Expanding EMDR and Therapy Accessibility
NOTE: You will notice that I refer to myself using person-first language (person with a disability) rather than disability-first language (disabled person). This is my personal preference and may not be the same for everyone. The best practice is to always ask individuals how they prefer to be identified.
Recently, I was reminded how often disability is overlooked in systems meant to protect people. It made me reflect on how frequently disability is also under-addressed in our clinical training.
How much education did you get in grad school about working with people with various types of disabilities? My culture and diversity class got an hour and a half on the topic, and as the token student with a physical disability, I taught the class. Ninety minutes is not enough time to prepare clinicians to competently work with disabled clients. Disabilities are experienced differently across race, religion, and culture, and the spectrum of disability itself is huge. I think it should be a mandatory class on its own. The reality is, even if we do not market specifically to individuals with disabilities, we will have people who need accommodation come through our practices. I realized that I wasn’t the only one who had a gap in their education during a recent EMDR course. Several of the other therapists there struggled with the idea that people with vision loss, or individuals experiencing aphantasia (the inability to voluntarily create mental images in one’s “minds eye”) could successfully do EMDR.
I think my partner who experiences aphantasia said it best: “It’s important to keep in mind that there are internal senses as well as the classic physical senses, body state sensations, emotional sense, and (especially with memory) what I can best describe as “narrative” sense: something that’s much like an internal equivalent to the audio description track for a movie or alt text for a picture online. For someone with aphantasia, these internal senses become the substance of memory.
As an example, where you might ask someone to picture a relaxing or peaceful scene, you could ask them to describe (aloud or to themselves) something that they would find very relaxing. Have them focus on what it would feel like to be in that situation as they tell the story to themselves in as much detail as they need to imagine how their body and mind would respond to the experiences. Things that could represent the worst part of a situation can similarly be short narratives. In contrast to the more factual diagnostic statements about what they believe or are feeling, encourage them to use the most evocative language possible.
Examples: “Desperately trying to make someone hear what I’m saying, but no one is listening to me,” or “Tensed up, constantly ready for the other shoe to drop, but never knowing exactly when it’s coming.”
The more vividly they can paint the scene or sensations with words, the better (particularly since the language needed connects to their senses without needing to specify a specific thing being sensed).
As far as my blindness and me, after talking to Dr. Jamie Marich about doing this article, I also spoke to her about doing a demo EMDR tape. In thinking about doing that, I identified a “little t” trauma that occurred while I was in an orientation and mobility class (where people learn to use canes and orientation skills using different senses), wearing sleep shades (a blindfold so I could see nothing). I was 18, and we were learning (as a small group class) to walk on the side of a highway (a skill intended for emergency navigation).
It was a long walk on a hot day in Ruston, Louisiana. I had skipped breakfast and neglected to bring water. This was a 6-mile walk. By the end of mile 5, I was miserable. I could, however, sense our closeness to our destination: Sonic! My ice cream was so close. We made it back into the city, navigating more intersections and general city travel, and I got disoriented. I could hear cars going nearby, and I thought that based on what I was hearing, I was at an intersection. I felt a drop with my cane, which I assumed was the road. I waited until I felt it safe to cross. I took a step, and there was… nothing. I was not in fact at an intersection, but I had found a hole. There were railings around 3 sides of the hole, but not on my side. I fell. The teacher lifted his sleep shades to check on our progress and saw me step into the hole. I remember him jumping in to make sure I was ok, as well as hearing a gaggle of bystanders above the hole. I was in significant pain. The ground was rocky and gross. I likely should have gone to the hospital.
The misconception that EMDR requires visual imagery is not only inaccurate; it limits access to care.
Read that story again, and think of all of the other sensations I mentioned. There was the physical sensation of being hot, tired, and in pain. I could hear cars and the concern of other people. That’s more than plenty of sensory data to go on as an EMDR target. The only difference I would make to work with a blind or low-vision client is to ask for the worst part or moment of the experience (the gaggle of onlookers assessing me). From there, clinicians can utilize the client’s preferred form of DAS and proceed with standard EMDR protocols. Adapting EMDR for clients with visual (or any other) disabilities does not require abandoning the model—only expanding our understanding of sensory processing.
I am older than the Americans with Disabilities Act (ADA). I’ve been navigating the world with physical disability for almost 37 years. I’ve met many different types of people and spoken to individuals with a variety of disabilities. I cannot and will not speak for every person with a disability. However, these are some principles that I believe every clinician should consider:
- Accessibility is not just about stairs. If the print on your business cards or flyers lacks contrast or uses small type, your practice is not accessible. If materials cannot be enlarged or accessed digitally, your practice is not accessible.
- Ask people how they identify. Language preference varies. For some, disability is an identity. For others, it is one attribute among many. Do not assume—ask.
- If your only options for EMDR are watching a light bar or watching your fingers move, your EMDR practice is not accessible. Bilateral stimulation can be auditory, tactile, or self-administered. Limiting options limits clients.
- If, when asking about a memory, the only sensory channel you inquire about is visual, your EMDR practice is not accessible.
- Consider what it would be like to not see the sign on your therapist’s office door, to not read intake paperwork independently, to search every side of a building to find an accessible entrance, or to rely on an interpreter to discuss your most vulnerable memories.
EMDR basic training has a lot to accomplish in a small amount of time. The basic curriculum cannot often address the variety of ways that EMDR might be adapted to meet the needs of individuals with disabilities. There are, however, special topics classes through ICM (Institute for Creative Mindfulness) that do cover this topic in more depth. I feel that it’s part of our ethical responsibility as therapists to seek out education about people with disabilities, because you never know when you might need those skills for a client, or even for yourself. The disabled population is the only population anyone can join at any point in life—through illness, accident, aging, or circumstance.
Disability competence is not niche training. It is human training.
A few questions to consider about your practice’s accessibility:
- Does your Psychology Today profile, website, or other advertisement mention accessibility?
- Do your online pictures or videos have captions?
- Does the building you practice in meet ADA criteria? (Remember that ADA is supposed to be the minimum requirement.)
- Do you know who you would call if a client needed an interpreter?
- Do you offer telehealth?
- Is there enough room in your office/waiting room to maneuver with a mobility device?
You could answer yes to all of these questions and still not be able to fully accommodate every client. For example, you might have used Open Dyslexic font on your forms or pamphlets, and I wouldn’t be able to read that. Elevators break, print size and contrast needs vary, and mobility needs vary. No one is asking you to be perfect, but to let people with different access needs know that they are welcome in your office or facility.
