From Caution to a Paradigm Shift
A now-established etiological link
For a long time, applying EMDR to psychotic patients was avoided out of concern for destabilization. This clinical caution has gradually given way as empirical evidence accumulated: the link between childhood trauma and the development of psychosis is now well established. Individuals who experienced three or more adverse childhood experiences (ACEs) face a risk of psychosis 2.8 to 4.6 times higher than the general population (Varese, 2012; Flinn, 2025).
At the neurobiological level, early trauma produces lasting changes: reduced grey matter in areas involved in emotional regulation, epigenetic modifications of genes implicated in the stress response (NR3C1, FKBP5), and dysregulation of the hypothalamic-pituitary-adrenal axis. These changes, though deep, appear reversible through appropriate psychotherapy — one of the most compelling arguments in favor of EMDR.
Reframing psychosis: from deficit to adaptive response
The Adaptive Information Processing (AIP) model offers a productive conceptual framework. Psychosis is no longer understood as an “irreversible break with reality,” but as an adaptive attempt by the nervous system to manage an overwhelming load of unintegrated traumatic material. This perspective converges with Liz Jing Zhang’s “Bold Hypothesis,” which proposes that psychosis results from a joint failure of the brain mechanisms regulating arousal and dream suppression — in essence, a “waking dream” in which traumatic content intrudes into lived reality.
Eleanor Longden, whose story has become a reference point in participatory psychiatry, illustrates this vision: her auditory hallucinations were not enemies to be eliminated, but meaningful responses to traumatic events, carrying insight into resolvable emotional difficulties. This reframing is the foundation of a genuine therapeutic alliance.
What the data show: safety and efficacy
Recent systematic reviews and randomized controlled trials confirm two essential points.
On safety: applying EMDR to psychotic patients produces no serious adverse events and no significant worsening of symptoms. Dropout rates are low (around 4% in some case series), reflecting strong acceptability — including among adolescents who are often reluctant to engage with conventional treatment. The feasibility trial by Varese et al. (2023) in early intervention services confirmed both the safety and feasibility of the EMDRp protocol in first-episode psychosis contexts.
On efficacy: EMDR shows significant reductions in post-traumatic stress symptoms, depression, anxiety, and paranoid and negative symptoms. Results remain more nuanced regarding hallucinations. Compared to trauma-focused cognitive behavioral therapy (TF-CBT), EMDR demonstrates equivalent efficacy with the added advantage of requiring fewer sessions and no homework, which improves therapeutic adherence.
Essential clinical adaptations
EMDR cannot be applied to psychosis directly. It requires structural adaptations.
Managing the window of tolerance is the central challenge. Psychotic patients oscillate between hyperactivation (paranoia, terrifying hallucinations) and hypoactivation (flat affect, catatonic withdrawal). The aim of the preparation phase is precisely to widen this window before any reprocessing begins. Practical tools — body grounding, gentle bilateral stimulation, EFT techniques, sensory objects — help maintain the patient within a tolerable zone of activation.
The Two-Method Protocol (Van den Berg) offers a framework organized around two complementary axes.
Method 1 targets etiological traumatic memories: the events that preceded or fed the emergence of the disorder, working back through chains of association to identify foundational negative beliefs (“I am in danger,” “I am bad”).
Method 2 addresses maintenance factors: first, the “trauma of psychosis” itself (involuntary hospitalization, forced sedation, the terror of first hallucinations); second, anxious flash-forwards — catastrophic representations of a dreaded future that sustain avoidance and social withdrawal.
Abbreviated assessment across phases 3 to 6 is often preferable for patients with limited insight. Rather than eliciting a formalized negative cognition, the therapist anchors on an isolated image (the face of the alien figure, a physical sensation) to initiate reprocessing without risking disorganization.
Early intervention as neuroprotection
Integrating EMDR from the first signs of psychosis — or even at the at-risk mental state (ARMS) stage — follows a neuroprotective logic. One feasibility study observed that among 11 at-risk participants treated with EMDR, only one (11%) transitioned to psychosis at 12 months. This preventive signal, while preliminary, warrants attention.
The R-TEP (Recent Traumatic Episode Protocol) and PRECI protocols allow rapid intervention following an acute episode to prevent the consolidation of new traumatic memories. Treating the “trauma of psychosis” early — the distress linked to the episode itself — substantially shapes the quality of subsequent functional recovery.
The specific challenges of first-episode psychosis (therapeutic window, adapted protocols, prevention of chronicity) are discussed in detail in a dedicated article, to which interested readers are referred. (link)
Toward an integrative and systemic approach
Therapeutic success extends beyond the EMDR protocol itself. It requires systemic mobilization: involving the family system as a regulatory resource between sessions, coordinating with the prescribing psychiatrist to adjust medication in line with reprocessing progress, and integrating occupational therapy for bodily and sensory grounding. Parents who are informed and supported become “guardians of integration,” able to reframe their child’s difficult behaviors as trauma responses rather than character flaws.
EMDR in psychosis is no longer an experimental undertaking.
It is progressively establishing itself as a validated therapeutic pillar, capable of addressing the neurobiological and traumatic roots of the most severe disorders – provided it is practiced with rigor, clinical flexibility, and constant attention to patient safety.
Clinical illustration
The theoretical principles developed in this article take on their full meaning through clinical reality. The following case illustrates the concrete implementation of the Two-Method Protocol with an adult patient diagnosed with paranoid schizophrenia, and shows how a traumatic conceptualization can guide treatment where medication alone had reached its limits.
This case is shared with the patient’s consent, and I am grateful for his trust and for his agreement to allow his experience to contribute to collective clinical reflection. His story, carefully anonymized, illustrates more vividly than any theoretical account what the AIP model makes it possible to understand — and to transform.
A young man followed at a community mental health center (CMP) was referred by his prescribing psychiatrist with a diagnosis of paranoid schizophrenia established at age 15. He presented at 23 in the context of a crisis: an escalation of aggressive behavior toward peers at his supported employment center (ESAT) had led to his dismissal. Despite a stabilized medication regimen, this proved insufficient to address persistent traumatic intrusions fueling his distress and behavioral instability.
The dismissal from the ESAT was itself a significant secondary traumatic experience: a brutal confrontation with his own perceived dangerousness, intense social shame, the loss of structuring reference points, and the rupture of a community connection that had constituted the core of his daily framework. This “trauma of psychosis” — in the sense that the illness and its consequences become a source of traumatization in their own right — had been layered over prior traumas without the possibility of elaboration.
Clinical conceptualization
Consistent with the AIP model, the presenting symptoms were conceptualized as memory fragments stored dysfunctionally in isolated neural networks, activated erratically by social environmental cues. The intrusions were organized across three complementary registers, directly articulated to the two axes of Van den Berg’s protocol:
1. Childhood traumatic memories (Method 1 targets: etiological past) Assaults experienced during childhood constituted the etiological basis of his chronic mistrust of others. These dysfunctional memory networks directly fed his paranoid interpretations of present social interactions.
2. Flashbacks of recent violent behavior (Method 2A targets: trauma of the illness) Visual and somatic intrusions linked to his own acts of violence at the ESAT generated intense guilt and profound identity confusion. This register raises a specific theoretical complexity: the patient was simultaneously a victim of trauma experienced and a perpetrator of violence enacted.
Within the AIP framework, the associated negative cognitions are organized differently depending on this polarity. As victim, they center on helplessness (“I am defenseless,” “I cannot protect myself”); as perpetrator, they mobilize shame and identity threat (“I am dangerous,” “I am bad”).
This dual register required particular clinical attention to avoid conflating targets with opposing dynamics.
3. Impulse phobias in the form of flash-forwards (Method 2B targets: maintenance factors) Intrusive images of future violent acts provoked a panic-like fear of losing control. Consistent with the theoretical framework, these anticipatory representations were treated as targets in their own right: their desensitization aimed to reduce their emotional credibility and the behavioral avoidance they generated.
EMDR treatment strategy
Extended preparation phase
Given the risks of exceeding the window of tolerance and psychotic decompensation, the preparation phase was considerably extended before any reprocessing was initiated. The central objective was to broaden the patient’s self-regulation capacity — that is, to strengthen his tolerance for emotional activation without tipping into dissociative or paranoid states.
The consultation space itself was established as a “Safe Place.” This adaptation, recommended for psychotic patients whose capacity for internal imagery is sometimes fragmented or intrusive, allows immediate grounding in present perceptual reality whenever instability increases. The concrete physical environment — the room, the blue curtain rail, the framed photograph of the sea, the therapist’s voice — became the support for safety rather than a mental representation potentially contaminated by psychotic material.
Psychoeducation was a central lever during this phase: explaining the functioning of traumatic memory, dissociation, and the link between experienced trauma and violent behavior allowed the patient to begin perceiving himself not as “fundamentally dangerous,” but as someone carrying understandable reactions to abnormal events.
Graduated technical progression: CIPOS –> EMD –> EMDr
Reprocessing followed a three-stage progression, with each transition governed by observable clinical indicators rather than a predetermined schedule.
Stage 1 – CIPOS (Constant Installation of Present Orientation and Safety)
All targets were initially approached through this protocol, designed to keep the patient within his window of tolerance by alternating constantly between target activation and return to present orientation. This framework prevented full immersion in assault imagery, which risked triggering a paranoid crisis or dissociation. Progression to the next stage was permitted when three criteria were consistently met across several consecutive sessions: no observable dissociation, maintained eye contact and dual attention, and spontaneous reduction in distress levels without therapist reframing. Session length was adapted to the patient’s capacities and reduced to 45 minutes (rather than the standard 90 minutes), at a frequency of one session per week.
Stage 2 – EMD (Eye Movement Desensitization)
Once dual attention capacity was sufficiently consolidated, reprocessing evolved toward EMD, allowing more targeted desensitization of images of both experienced and enacted violence, without aiming for full reconsolidation of the memory network. The transition to this stage 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 sessions as reported by his support network.
Stage 3 – EMDr (maximum reprocessing range retained)
Reprocessing progressed toward an expanded form allowing deeper desensitization. The full standard EMDR protocol — including formalized installation of a positive cognition and VoC verification — was not pursued, out of clinical caution regarding the risk of decompensation associated with active installation of positive beliefs in a patient whose self-regulation structures remained fragile. The retained objective was the transformation of intrusive memories into integrated episodes of personal history, losing their quality of immediate threat, without forcing a cognitive restructuring the nervous system was not yet in a position to consolidate durably.
Chronological ordering of targets
The targeting plan followed a progressive clinical hierarchy rather than a strict chronological order, prioritizing the most current and destabilizing targets first, then older traumatic networks:
- Violent events at the ESAT and the dismissal: secondary traumatization, shame, loss of structuring framework
- Flash-forwards: intrusive images of future violent acts, fear of losing control
- Current triggers: stressful social situations, peer interactions, residual hyperreactivity
- Childhood traumas: experienced assaults, the origin of beliefs centered on mistrust and helplessness
Processing current triggers and installing future templates
Following reprocessing of the past, current contextual triggers were addressed to reduce hyperreactivity in social situations. Finally, positive future scenarios (future templates) were constructed and installed to directly address impulse phobias. The patient was able to imagine himself facing a tense social situation and maintaining control of his reactions, progressively installing a positive belief of the form “I can manage what I feel” – a formulation deliberately anchored in emotional regulation rather than affect suppression.
Observed clinical evolution
At the conclusion of the protocol, several significant developments were observed. The frequency and intensity of traumatic intrusions decreased markedly, with the patient reporting a reduction in nocturnal flashbacks and reduced activation during social interactions. The impulse phobias, while not entirely resolved, lost their quality of imminent certainty: the patient now recognizes them as fears rather than predictions. At the identity level, a gradual distinction between “what I did” and “what I am” opened the possibility of work on self-esteem, which had previously been blocked by shame.
The most tangible indicator of functional recovery was the resumption of activity in a supported setting: the patient joined an animal welfare association through a supported employment program. This context proved particularly well suited to his trajectory. The relationship with animals offered a structuring and non-threatening affective connection, allowing a gradual rebuilding of experiences of trust and responsibility — without the complex interpersonal stakes that had been central to his initial vulnerability.
For a patient whose mistrust of others was etiologically central, this non-human bond constituted a valuable transitional space toward progressive social reintegration.
The work is ongoing. Consolidating gains and monitoring the stability of integrated networks during regular follow-up sessions remain the priority axes going forward.
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 within a single patient’s traumatic history is not an obstacle to treatment, but a complexity to be explicitly conceptualized in order to avoid conflating targets and their associated cognitions. It confirms, second, the value of a graduated technical progression (CIPOS, EMD, EMDr) as an alternative to immediate application of the standard protocol, allowing the intensity of reprocessing to be calibrated to the patient’s actual self-regulation capacity at each stage. It underscores, finally, the importance of treating the “trauma of psychosis” itself — here, the ESAT dismissal 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 maintenance factor.
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