good place to find someone with the right specialization)

Veterans

Combat trauma is rarely one memory.

You can think of it like a network.

A single deployment can hold dozens of critical incidents, and multiple deployments compound that. Some might fall into themes like survivors guilt, moral injury, intense life-or-death scenarios, etc. Still underneath the combat material, there's often pre-service trauma that shaped why the client joined in the first place.

That's why sitting down to select targets with a veteran looks more like mapping out a web of interconnected experiences (as opposed to choosing from a list}.

This also means the linear targeting approach we learned in basic training often doesn't hold up. Floatback often reveals that it is connected to earlier material the client hasn't touched in years, and as a result, standard target sequencing can quickly become unworkable.

And a note on moral injury.

This type of trauma behaves differently from other trauma, because it involves what they did, witnessed, or failed to prevent. Reprocessing moral injury material tends to surface shame that doesn't have a natural resolution, so it usually needs more attention to values and identity.

Then there's the cultural piece.

Veterans often come in skeptical of therapy. They tend to want direct communication and don't respond well to reflective listening that reads as evasive or overly emotional. Rapport looks different with this population than with others.

Prenatal and perinatal clients

A central clinical question with pregnant clients is around activation.

Pregnancy is already a heightened physiological state. Cortisol crosses the placenta, and extended sympathetic activation during pregnancy is not neutral for the fetus. That doesn't mean EMDR is contraindicated (it's often exactly what perinatal clients need!). However pacing and titration, among a few other clinical considerations, matter more than with a non-pregnant client.

Postpartum introduces its own set of considerations:

• Sleep deprivation narrows the window of tolerance
• Hormonal changes affect regulation
• Birth trauma is often present but not yet named as such by the client
• Attachment material from the client's own childhood tends to spontaneously activate in the perinatal period
• Misaligned or unmet expectations (nature going against what was anticipated)

Clients who've done years of therapy sometimes find themselves back in unexpected places after having a baby. Which, far from being a clinical regression, is a normal (and often necessary) part of processing. It can look like symptoms are getting worse, leading to treatment aimed at a flare-up rather than what's actually happening.

OCD

EMDR with OCD requires a different kind of case conceptualization than standard trauma work. Standard EMDR targets memory, whereas OCD often doesn't have a clear memory as the driver.

Instead, there's usually a network of intrusive thoughts, feared outcomes, compulsions, and beliefs that maintain the disorder. So if you go looking for the touchstone memory, don’t be fooled. You might not find one at all.

That said, OCD frequently has underlying trauma that intensifies or triggers the symptoms. Even in cases without discrete trauma, EMDR can work with the feared outcome (the imagined future the client is trying to prevent) as if it were a memory. (Knipe's work on this is a good starting point if you haven't yet read it)

The bigger clinical issue is that OCD compulsions look like effective coping until they aren't. Clients often minimize how much time and energy compulsions consume, and processing without addressing the compulsive behavior can leave clients stuck in the loop even after the underlying material has been resolved.

If you're doing EMDR with OCD, make sure to plan for parallel attention to compulsions, such as ERP-informed work or coordination with a colleague who does CBT for OCD.

Complex dissociation

In my clinical experience, complex dissociative clients are the population that requires the most substantial adaptation. This is because standard EMDR assumes a level of integration that structurally dissociative clients don't have yet.

Dual awareness during reprocessing requires the client to hold both the trauma memory and present-moment awareness simultaneously. So, if the client's system isn't set up for that, standard protocol will either fail to produce processing or actively destabilize them.

So what should the adjustments look like?

In the case of complex dissociation:

• Preparation often runs several months.
• Work with parts becomes central to the process, and processing itself gets titrated to fractions of what you'd use with a non-dissociative client.
• Grounding runs continuously through a session (not just at the start and end), and the process of communicating between parts integrates directly into the EMDR process.

One word of advice:

If you're planning to do EMDR with structurally dissociative clients, make sure to get dissociation-informed training and consultation.

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Closing Thoughts

We’ve covered 4 special clinical profiles today:

• Veterans
• Prenatal and perinatal clients
• OCD
• Complex dissociation

Many clinicians assume that modifying the setup means breaking the method, but the underlying mechanisms of bilateral stimulation remain completely identical and all can be informed by the AIP lens.

The core protocol stays, and so does the mechanism.

The only difference is how we’re delivering the pacing, titration, and therapeutic container. This can include extending preparation, titrating processing, honoring the context of the client in front of you, and communicating in a way that they best respond to.

Which, as it usually does, brings us back to Phase 2.

Almost every special population consideration eventually reduces to more careful, more extended, more tailored resourcing.

I’ll leave it at this:

If you're taking on work with any of these populations, the most useful thing you can do (beyond specialized training) is treat Phase 2 as a distinct clinical focus. That will take you further than any specific protocol modification or technique you could ever learn.

Which populations have pushed you to adapt most in your own work?

What have you learned?

Hit reply and let me know.

Until next time,

Chris

Thanks for reading Helicon's EMDR Therapist Weekly, where we aim to provide a weekly dose of insights, tools, and opportunities for EMDR therapists; designed to support your growth, sharpen your practice, and connect you with what's next.

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Disclaimer: The information contained in this article is for informational purposes only. This is not legal or clinical advice and we make no guarantees about the outcomes or results from information shared in this document. Proceed at your own risk and discretion.​
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