EMDR and Psychosis

From Prudence to Paradigm Shift

A Now-Established Etiological Link

For a long time, the application of EMDR to psychotic patients was avoided due to fears of destabilization. This clinical caution has gradually transformed as empirical data has accumulated: the link between childhood trauma and the development of psychosis is now solidly supported. Individuals who experienced three or more adverse childhood experiences (ACEs) show a risk of psychosis that is 2.8 to 4.6 times higher compared to the general population (Varese, 2012; Flinn, 2025).

At the neurobiological level, early trauma causes lasting changes: a reduction in gray matter in emotional regulation areas, epigenetic alterations of genes involved in the stress response (NR3C1, FKBP5), and dysregulation of the hypothalamic-pituitary-adrenal axis. These changes, although profound, appear to be reversible under the influence of adapted psychotherapy — which constitutes one of the most compelling arguments in favor of EMDR.

Reframing Psychosis: From a Deficit to an Attempt at Adaptation

The Adaptive Information Processing (AIP) model offers a fruitful conceptual framework. Psychosis is no longer perceived as an "irremediable break with reality," but as an adaptive attempt by the nervous system to cope with an overload of unintegrated traumatic material. This perspective aligns with Liz Jing Zhang's "Bold Hypothesis," which posits that psychosis results from a joint failure of brain mechanisms regulating the state of arousal and dream suppression... in short, an "awake dream" where traumatic content intrudes into reality.

Eleanor Longden, whose journey is a benchmark in participatory psychiatry, illustrates this vision: her hallucinatory voices were not enemies to be eliminated, but meaningful responses to traumatic events, carrying insight into resolvable emotional issues. This reframing is the foundation of an authentic therapeutic alliance.

What the Data Says: Safety and Efficacy

Recent systematic reviews and randomized controlled trials confirm two essential points.

Regarding safety, the application of EMDR to psychotic patients causes no serious adverse events or significant symptomatic worsening. Dropout rates are low (around 4% in certain case series), demonstrating excellent acceptability, including among adolescents who are often reluctant to receive traditional care. The feasibility trial by Varese et al. (2023) in early intervention services confirmed the safety and feasibility of the EMDRp protocol in the context of a first psychotic episode.

Regarding efficacy, EMDR demonstrates a significant reduction in post-traumatic stress symptoms, depression, anxiety, as well as paranoid and negative symptoms. Results remain more nuanced concerning hallucinations. Compared to trauma-focused cognitive behavioral therapy (TF-CBT), EMDR shows equivalent efficacy with the advantage of requiring fewer sessions and no homework, which improves therapeutic adherence.

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Essential Clinical Adaptations

The application of EMDR to psychosis cannot be direct. It requires structural adaptations.

Managing the window of tolerance constitutes the central challenge. Psychotic patients oscillate between hyper-activation (paranoia, terrifying hallucinations) and hypo-activation (flat affect, catatonic withdrawal). The objective of the preparation phase is precisely to expand this window before any reprocessing. Practical tools — bodily grounding, gentle bilateral stimulations, EFT techniques, manipulation of sensory objects — help keep the patient within a tolerable zone of activation.

The Two-Method protocol (Van den Berg) proposes an organization based on two complementary axes.
Method 1 targets the etiological traumatic memories, the events that preceded or fueled the emergence of the disorder, by tracing back the chain of associations to identify the foundational negative beliefs ("I am in danger," "I am bad").
Method 2 addresses maintaining factors: on the one hand, the "trauma of psychosis" itself (involuntary hospitalization, forced sedation, the terror of initial hallucinations); on the other hand, anxious flash-forwards, those catastrophic representations of a dreaded future that sustain avoidance and social withdrawal.

Abbreviated assessment in phases 3 to 6 is often preferable for patients with low insight. Rather than soliciting formal negative cognition, the therapist anchors on an isolated image (the alien's face, a physical sensation) to initiate reprocessing without risking disorganization.

Early Intervention as Neuroprotection

Integrating EMDR at the earliest signs of psychosis — or even at the At-Risk Mental State (ARMS) stage — aligns with a neuroprotective logic. A feasibility study observed that out of 11 at-risk participants treated with EMDR, only one (11%) transitioned to psychosis at 12 months. This preventive signal, though preliminary, warrants attention.

The R-TEP (Recent-Traumatic Episode Protocol) and PRECI protocols allow for rapid intervention following an acute episode to prevent the consolidation of new traumatic memories. Treating the "trauma of psychosis" early (the distress associated with the episode itself) heavily conditions the quality of subsequent functional recovery.

The specific challenges of the first psychotic episode (therapeutic window, adapted protocols, prevention of chronicity) are detailed in a dedicated article to which we refer readers wishing to delve deeper into this dimension. (link)

Toward an Integrative and Systemic Approach

Therapeutic success goes beyond the EMDR protocol itself. It requires systemic mobilization: involvement of the family system as a regulation resource between sessions, coordination with the psychiatrist to adjust medication based on reprocessing progress, and integration of occupational therapy for bodily and sensory grounding. Parents, informed and supported, become "guardians of integration," capable of reframing their child's difficult behaviors as traumatic symptoms rather than character flaws.

EMDR in psychosis is no longer a daring experimental endeavor.
It is gradually establishing itself as a validated therapeutic pillar, capable of acting on the neurobiological and traumatic roots of the most severe disorders.
Provided it is practiced with rigor, clinical flexibility, and constant attention to patient safety.

The theoretical principles developed in this article only take on their full meaning through clinical reality. The following case concretely illustrates the implementation of the Two-Method protocol in an adult patient suffering from paranoid schizophrenia, and shows how traumatic conceptualization can guide management where pharmacological treatment alone had reached its limits.

This clinical case is shared with the patient's agreement, whom I thank for his trust and for agreeing that his journey could contribute to collective clinical reflection. His story, carefully anonymized, illustrates better than any theoretical discourse what the AIP model allows us to understand and transform.

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A young man, followed in a mental health center (CMP), presents himself, referred by his prescribing psychiatrist, with a diagnosis of paranoid schizophrenia established at the age of 15. He consults at age 23 in a crisis context: an escalation of aggressive behaviors toward his peers within his ESAT (work assistance service) led to his dismissal. Despite a stabilized medication regimen, it proved insufficient to treat persistent traumatic intrusions that fuel his distress and behavioral instability.

The dismissal from the ESAT itself constitutes a significant secondary traumatic experience: a brutal confrontation with his own perceived dangerousness, intense social shame, loss of structuring reference points, and the rupture of a community link that constituted the bulk of his life framework. This "trauma of psychosis" (in the sense that the illness and its consequences themselves become a source of traumatization) was superimposed on prior traumas without being able to be processed.

Clinical Conceptualization

In accordance with the Adaptive Information Processing (AIP) model, the symptoms presented are conceptualized as memory fragments stored dysfunctionally in isolated neuronal networks, activated untimely by social environment triggers. The intrusions are structured according to three complementary registers, directly linked to the two axes of Van den Berg's protocol:

1. Childhood traumatic memories (Method 1 targets: etiological past)
Abuse experienced during childhood forms the etiological foundation of his chronic mistrust of others.
These dysfunctional memory networks directly fuel his paranoid interpretations of present social interactions.

2. Flashbacks of recent violent behaviors (Method 2A targets: trauma of the illness)
Visual and somatic intrusions related to his own acts of acting out in ESAT generate intense guilt and a profound identity confusion. This register raises a specific theoretical complexity: the patient is simultaneously a victim of experienced abuse and an author of acted-out violence.
Within the AIP framework, the associated negative cognitions are organized differently according to this polarity. As a victim, they revolve around powerlessness ("I am defenseless," "I cannot protect myself"); as an author, they mobilize shame and identity threat ("I am dangerous," "I am bad").
This double register required special clinical attention to avoid merging targets with opposing dynamics.

3. Impulsion phobias in the form of flash-forwards (Method 2B targets: maintaining factors)
Intrusive images of future violent acting out cause a panic fear of losing control. In line with the theoretical framework, these anticipatory representations are treated as targets in their own right: their desensitization aims to reduce their emotional credibility and the behavioral avoidance they engender.

EMDR Treatment Strategy

Reinforced Preparation Phase

Given the risk of exceeding the window of tolerance and psychotic decompensation, the preparation phase was significantly extended before any initiation of reprocessing. The central objective was to expand the patient's self-regulation capacity, meaning reinforcing his tolerance to emotional activation without shifting into dissociative or paranoid states.

The consultation space itself was set up as a "Safe Place." This adaptation, recommended for psychotic patients whose internal imagery capacity is sometimes fragmented or overwhelming, allows for immediate grounding in present perceptual reality as soon as instability increases. The concrete physical environment (the room with the blue shelf, the frame with the photo of the sea, the therapist's voice) becomes the support for safety rather than a mental representation potentially contaminated by psychotic material.

Psychoeducation was a central lever of this phase: explaining how traumatic memory works, dissociation, and the link between experienced trauma and violent behavior allowed the patient to begin perceiving himself not as "fundamentally dangerous," but as carrying understandable reactions to abnormal events.

Graduated Technical Progression:
CIPOS → EMD → EMDr

Reprocessing followed a three-step progression, with each transition determined by observable clinical indicators rather than a predefined schedule.

Step 1 - CIPOS (Constant Installation of Present Orientation and Safety) 
All targets were initially approached via this protocol, designed to keep the patient within his window of tolerance by constantly alternating between target activation and a return to present orientation. This framework avoided total immersion in images of violence, which would have risked triggering a paranoid crisis or dissociation. Progression to the next step was authorized when three criteria were met over several consecutive sessions: absence of observable dissociation, maintenance of eye contact and dual attention, and spontaneous reduction in distress levels without therapist reframing intervention. I should specify here that session durations were adapted to the patient's capacities and reduced to 45 minutes (instead of the usual 1.5 hours) at a rate of one session per week.

Step 2 - EMD (Eye Movement Desensitization) 
Once the capacity for dual attention was sufficiently consolidated, reprocessing progressed to EMD, allowing for more targeted desensitization of images of experienced and acted-out violence, without aiming for complete reconsolidation of the memory network. The transition to this step was guided by the patient's ability to maintain an observer perspective on his memories without being overwhelmed, and by the stabilization of his behavior outside of sessions reported by his family.

Step 3 - EMDr (maximum selected reprocessing zone) 
Reprocessing progressed to an expanded form allowing for deeper desensitization. The full standard EMDR protocol (including notably the formal installation of a positive cognition and VoC check) was not pursued, due to clinical caution regarding the risk of decompensation associated with the active installation of positive beliefs in a patient whose self-regulation structures remained fragile. The chosen objective was the transformation of intrusive memories into integrated episodes of personal history, losing their character of immediate threat, without forcing a cognitive restructuring that the nervous system was not yet ready to durably consolidate.

Chronological Ordering of Targets

The targeting plan followed a progressive clinical hierarchy rather than a strict chronological order, prioritizing first the most current and destabilizing targets, followed by older traumatic networks:

1. Violent events in ESAT and dismissal : secondary traumatization, shame, loss of structuring framework.

2. Flash-forwards : intrusive images of future acting out, fear of losing control.

3. Current triggers : stressful social situations, interactions with peers, residual hyper-reactivity.

4. Childhood traumas : abuse experienced, at the origin of beliefs of mistrust and powerlessness.

Treatment of Current Triggers and Installation of Future Templates

After reprocessing the past, contextual triggers were addressed to reduce hyper-reactivity in social situations. Finally, positive future scenarios (future templates) were constructed and installed to directly treat impulsion phobias. The patient was able to imagine himself facing a tense social situation and maintaining control over his reactions, gradually installing a positive belief such as "I can manage what I feel" (a phrasing deliberately anchored on emotional regulation rather than the suppression of affects).

Observed Clinical Outcomes

At the end of the protocol, several significant improvements were observed. The frequency and intensity of traumatic intrusions decreased notably, with the patient reporting a reduction in nighttime flashbacks and less activation during social interactions. The impulsion phobias, though they have not completely disappeared, have lost their character of imminent certainty; the patient now recognizes them as fears rather than predictions. At the identity level, the gradual distinction between "what I did" and "who I am" allowed for the beginning of work on self-esteem, which had previously been blocked by shame.

The most tangible indicator of functional recovery remains the resumption of activity in a protected environment: the patient integrated an animal protection association within the framework of a supported employment scheme. This context proved particularly suited to his trajectory, as the connection with animals offers a structuring and non-threatening emotional relationship, allowing for the gradual rebuilding of an experience of trust and responsibility, without the complex interpersonal stakes that formed the core of his initial vulnerability.
For a patient whose mistrust of others was etiologically central, this non-human connection provided a valuable transitional space toward progressive social reintegration.

Work remains ongoing. Consolidating gains and monitoring the stability of integrated networks during regular re-evaluations constitute the priority axes for the continuation of care.

Discussion

This case illustrates several clinical principles developed in the literature on EMDR and psychosis. It shows first that the distinction between victim and perpetrator in the traumatic history of a single patient is not an obstacle to treatment, but a complexity to be explicitly conceptualized to avoid confusion of targets and associated cognitions. It then confirms the value of a graduated technical progression (CIPOS, EMD, EMDr) as an alternative to the immediate application of the standard protocol, allowing the intensity of reprocessing to be adapted to the patient's actual self-regulation capacity at each stage. Finally, it highlights the importance of treating the "trauma of psychosis" itself (here, the dismissal from ESAT and the confrontation with his own violence) as a therapeutic target in its own right, the non-treatment of which would have constituted a major maintaining factor.