Complex Trauma and EMDR: Why Treatment May Need to Look Different

At a glance

A long or repeated trauma history can make treatment planning more complicated, but it does not by itself prove that EMDR is unsuitable. Nor does it establish that everyone must complete a lengthy separate stabilization program before trauma-focused work. A randomized trial of adults with PTSD related to childhood abuse found no added overall benefit from a mandatory skills-training phase before EMDR compared with EMDR without that extra phase. ^[1]

The important distinction is between individualized preparation, which remains part of responsible care, and a fixed additional sequence required of every person with a complex history.

Complexity is a description, not a complete plan

In everyday conversation, “complex trauma” may refer to repeated experiences, relationship-based harm, difficult current circumstances, or a broad pattern of symptoms. Those descriptions can overlap without telling the clinician exactly what to do next. The treatment plan still needs a specific account of the person's present difficulties and goals.

Our editorial recommendation is to move from the label to a shared formulation: What is troubling the person now? Which experiences may be relevant? What is ongoing rather than remembered? What additional needs require care? What would make the next stage workable?

A detailed history is useful only if it helps organize treatment. It should not become a requirement to recount every painful experience before receiving any practical support.

What the sequencing study actually tested

The van Vliet trial compared eight sessions of Skills Training in Affective and Interpersonal Regulation followed by sixteen EMDR sessions with sixteen EMDR sessions without that preceding skills program. The study involved 121 adults. Results did not show significant differences between conditions at the principal post-treatment and follow-up comparisons. ^[1]

This does not mean the comparison group received no assessment, no therapeutic relationship, or no standard EMDR preparation. It also does not mean the study covered every high-risk circumstance or every dissociative disorder. Its contribution is to question an automatic extra phase for all similar clients, not to abolish clinical judgment.

Two unhelpful extremes

One extreme says, “Your history is too complicated, so we cannot approach the memories.” The other says, “You have trauma, so we should begin intensive processing immediately.” Both allow a general rule to replace an individual assessment.

A more useful conversation asks what makes a particular next step appropriate. Preparation should have a purpose that the client can understand. For example, the clinician might explain how they will maintain communication, recognize when the client is becoming disconnected, or coordinate care for a current difficulty.

Equally, progress should not depend on achieving perfect calm. The goal of treatment planning is not to create a person who never experiences distress. It is to establish a sufficiently workable plan for the care being proposed.

Dissociation deserves assessment, not automatic exclusion

A meta-analysis of PTSD psychotherapy found that pretreatment dissociation was not, overall, associated with poorer treatment outcomes. That result challenges a blanket assumption that dissociation makes trauma-focused work ineffective. The review covered mixed therapies and does not settle treatment for every dissociative presentation. ^[2]

For the consultation, we suggest asking what the clinician means by dissociation and how it affects the plan. Feeling detached, losing track of the room, and having significant gaps in awareness are not details to collapse into one undifferentiated label. The person deserves an explanation that connects observed needs with specific clinical decisions.

Current conditions are not merely old memories

Consider a hypothetical client who has painful childhood experiences and is also living with present coercion. It would be a mistake to treat every sense of danger as an outdated alarm. A formulation should distinguish a remembered threat from an ongoing one.

This is a practical and ethical recommendation, not a finding that one EMDR study can establish for every household. Treatment should not ask a person to replace accurate concerns with reassuring statements. Support for current safety, access to resources, and coordination with other services may belong alongside psychological care.

The same principle applies to housing instability, physical illness, or conflict at work. Processing a memory does not remove the surrounding conditions that may still need attention.

Measure change beyond one completed target

The standard EMDR framework includes review over time rather than treating a single target as the entire treatment. ^[3]

For a complex presentation, our recommendation is to track a small set of meaningful outcomes across the broader plan. A hypothetical client might notice improved sleep while still struggling with boundaries. Another may feel less shame about one experience but remain easily overwhelmed by current demands. These observations can guide the next conversation without erasing genuine progress.

A completed target should not be used to declare the whole person recovered, and a remaining difficulty should not be used to declare the entire treatment a failure.

Questions that make preparation concrete

“What are we preparing for, how will we know the preparation is sufficient, and when will we review that decision?”

These questions can protect against both rushing and indefinite delay. They invite the therapist to describe a reasoned plan rather than relying on the word “complex” as an explanation by itself.

Bottom line

Complex trauma calls for more precise thinking, not a rigid assumption about speed. EMDR may belong in a broader, individualized plan. Research supports questioning automatic delays, while careful assessment, consent, current safety, and ongoing review remain central to the decision about what happens next.