EMDR for trauma in psychosis: what the research shows

EMDR — Eye Movement Desensitisation and Reprocessing — is a trauma-focused therapy that looked unusual when Francine Shapiro first described it in 1989. Patients are asked to recall a traumatic memory while their eyes follow the therapist's fingers moving back and forth, or while feeling alternating taps on the knees, or hearing alternating tones in headphones. After several decades of research, EMDR is now recommended by major guidelines including the WHO and NICE for PTSD, and a growing body of work suggests it can be safely and effectively used in people with psychosis.

How EMDR works (or is thought to work)

The mechanism is still being studied. The leading theory, the Adaptive Information Processing model, holds that traumatic memories get "stuck" in raw, unprocessed form, and that bilateral stimulation while attending to the memory facilitates the brain's normal processing — similar to what may happen during REM sleep. The end result is that the memory is still accessible but no longer triggers the same emotional and physiological storm.

What a session looks like

Standard EMDR has eight phases. In practice, sessions look like this:

1. The therapist and client identify a target memory.
2. The client identifies a negative belief associated with the memory ("I am powerless") and a desired positive belief ("I have choice now").
3. The client briefly brings up the memory and the negative belief while the therapist provides bilateral stimulation (eye movements, tapping, or tones) for 30 seconds or so.
4. The client notices what comes up — thoughts, emotions, body sensations, images.
5. The cycle repeats with whatever emerged, gradually moving toward less distress.
6. The session ends with the positive belief paired with the memory.

Sessions are typically 60–90 minutes and a course of treatment is often 8–16 sessions, sometimes more for complex trauma.

The evidence in psychosis

The breakthrough study was van den Berg and colleagues' randomised controlled trial in JAMA Psychiatry (2015), which enrolled 155 patients with psychosis and PTSD. EMDR (and prolonged exposure) reduced PTSD symptoms substantially compared to waitlist. Importantly, no increase in psychotic symptoms or relapse rates was observed — addressing the long-standing fear that trauma processing would destabilise psychosis. Subsequent work has replicated these findings, and current Dutch and UK guidelines explicitly recommend trauma-focused therapy, including EMDR, for people with psychosis and PTSD.

Why people with psychosis often have unprocessed trauma

Multiple converging factors:

• Higher rates of childhood adversity in people who later develop psychosis
• The traumatic nature of psychotic episodes themselves — paranoid certainty, terrifying voices, loss of reality testing
• Hospital trauma — restraint, seclusion, involuntary admission
• Stigma and social losses
• Historical reluctance to offer trauma therapy to this group, leaving years of untreated PTSD

How EMDR is adapted for psychosis

• Strong stabilisation phase — grounding skills, "container" exercises for distressing material between sessions
• Coordination with the prescriber and treatment team
• Shorter sets of bilateral stimulation (sometimes), with frequent grounding
• Eyes-open, externally anchored grounding before and after
• Processing voices that arise as part of the experience, rather than ignoring or pathologising them

What to expect emotionally

EMDR can be intense. Memories that have been pushed away surface clearly, sometimes with fresh emotional charge. Clients often feel exhausted after a session. Most also describe a clear shift — the memory becomes more like a story than a re-experience. Disturbances usually fade between sessions; if they don't, the pace slows.

Who tends to benefit

• People with clear PTSD symptoms — intrusive memories, nightmares, hypervigilance, avoidance
• People whose voices echo perpetrators or contain trauma fragments
• People whose paranoia is rooted in past harm
• People who have struggled with verbal-only therapies

Who might want a different approach

• People in acute, unstabilised psychosis
• People with severe dissociation that hasn't been addressed
• People without housing, safety, or stable supports
• People who actively prefer other models such as prolonged exposure

How to find an EMDR therapist

The EMDR International Association maintains a clinician directory. Look for therapists with both EMDR certification and experience working with psychosis. Some early intervention services now have EMDR-trained clinicians on staff.

Practical questions to ask

• Are you trained in working with people who experience psychosis?
• How will we coordinate with my psychiatrist?
• What stabilisation work do we need first?
• How will we handle voices that come up during a session?
• What are signs we should slow down?

The bigger picture

For people with psychosis and PTSD, EMDR is no longer experimental. It is a recognised, evidence-supported option that — done well — can reduce the persistent influence of trauma on present-day life. Not everyone needs it. Not everyone is ready for it. But for those who are, it can lift a weight that medication alone cannot reach.

This article is for educational purposes only and is not medical advice, diagnosis, or treatment. Always consult a qualified mental health professional. If you or someone you know is in crisis, call or text 988 in the US, or your local emergency number.