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Informed Consent for EMDR

This form provides you, the client, with information that is additional to that detailed in the Notice of Privacy Practices and the Informed Consent for Psychotherapy, and it is subject to HIPAA preemptive analysis. Please initial where indicated only if you have read and consent to the material. A printable version of this form can be found here. Please keep a copy for your records.

EMDR is a particular form of psychotherapy using bilateral stimulation (BLS), defined as tapping, auditory tones or eye movements, to accelerate the brain’s capacity to process and heal. BLS, which occurs naturally during dream sleep, seems to allow the mind to work more effectively to reintegrate memories and to explore, grow, and heal emotionally. Some clients experience relief or positive effects in just a few sessions. EMDR can be effective in alleviating trauma-related and other symptoms, whether the traumatic event occurred many years ago or yesterday, with little talking, without using drugs, and requiring no homework between sessions.

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Scientific research has established EMDR as effective for the treatment of posttraumatic stress, phobias, panic attacks, anxiety disorders, stress, sexual and physical abuse, disturbing memories, complicated grief, and addictions. The possible benefits of EMDR treatment include: The memory may be remembered but the painful emotions and physical sensations and the disturbing images and thoughts may no longer be present; also, EMDR may help the mind reintegrate the memory and store memories more appropriately. The client’s own mind reintegrates the memory and does the healing.

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The possible risks of EMDR treatment include the following: Reprocessing a memory may bring up associated memories. This is normal and those memories will also be reprocessed. During EMDR, the client may experience physical sensations and retrieve images, emotions and sounds associated with the memory. Reprocessing of the memory normally continues after the end of the therapy session. Other memories, flashbacks, feelings and sensations may occur. The client may have dreams associated with the memory. Frequently the brain is able to process these additional memories without help, but arrangements for assistance will be made in a timely manner if the client expresses difficulty coping.

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As with any other therapeutic approach, reprocessing traumatic memories can be uncomfortable; some people may not like or be able to tolerate EMDR treatment well. Others may require more preparation, offered by the therapist, before processing traumatic events using EMDR. There are no known adverse effects due to interrupting EMDR therapy; a client can discontinue treatment at any time. Alternative therapeutic approaches may include individual or group therapy, medication, or a different psychotherapy modality. EMDR treatment is facilitated by a psychotherapist having EMDRIA-approved training.

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History and Safety Factors

I am willing to tell the therapist the truth about what I am experiencing.

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I am able to tolerate high levels of emotional disturbance, I have the ability to reprocess associated memories resulting from EMDR therapy, and I am able to use self-control and relaxation techniques (e.g. calm place exercise).

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I will remember debriefing instructions and call my therapist, connect with supportive family or friends, or use meditation or other techniques (e.g. calm place exercise) as agreed to in therapy, if needed.

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I will disclose to the therapist and consult with my physician before EMDR therapy if I have a history of or current eye problems, a diagnosed heart disease, elevated blood pressure, or am at risk for or have a history of stroke, heart attack, seizure, or other limiting medical conditions that may put me at medical risk. Due to stress related to reprocessing traumatic events, pregnant women should consider postponing EMDR therapy.

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I will inform the therapist if I am wearing contact lenses and will remove them if they impede eye movements due to irritation or eye dryness. The therapist will discontinue bilateral stimulation (BLS) via eye movements if I report eye pain and use other dual stimulation (tapping, sounds) to continue reprocessing.

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I will assess my current life situation to determine fitness of EMDR approach. I may need the ability to postpone demanding work or other obligations immediately following EMDR session.

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I am willing to explore the issues(s) which may arise as change occurs. For example, changes regarding my identity, finances, loss of identification with a peer group, and/ or attention.

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Before participating in EMDR, I will discuss with the therapist all aspects of an upcoming legal court case where testimony is required. I may need to postpone EMDR treatment if I am a victim or witness to a crime that is being prosecuted because the traumatic material processed using EMDR may fade, blur or disappear and my testimony may be challenged.

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I understand disagreements with family and/or friends may occur as I learn new skills such as assertiveness or social skills after processing problems and disturbing material using EMDR. Vulnerable clients may need to be protected.

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I will consult with my medical doctor before utilizing medication. Some medications may reduce the effectiveness of EMDR. For example, benzodiazapines may reduce effectiveness, possibly due to state-dependent processing, and/or regression may occur after ceasing anti-depressants.

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I will address with the therapist my ability to attend to EMDR due to recent cocaine dependence, long term amphetamine abuse, seizures, and/or other neurological conditions. EMDR is contraindicated with recent cocaine users and long term amphetamine users.

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I will discuss with the therapist any Dissociative Disorders, Dissociative Identity Disorder, unexplained somatic symptoms, sleep problems, flashbacks, derealization and/or depersonalization, hearing voices, unexplained feelings, memory lapses, multiple psychiatric hospitalizations, or multiple diagnoses with little treatment progress, as EMDR may trigger these or correlated symptoms.

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By entering my name, I affirm that I have read the above Informed Consent for EMDR carefully; I understand it and agree to comply with it; I understand the possible outcomes of EMDR; I understand that I can end EMDR therapy at any time; I agree to participate in EMDR treatment and I assume any risks involved in such participation.

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