🔄 A NECESSARY PARADIGM SHIFT
The treatment of adolescents experiencing psychosis or complex trauma has undergone a significant evolution. Historically, trauma-focused therapies were avoided in psychotic patients out of concern for destabilization or symptom exacerbation. Yet recent evidence demonstrates that EMDR is not only safe for these populations — it is necessary.
The etiological link between childhood trauma and the development of severe psychiatric disorders is now well established. Research shows a significantly elevated risk of psychosis following exposure to three or more traumatic events during childhood (Odds Ratio 2.8 to 4.6: individuals who experienced three or more ACEs – Adverse Childhood Experiences such as abuse or neglect – face a 2.8 to 4.6 times greater risk of developing psychosis compared to those without such exposure; Varese meta-analysis 2012, Flinn 2025).
🧠 NEUROBIOLOGICAL AND CLINICAL FOUNDATIONS
The link between childhood trauma and psychopathology
Adverse Childhood Experiences (ACEs) are directly correlated with the development of psychosis and complex disorders. Early exposure to stress and maltreatment produces tangible neurobiological changes:
Cerebral alterations: Reduced grey and white matter, particularly in areas involved in emotional regulation.
- Epigenetic mechanisms: Traumatic stress induces methylation of specific genes (NR3C1 and FKBP5), altering cortisol regulation and the stress response. These modifications may be reversible through psychotherapy.
- Exponential increase in risk: The accumulation of adversities increases the risk of mental disorders, suicide attempts, and chronic illness in adulthood.
Clinical specificities: complex PTSD and first-episode psychosis
In adolescents, complex trauma (C-PTSD) manifests as emotional dysregulation, a negative self-image, and relational difficulties — extending well beyond simple PTSD. For young people presenting with first-episode psychosis (FEP), a history of trauma is common and constitutes a critical therapeutic target for improving long-term prognosis.
✅ EFFICACY AND SAFETY OF EMDR
Safety and feasibility in psychosis
Systematic reviews and randomized controlled trials confirm that EMDR produces no serious adverse events and no worsening of psychotic symptoms. The approach is considered feasible and safe, even in patients presenting with an at-risk mental state or FEP.
Comparative clinical efficacy
EMDR demonstrates efficacy in reducing post-traumatic stress symptoms, depression, and anxiety, as well as a significant reduction in paranoid and negative symptoms in psychotic patients and traumatized adolescents. Results remain mixed regarding hallucinations (systematic reviews, 2024).
Several meta-analyses and comparative trials indicate that EMDR is as effective as trauma-focused cognitive behavioral therapy (TF-CBT). EMDR has the additional advantage of being more efficient (fewer sessions required to achieve remission) and requiring no homework (in vivo exposure or assignments), which facilitates adherence in adolescents or patients with concentration difficulties.
Some studies suggest that EMDR may promote an increase in left amygdala volume, correlated with clinical improvement – an effect not consistently observed with other therapies.
🔧 PROTOCOL ADAPTATIONS FOR ADOLESCENTS AND PSYCHOSIS
Applying EMDR to these populations requires specific adjustments to the standard protocol.
A. PHASE-BASED APPROACH AND STABILIZATION
For adolescents presenting with FEP or complex trauma, a phased approach is recommended. The preparation phase is essential for widening the emotional window of tolerance before processing traumatic memories.
1. The need for a phased and modular approach
For adolescents presenting with a complex clinical picture (C-PTSD or FEP), immediate processing of traumatic memories is often contraindicated. International guidelines (such as those from the ISTSS) advocate a sequential multimodal approach.
Modular structure: Specialized services, such as the Lancashire Traumatic Stress Service, use a multi-module model. Before addressing trauma (Module 5), the patient works through modules covering safety, stabilization, resource building, and sleep management.
Temporal adaptation: In studies of adolescent sexual assault survivors, the protocol is adjusted to include a reinforced preparation phase (for example, 4 stabilization sessions before 6 processing sessions), in order to establish a secure therapeutic relationship before any exposure work.
2. Managing the window of tolerance
The central objective of the preparation phase is to widen the adolescent’s emotional window of tolerance — the optimal activation zone in which the patient can process information without tipping into hyperactivation (panic, rage) or hypoactivation (dissociation, numbing).
Traumatized adolescents often shift rapidly between these states. In those with psychosis, stress can trigger an exacerbation of positive symptoms (voices, paranoia) through dopaminergic dysregulation and HPA axis disruption.
To keep the adolescent within this window, the therapist must use concrete and sometimes playful tools: a yoga ball for bouncing, stress balls or sticky balls, music, or drawing. Body-based grounding techniques are essential for returning the patient to the present when dissociation occurs.
3. Resource-building techniques
Before confronting painful memories, it is essential to equip the adolescent with solid internal and external resources.
Safe Place and Protective Screen: The standard Safe Place installation is supplemented with distancing techniques such as imagining a protective screen or a remote control, giving the patient a sense of control over intrusive images.
Future Self: For depressed or hopeless adolescents, visualizing a positive future (imagining oneself in 5 or 10 years having achieved a meaningful goal) is a powerful motivator. It provides a rationale for difficult work on the past as a pathway toward a desired future.
Psychoeducation: Explaining how the brain functions, what dissociation is, and the link between trauma and symptoms (including voices) helps the adolescent understand that they are not “crazy” or “broken,” but that they are having normal reactions to abnormal events.
4. Positive Affect Tolerance (PAT) protocol
A significant innovation for patients who have experienced emotional neglect or attachment difficulties is the PAT (Positive Affect Tolerance) protocol – Leeds, A. M. (2009).
The challenge: In survivors of early neglect, shared positive affective states (warmth, affection, compliments) can paradoxically trigger anxiety, avoidance, or depersonalization, because these neural circuits have become associated with absence or danger.
The intervention: Rather than immediately processing traumas, PAT focuses on the patient’s current capacity to tolerate positive interactions. The patient learns to accept small moments of positive affect (a compliment from the therapist) through behavioral exercises (eye contact, breathing) paired with short bilateral stimulation.
Objective: This work restructures relational capacity and prepares the nervous system to receive care — often a prerequisite for heavier trauma processing to be tolerable.
5. Involving the family system as a resource
Stabilization extends beyond the individual. Parental or caregiver involvement is often necessary to create a safe environment.
Parents are integrated as “guardians of integration,” supporting the adolescent in regulating emotions between sessions. The work typically includes separate sessions with parents to reframe the adolescent’s “difficult” behaviors as trauma responses, reducing blame and restoring the attachment bond.
B. THE TWO-METHOD PROTOCOL (VAN DEN BERG)
In the context of psychosis, the adapted protocol conceptualizes and addresses the disorder across two complementary axes.
The importance of stabilization
The stabilization phase is indispensable before using the Two-Method Protocol. It creates a safe environment that prevents decompensation, widens the patient’s window of tolerance so that emotions can be managed without extreme reactions, and prepares for processing through the learning of self-soothing techniques. This stage also fosters a solid therapeutic alliance and may involve the family in supporting the adolescent before traumatic memories are addressed.
METHOD 1: PROCESSING ETIOLOGICAL TRAUMATIC MEMORIES (THE PAST)
This method focuses on the patient’s life history to identify and process the events that caused or triggered the psychotic disorder.
Direct link (etiology): The aim is to target the negative experiences that directly preceded the onset of symptoms or that are thematically linked to the content of delusions and hallucinations.
Example: For an adolescent convinced they are being watched (paranoia), Method 1 will target specific memories of bullying or assault that initially established this sense of insecurity.
Indirect link (beliefs): It also targets memories that formed negative core beliefs about the self (“I am weak,” “I am bad”) that render the adolescent vulnerable to stress and psychosis. The therapist asks: “What events led you to believe this?”
Target identification: A timeline is often used to identify significant events (losses, abuse, neglect), and the most disturbing memories are selected for processing with the standard EMDR protocol.
METHOD 2: PROCESSING MAINTENANCE FACTORS AND THE ILLNESS (THE PRESENT AND FUTURE)
This method is essential because psychosis itself becomes a source of trauma and anxiety that maintains the disorder. It addresses two main dimensions:
A. The traumatizing aspects of the illness (the “trauma of psychosis”)
The experience of a first psychotic episode is often terrifying. Treatment aims to desensitize these recent memories in order to reduce post-psychotic stress.
Typical targets: Involuntary hospitalization, seclusion, the arrival of police, forced sedation, or the intense fear experienced during first hallucinations.
R-TEP Protocol: For these recent events, specific protocols such as R-TEP (Recent Traumatic Episode Protocol-Shapiro & Laub, 2015) can be used to prevent the consolidation of these new traumas.
B. Future-oriented fears and current symptoms (flash-forwards)
Anticipatory anxiety plays a major role in maintaining psychosis (avoidance, social withdrawal).
Targeting flash-forwards: These are mental representations of dreaded future catastrophes (“I will be permanently unwell,” “I will be attacked again”). In EMDR, these future images are processed as though they were past traumatic memories. Once desensitized, the catastrophic scenario loses its emotional credibility, reducing avoidance.
Processing symptoms (“icons”): The mental image of a hallucinatory voice or a physical sensation associated with a delusion can be targeted directly. These symptoms are treated as “icons” — fragments of unprocessed memory networks. By focusing on the image of the voice or the sensation, the brain can trace back toward the underlying traumatic memories.
PROTOCOL OVERVIEW
The phased approach is sequential but dynamic: stabilization provides the safety equipment the adolescent needs to venture, through Method 1, into their traumatic past, and through Method 2, to confront the terror of their illness and their future.
| Protocol | Indication | Key Phases | Advantage for adolescents/FEP |
| Standard EMDR | Simple PTSD | 8 phases | Effective, rapid |
| Two Methods (Van den Berg) | Psychosis | Method 1 (past), Method 2 (present/future) | Addresses roots and maintenance |
| R-TEP | Recent events (FEP) | Immediate PODs* | Empêche consolidation trauma |
| PAT | Neglect/attachment | Positive affect tolerance + BLS | Prepares relational capacity |
| Phases (ISTSS) | C-PTSD | Stabilization → Processing | Window of tolerance safety |
*PODs : points of disturbance
⚡ EARLY INTERVENTION
Rapid integration of EMDR following a critical incident or at the first signs of psychosis is encouraged to prevent the chronicity of disorders and support functional recovery.
1. The window of opportunity: preventing chronicity and transition
Early intervention rests on the recognition that untreated trauma has a deleterious neurodevelopmental impact on adolescents, increasing the risk of comorbidities and reducing life expectancy.
At-risk mental states (ARMS): Research is exploring the use of EMDR in individuals presenting with an at-risk mental state to prevent transition to full first-episode psychosis. A feasibility study found that among 11 at-risk participants treated with EMDR, only one (11%) transitioned to psychosis at 12 months, suggesting significant preventive potential — though recruitment and retention challenges remain.
Neuroprotection: Early trauma-centered care aims to prevent disorders from becoming entrenched and from disrupting the adolescent’s personality development and neurodevelopment.
2. Treating the “trauma of psychosis” (secondary traumatization)
An essential component of early intervention is the immediate processing of traumatic events linked to the emergence of the illness itself (post-psychotic stress syndrome).
The first-episode experience: The first psychotic episode is often terrifying. Specific targets for early processing include involuntary hospitalization, police involvement, seclusion, or the distress caused by threatening delusions and voices.
Impact on recovery: If this “trauma of psychosis” is left untreated, it can obstruct social recovery (return to school or work) and psychological recovery. Early intervention reduces post-traumatic distress and supports faster functional resumption.
3. Specific emergency protocols (R-TEP and PRECI)
For rapid intervention, EMDR protocols adapted to recent events are preferred over the longer standard protocol.
R-TEP (Recent Traumatic Episode Protocol): Particularly suited to early intervention services, this protocol allows intervention shortly after the acute episode (once the patient is stabilized but still distressed by the memories) to prevent traumatic memory consolidation.
Example: A case study illustrates the use of R-TEP to address points of disturbance (PODs) linked to recent sexual and suicidal delusions. Treatment allowed a shift in cognitions from “I am mad” to “That was just an episode,” reducing internalized stigma.
PRECI Protocol – Jarero & Artigas, 2012 : Used following critical incidents (such as disasters or sudden violent events), this protocol allows significant reduction of post-traumatic stress symptoms within a few sessions, even when stressors (such as aftershocks, or by analogy, residual symptoms) persist.
4. Safety and feasibility in early intervention services
Integration of EMDR into specialized first-episode psychosis services (Early Intervention Services — EIS) is now supported by clinical trials.
Trial results (EMDRp): The feasibility trial by Varese et al. (2023) in early intervention services demonstrated that EMDR for psychosis (EMDRp) is safe and feasible. At 6 months, promising efficacy signals were observed regarding psychotic symptom severity, subjective recovery, and traumatic symptoms.
Reduction of suicide risk: There is an elevated risk of suicide among individuals with FEP and a trauma history. Early EMDR intervention targeting memories of the episode and depressive symptoms is a key strategy for mitigating this risk.
Early intervention aims not only to address childhood traumas (the past), but to use adapted protocols (such as R-TEP) to immediately treat the traumatic impact of the first psychotic episode — preventing it from becoming a maintenance factor and obstructing the young adult’s development.
🏆 EMDR AS A VALIDATED AND INTEGRATIVE THERAPEUTIC PILLAR
Current evidence positions EMDR therapy no longer as an experimental intervention, but as a treatment of choice, firmly grounded in international public health recommendations.
International institutional validation
The legitimacy of EMDR is now well established, validated by the highest health authorities for the treatment of PTSD in children, adolescents, and adults.
The World Health Organization (WHO) has recommended it since 2013 as one of only two advanced psychotherapies for stress-related disorders in young people. Reference bodies including the National Institute for Health and Care Excellence (NICE) in the United Kingdom, INSERM and the Haute Autorité de Santé (HAS) in France, and the American Psychiatric Association classify EMDR at the highest level of evidence (Grade A or equivalent), often on a par with trauma-focused cognitive behavioral therapies (TF-CBT).
Safety and feasibility: the end of a myth
The application of EMDR to adolescents with FEP or complex trauma was long held back by concerns about destabilization. Recent research formally refutes this assumption.
Systematic reviews of randomized trials, including patients with established psychosis, report no serious adverse events (such as suicide or increased hospitalization) attributable to the therapy. EMDR is considered safe and feasible even in early intervention services. It shows low dropout rates (around 4% in some case series of abused adolescents), reflecting strong acceptability among young people who are often reluctant to engage with conventional treatment.
Clinical efficacy: broad symptom reduction
The impact of EMDR in adolescents extends well beyond simple post-traumatic stress symptom reduction to address the broader complex clinical picture.
EMDR significantly reduces negative psychotic symptoms, paranoid thinking, and distress associated with auditory hallucinations, by processing the memories that fuel these phenomena. In adolescents with complex trauma, EMDR produces a notable decrease in depression, anxiety, insomnia, and risk behaviors (substance use), while significantly improving quality of life, family cohesion, and emotional regulation.
Addressing the roots: neurobiological and epigenetic mechanisms
EMDR is distinguished by its capacity to act on the neurobiological roots of the disorder, consistent with the AIP model.
Rather than simply managing symptoms, EMDR appears to support healing of dysfunctional memory networks. Studies suggest it may induce volumetric changes in the amygdala (the fear center) and modulate the stress axis. Psychotherapy – EMDR in particular — is envisioned as a form of environmental regulation capable of positively influencing the epigenetic marks left by trauma, working on the reversibility of the biological alterations associated with early stress.
Integrating EMDR into the care pathway of vulnerable adolescents constitutes a neuroprotective and restorative approach. It makes it possible to prevent the chronicity of severe psychiatric disorders by transforming traumatic experience – often at the origin of psychic disorganization – into an integrated and more settled life narrative.
📚 REFERENCES
Foundational references
Felitti, V. J., Anda, R. F., Nordenberg, D., Williamson, D. F., Spitz, A. M., Edwards, V., Koss, M. P., & Marks, J. S. (1998). Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. American Journal of Preventive Medicine, 14(4), 245-258.
Shapiro, F. (2018). Eye movement desensitization and reprocessing (EMDR) therapy (3rd ed.). Guilford Press.
Van den Berg, D. P. G., de Bont, P., van der Vleumen, M., de Ronde, S., de Weert, M. C., Jongh, A., … & van Minnen, A. (2014). Eye movement desensitization and reprocessing (EMDR) for treating psychosis: A conceptualisation and case illustration. Journal of EMDR Practice and Research, 8(3), 146-156.
Recent publications (2024-2026)
Varese, F., Sellwood, W., Aseem, S., Awenat, Y., Bird, J. C., Bhutani, S., … & Bentall, R. P. (2024). Trauma-focused therapy in early psychosis: Results of a feasibility randomized controlled trial of EMDR for psychosis (EMDRp) in early intervention settings. Psychological Medicine, 54(10), 1-12.
Jankowski, S. E., et al. (2024). EMDR-Teens-cPTSD: Efficacy of eye movement desensitization and reprocessing in adolescents with complex PTSD secondary to childhood abuse: A case series. Healthcare, 12(19), 1993.
Ward-Brown, J., et al. (2025). Trauma-focused treatment in early and lifetime psychosis: A scoping review. Schizophrenia Bulletin.
Hu, J., et al. (2025). Efficacité des interventions psychologiques pour le TSPT-C chez les adultes exposés à des traumatismes complexes : Méta-analyse de 27 ECR. Journal of Traumatic Stress.
Flinn, J., et al. (2025). Cumulative exposure to childhood adversity and risk of adult psychotic disorder: Dose-response meta-analysis. Schizophrenia Research, 265, 1-10.
Strelchuk, D., Wiles, N., Turner, K. M., Derrick, C., & Zammit, S. (2020). Feasibility study of eye movement desensitisation and reprocessing (EMDR) in people with an at-risk mental state (ARMS) for psychosis: Study protocol. BMJ Open, 10(9), e038620.
Chen, Y., et al. (2025). EMDR versus waiting list in individuals at clinical high risk (CHR) for psychosis: A randomized controlled trial. Schizophrenia Research, 266, 45-52.
Bayhan, S., Tarquinio, C., Rydberg, J. A., & Korkmazlar, Ü. (2026). Group EMDR therapy for disaster-affected adolescents: Effects on PTSD, depression, anxiety, and resilience. Frontiers in Psychiatry, 16, Article 1660046.
Power, K. G., et al. (2018/2024 reprint). Comparing the effectiveness of EMDR and TF-CBT for children and adolescents: A meta-analysis. Journal of Child & Adolescent Trauma, 11(4), 345-356.
Hardy, A., et al. (2023). Trauma therapies in psychosis: Emerging evidence for EMDR. British Journal of Psychiatry Open, 9(6).
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