Do You Need to Be "Stable" Before Starting EMDR?

Here is a common experience. Someone seeks help for childhood trauma and is told that before any trauma processing can begin, they must first complete a lengthy period of stabilisation work: learning to manage intense emotions, building coping skills, and strengthening relationships. Only then, once they are "ready", can the actual trauma work start. This phased approach has been standard advice in many guidelines for complex trauma, and the reasoning behind it is sensible on its face. Processing traumatic memories is demanding. Someone who struggles to regulate overwhelming emotion might be destabilised by it. Preparation first seems the safer order. But it carries an obvious cost, which is delay, sometimes of many months. And some researchers have argued that the evidence for requiring it was never as strong as its popularity suggested. A randomised trial by Nicole van Vliet and colleagues, published in *BJPsych Open* (2021), tested it properly. The researchers worked with adults who had PTSD following childhood sexual or physical abuse, and randomly assigned them to one of two treatments. One group received eight sessions of a skills-based preparation programme focused on emotion regulation and relationships, followed by sixteen sessions of EMDR. The other group received sixteen sessions of EMDR and nothing else first. The outcome was unambiguous. There were no significant differences between the two groups on any measure, either at the end of treatment or at follow-up. Across both groups, around 69% of participants no longer met the criteria for PTSD afterwards. The dropout figures deserve particular attention, because the safety argument for preparation predicts that going straight into trauma work should drive people out of therapy. It did not. Dropout was similar in both groups, and slightly lower in the EMDR-only condition. The authors conclude that the preparatory phase was unnecessary for this group. Two sensible caveats. This is one trial in one specific population, and it does not prove that preparation never helps anyone. Some people do need groundwork first, for reasons a good therapist will recognise. But if you have been told you must wait months before trauma processing can begin, this is worth raising rather than accepting as settled fact. Delay has costs of its own, and the evidence that it buys you anything is thinner than most people assume. *Source: van Vliet, N. I., Huntjens, R. J. C., van Dijk, M. K., Bachrach, N., Meewisse, M.-L., & de Jongh, A. (2021). Phase-based treatment versus immediate trauma-focused treatment for post-traumatic stress disorder due to childhood abuse: randomised clinical trial. BJPsych Open, 7(6), e211.*