The Other 167 Hours of EMDR

Summary

Eye Movement Desensitization and Reprocessing (EMDR) therapy is unusual among psychotherapies in how much of the work happens outside the room. Reprocessing continues after a session ends. Targets get activated by ordinary life. The published protocol warns clients that between-session disturbance may occur, asks them to keep a log of what surfaces, and asks clinicians to open the next session by reviewing it.

In practice that log is the weakest link in the protocol. It lives on paper, in a notes app, or in memory. It is filled in the night before, if at all. It arrives as a page the clinician reads in the first minutes of a 50-minute hour. The result is a treatment designed around between-session information and delivered without most of it.

This paper describes the gap as we understood it through interviews with multiple EMDR clinicians, highlights why the tools EMDR clinicians currently use do not close it, and describes how a voice-first, client-controlled log built for EMDR may close that gap.

Terms used in this paper

EMDR clinicians can skip this. For everyone else, the short version of each term, as the protocol uses it:

• Eye Movement Desensitization and Reprocessing (EMDR) therapy. A structured psychotherapy delivered in eight phases. In the reprocessing phases the client holds a distressing memory in mind while following bilateral stimulation, and reports what comes up.
• Target. A specific memory or situation chosen for reprocessing. Targets can be past adverse life experiences, present-day triggers, or future situations the client wants to handle differently.
• Reprocessing. The phases (desensitization, installation, body scan) in which the client works on a target, set after set, until it no longer causes distress.
• Bilateral stimulation (BLS). Left-right eye movements, sounds, or taps. Clinicians deliver it in person or, remotely, with on-screen lights, tones, or handheld buzzers.
• Set. One run of bilateral stimulation, a series of back-and-forth movements, after which the client says what came up.
• Subjective Units of Disturbance (SUD). The client's rating of how distressing a target feels right now, from 0 (none) to 10 (the most).
• Negative and positive cognition. A belief about oneself tied to the target, such as "I am not safe", and the belief the client would rather hold, such as "It's over; I am safe now."
• Validity of Cognition (VOC). How true the positive cognition feels right now, from 1 (completely false) to 7 (completely true).
• Body scan. The client holds the target and the positive cognition in mind while moving attention through the body, and reports any remaining sensation.
• Reevaluation. The eighth phase, which opens the next session: what happened since the last session, and where the previous target stands.
• TICES log. The between-session log described in section 1.

1. What the protocol asks for

EMDR therapy runs in eight phases: history-taking and treatment planning, preparation, assessment, desensitization, installation, body scan, closure, and reevaluation. Reprocessing works on targets: specific memories from the past, or present-day triggers, that the client wants to have a different relationship with. Progress is tracked with two ratings the client gives out loud: the Subjective Units of Disturbance (SUD) scale, from 0 to 10, which works like the pain chart on a hospital wall but for distress; and the Validity of Cognition (VOC) scale, from 1 (completely false) to 7 (completely true), for how true a chosen positive belief feels.

Two parts of the protocol reach into the client's week:

• Informed consent, in the preparation phase, tells the client that distressing memories may surface after a session and that between-session disturbance, such as nightmares or other memories, may occur.
• The Weekly Log (TICES) Report, which the client keeps between sessions. TICES stands for Trigger, Image, Cognition, Emotion, Sensation. The published form has six columns: Date, Trigger, Image, Cognition, Emotion, and Sensation with the SUD rating. Many clinicians add a seventh, Behavior.

Read the way a clinician explains it to a client, the log records:

• Trigger. What happened before the reaction, if known. Example: thinking about the target before bed. Sometimes there is no trigger the client can name, and that is worth recording too.
• Image. What image or memory came up. Example: seeing a person's face in a dream.
• Cognition. Thoughts or beliefs that appeared. Example: "Why am I still thinking about this? Why am I not over it?"
• Emotion. Feelings that came up. Example: fear, anger.
• Sensation (physical). What the body did, with a SUD rating. Example: sweating, heart pounding.
• Behavior. What the client did afterward. Example: getting a glass of water, practicing deep breathing.

The log serves three purposes:

1. Reevaluation. The next session opens by checking what happened to the target since the last one: whether the SUD held, and whether new material emerged. As one clinician put it, the log tells her "do we have more work to do on this issue, and if so, what kind."
2. Target selection. Activations between sessions are how a clinician learns that a queued target has moved up, or that a new one exists.
3. Safety. A client who reports rising distress, lost sleep, or a flood of new material needs a different next session than one who reports quiet integration. The behavior column shows whether the coping skills taught in preparation are being used.

Every one of these depends on the log being kept and being read.

2. Where it breaks

An EMDR clinician who works with us runs a weekly caseload in which around ten clients are in reprocessing at any time, three sessions out of four in a typical month, over anything from a few months for a single-incident trauma to a year or two for complex trauma. She described the same failure points other clinicians have described to us:

The log is taught as a coping skill and then left to the client. It is introduced during preparation, with the suggestion to keep it in a notes app or wherever is convenient. Some clients keep it. Some arrive and say they forgot all about it.

It is kept in the wrong medium. A notes app, a piece of paper, an email to the therapist. The medium changes week to week, so nothing accumulates.

It is completed at the wrong time. A dream at 3 a.m. on Tuesday is recalled days later, if at all, and the image and physical sensation are recorded from memory.

It is read at the wrong time. Clinicians check the log when the client is back in the room. Some clients email it during the week. The clinician told us plainly that it would help to see it sooner.

Distress ratings drift without a trend. During reprocessing the SUD goes up and down, set after set, until it goes down and stays down. A between-session rating of 4 means something different after three weeks at 6 than after three weeks at 2. Written logs rarely carry the trajectory, so the number is read without its history.

Where the last session ended is reconstructed from notes written for the clinician, not for the client. Clinicians who reprocess with many clients keep detailed per-client notes because, in one clinician's words, they "would never be able to remember." Those notes are private to the clinician; the client's week is not in them.

The client's own voice is lost. Logs written for a therapist to read are edited. The half-sentence a client says out loud in the parked car is closer to the material than the tidy line they write later.

3. Why existing tools do not close the gap

Most software EMDR clinicians already pay for is built for the session or for the note, not for the week in between.

• Remote EMDR platforms deliver the bilateral stimulation itself, lights, tones, or handheld buzzers, over video. They are session tools and do a good job of it. They have no between-session channel.
• Documentation tools produce an EMDR-format note after the session. Some clinicians keep their reprocessing notes separately because they want more detail than a generated note holds. Either way, the note is the clinician's record of the room, not the client's record of the week.
• Practice management and electronic health record (EHR) systems hold the treatment plan and the appointment. They have no between-session channel at all.
• Mood and journaling apps are generic. A daily mood score is not a trigger, an image, a cognition, an emotion, a sensation, and a behavior attached to a named target.
• Text messages and email are what many clients actually use. They are unstructured, unsearchable, and sit outside the record.

The gap is not a missing form. It is that nothing in the stack is built around the moment a target activates.

4. What good looks like

From those conversations, a between-session tool for EMDR has to meet four conditions:

1. Capture happens at the moment, by voice. The client speaks when something surfaces. Speaking takes seconds and needs no form.
2. The log is structured after capture, not before. The TICES elements, the SUD rating, and the behavior are drawn out of what the client said, with the client's own words kept alongside.
3. The clinician gets a picture, not a pile. Before the session: which targets activated, how often, what the SUD trend looks like, where the last session ended, and what the client said in their own words. Two minutes of reading, not twenty.
4. Skill use counts as data. Breathing used, calm place used, a client-initiated exposure: these are signal about stabilization, and they belong next to the activations.

5. Where Lisner stands today

Lisner is a voice journal for the hours between sessions, with a clinician dashboard that shows what a client has chosen to share. It is in use with founding practices, including the EMDR companion.

The EMDR companion is built with founding practices. In its current form it holds a target sequence with negative and positive cognitions and VOC ratings, SUD by session with a trend, where the last session ended, and a between-session log built from the client's voice entries.

Lisner is not a crisis service and is not a medical device. It does not diagnose, does not decide a treatment plan, and does not replace clinical judgment.

6. What we are asking of EMDR clinicians

We are looking for a small number of EMDR-trained founding practices to use the companion with clients who are already in reprocessing, provide their feedback, and shape what ships. Founding practices pay the founding seat rate; the EMDR companion is included at that rate, for as long as the account stays on the founding rate.

If that is you: lisner.ai/therapists, or write to hello@lisner.ai.