Abreactions and dissociation in online EMDR: how to respond

An abreaction is not a problem in itself

An abreaction is a strong release of emotion and body sensation while a memory is being processed: crying, trembling, fast breathing, anger. In EMDR this is often part of processing, not a sign that something is going wrong. The general principle is to keep the bilateral stimulation going and help the client move through the peak, rather than stopping at the worst moment. Stopping mid-peak can leave the client in the distress without the processing that resolves it.

Short, calm comments during the set help the client stay with it: “It's old stuff, just notice it”, “You're safe now, it's in the past”, or the image of watching the scenery go by from a moving train.

What matters is whether dual attention is intact: the client is aware of the memory and, at the same time, of being here with you now. As long as that's the case, even strong emotion is usually workable.

Signs that the client is leaving their window of tolerance

• No longer responding to your voice, or responding slowly and vaguely.
• A fixed, glazed stare, or eyes that stop following the ball.
• Sudden flatness, numbness or unreality (“it's like watching a film”, “I'm far away”).
• Speaking as if the event is happening now, without awareness of the room.
• Panic that keeps rising over several sets without new material.

These point to arousal beyond what the client can process, or to dissociation. They call for a different response than an ordinary abreaction.

What to do

1. Stop the stimulus and speak to the client by name, calmly and a little louder than usual.
2. Orient them to the present. Ask them to put their feet on the floor, look around the room, name objects and feel the chair. Ask where they are and what day it is.
3. Check dual attention before you continue. Jim Knipe's Back of the Head Scale is a quick way: the client points to a spot on an imaginary line running from in front of their face (fully present here with you) to the back of their head (completely caught up in the disturbance).
4. Reduce the intensity when you resume: shorter sets, a smaller part of the memory, a different type of stimulation, or a cognitive interweave that brings in safety (“Where are you now? How old are you now?”).
5. If the client can't get back into their window of tolerance, don't push on. Move to closure with the container and the calm place, and review the plan: more preparation, or sessions in person.

Why online needs extra care

• Less information. You see a face, often small and sometimes delayed. Ask the client to position the camera so you also see their shoulders and hands. A second device for the video call, separate from the stimulus screen, helps.
• Audio delay. Your supportive comments may arrive late. Keep them short and calm.
• The client is alone. Nobody brings them a glass of water, and there is no waiting room to settle in.
• The connection can drop at the worst moment. Agree beforehand what the client does (stop, ground, wait for your call) and how you will reach them.

Screen for dissociation before you start

Many difficult moments can be prevented in phase 1. Ask about dissociative symptoms and use a screening tool such as the Dissociative Experiences Scale (DES). For clients with significant dissociation, extend the preparation phase, consider specialised approaches, and think carefully about whether online reprocessing is suitable at this stage.

Closing an incomplete session

When a target isn't finished, use phase 7, closure:

• Stop reprocessing with enough time left: at least 10 to 15 minutes online.
• Acknowledge the client's work and explain that it's normal for processing to be unfinished.
• Use the container for what is left, and the calm place or another resource to settle.
• Check that the client is oriented and calm enough to go back into their day. Ask what they will do right after the call.
• Remind them that processing can continue, and ask them to keep a short log.
• Make sure they know how to get help if they feel unsafe.

The guide to the preparation phase explains how to set up the calm place and container so they work when you need them.

Settings that help in Remote EMDR

• Play/Stop ends a set immediately; the ball stops on the client's screen within a second.
• When processing gets too intense, try a slower speed, a calm background, or switching from visual to auditory stimulation.
• Write down what happened and what helped in the patient's dossier (free account), so you can adjust the plan for the next session.