EMDR Therapy Quarterly

Introduction

EMDR delivered from a medical model has been criticised for locating the problem within the person. There is a focus on the internal world of ‘victims,’ and the oppression they may have experienced is neglected (e.g., Afuape, 2022). EMDR research literature usually employs medicalised language to describe people; for example, “subjects who were suffering from posttraumatic stress disorders” (Shapiro, 1996, p. 209). Participants are regarded to hold ‘symptoms’ within them; for example, “Participants demonstrated statistically significant improvement in levels of anxiety, depression, overall functioning and PTSD” (Schwarz et al., 2020, p. 9). The use of medicalised language and focus on diagnosis and symptoms can overshadow the experiences the participants had that led to their being distressed, with the type of traumatic events experienced sometimes not being mentioned at all (e.g., Wood et al., 2018). This can serve to decontextualise the trauma-related distress, and so the person is regarded to hold the problem, rather than the problem being in the experiences they endured. This decontextualisation within the research literature is especially striking as one of the core functions of EMDR is to contextualise the trauma memory and create links with the individual’s autobiographical memories and other knowledge (Shapiro, 2018).

Also of concern is the tendency to export psychological therapies, including EMDR, developed in the West and assume they apply equally to different cultures around the world. Summerfield (2012) argued that the Western psychiatric model has a fundamental assumption that ‘mental illness’ can be regarded as outside of society and culture. Traditional cultural and community approaches to healing after trauma may be disregarded, with Western psychological models being privileged. This has been referred to as medical or psychological imperialism.

EMDR and the AIP Model

EMDR is a trauma-focused therapy involving processing unresolved trauma memory networks to enable people to leave these memories in the past and move forward into the present (Shapiro, 2018). EMDR started with a focus on posttraumatic stress – i.e. flashbacks, nightmares and hypervigilance. Now, EMDR is more widely applied to different forms of trauma-related distress; for example, depression (Wood et al., 2018), psychosis (Marlow et al., 2024), ongoing pain (Tesarz et al., 2014) and many more. Central to the ability of EMDR to be applied to these different experiences is adaptive information processing (Shapiro, 2007).

The AIP model describes humans as active meaning-makers, attempting to make sense of the world and events that occur. As such, this paper embraces a broad definition of trauma, incorporating the recurrent, adverse experiences embedded in people’s relationships, lives, and structures of the social world rather than merely referring to isolated and extreme events. Humans try to generate adaptive explanations of such experiences, which offer some form of control and ideas for the way forward and how to cope. However, the usual functioning of the AIP model can be overwhelmed by the threat of a traumatic event. Traumatic and adverse life experiences are, by their very nature, frightening and overwhelming. When a trauma occurs, the processing of that event differs from how usual everyday memories are formed. This gives rise to a trauma memory, or a trauma memory network if there have been multiple linked events.

Due to attentional and dissociative processes, the trauma memory may be decontextualised, lacking connections with autobiographical and other memories holding relevant information – i.e., they are not ‘time-stamped.’ Time-stamping of memories refers to the sense of how old a memory is from how old it feels when it is recalled. We have to ‘cast our minds back’ to retrieve older memories. As trauma memories are not time-stamped, they feel relevant now – i.e., memories in their unprocessed form are relived rather than remembered. This underlines why trauma survivors often say it feels like it happened yesterday.

According to the AIP model, another aspect of trauma memories being unresolved is the meaning the individual has made of what happened. This is the concern the individual has about what it might say about them as a person, that the trauma happened to them. For example, if someone has been assaulted, they may worry that they did not defend themselves, and conclude “I am weak”. Research has shown that women who are sexually assaulted may feel that “I’m to blame” or “I’m disgusting” (Colbert, 2024). This can be thought of as the trauma wound or, in EMDR terminology, the negative cognition. As the trauma memory is not time-stamped, this worry about the self continually feels relevant. The individual may carry this concern into each new situation in life.

It has been well established that some people experience life-threatening and other adverse events and do not go on to develop troubling forms of trauma-related distress (Bonanno, 2004). It may be that they were able to process the event at the time. For a child, perhaps they had a secure attachment figure who helped them make sense of what was happening. Maybe the event occurred in a community, and members of the community came together to work through what happened and make some sort of sense of it (Schultz et al., 2016). However, for others, dissociation, cutting off from the unbearable trauma memory (Dillon et al., 2014), or actively avoiding (Hayes et al., 1996) the painful memory may have interfered with processing. In EMDR therapy, the client and practitioner together attempt to create an environment for the mind to do the processing that was not able to occur at the time of the trauma. The trauma memory network is activated and brought into consciousness, and then the memory can be worked through and reprocessed. This involves connections being developed between the formerly decontextualised memory and other memories and information the individual holds. Through these connections, the memory takes its place in the individual’s life story. The memory becomes time-stamped and so feels like it belongs in the past. The trauma wound is updated with other relevant knowledge and memories; for example, I am safe now, I can protect myself, I am strong, I am good enough. In EMDR terminology, this is the positive cognition.

The PTMF

The Power, Threat, Meaning Framework (Johnstone & Boyle, 2018) argues that a narrative understanding, a story about what has happened to you, may replace ideas about what is wrong with you – i.e., it can replace psychiatric diagnosis. In the PTMF, it is proposed that emotional and psychological distress are understandable consequences of the experience of adverse life events. The PTMF focuses upon adverse life events arising from misuses of power, such as the misuse of power by force (e.g., assault, intimate partner violence), the misuse of economic power (resulting in, e.g., poverty, bankruptcy), and the misuse of ideological power (e.g., patriarchy, racism) leading to threats to the individual, family or community. As humans, we attempt to make sense of these events and form a narrative of what happened and what it means to, and about, us.

The PTMF reviews a wide range of evidence demonstrating that there is very little coherent, consistent evidence of any role of illness in emotional distress, suggesting that emotional and behavioural difficulties should be understood through frameworks other than bodily or brain dysfunction. Furthermore, positing an illness disrupts the link between the adverse events and the subsequent distress. For example, if someone is made redundant, they experience low mood. It is not necessary to claim that an illness commences at some point. The experience of redundancy itself, and what that means in the individual’s life, can account for the low mood. They do not also need to have an illness, a brain dysfunction or a genetic vulnerability. If they experience a traumatic event and have nightmares, these nightmares may be the mind’s attempt to process and integrate the unbearable traumatic material. This may represent an ‘ordered’ response to trauma, rather than a ‘disordered’ response – i.e. posttraumatic stress ‘disorder’.

The PTMF authors created a guided discussion tool that may help people apply these concepts to their own experiences, to move beyond diagnosis and develop a narrative understanding. The guided discussion poses six questions:

1. ‘What has happened to you?’ (How is Power operating in your life?)
2. ‘How did it affect you?’ (What kind of Threats does this pose?)
3. ‘What sense did you make of it?’ (What is the Meaning of these situations and experiences to you?)
4. ‘What did you have to do to survive?’ (What kinds of Threat Response are you using?)
5. ‘What are your strengths?’ (What access to Power resources do you have?)
6. ‘What is your story?’ (How does all this fit together?)
    

The misuse of power may take different forms. Widely understood might be the misuse of interpersonal power; for example, bullying, coercive control, overly critical parenting or neglect. There are known instances of the misuse of legal power, such as in some cases of stop-and-search (Bowling & Phillips, 2007), and lesbian mothers having children removed as late as the 1990s (Falk, 2021). The misuse of social or cultural capital may lead to some groups feeling like they do not fit in a professional workspace or being passed over for a promotion due to lacking social connections. The misuse of ideological power may be harder to notice. This is when powerful groups propose and promote ideas about less powerful groups in order to maintain the status quo and retain their power. Patriarchy, racism, homophobia and stigma against people with mental health concerns can be understood in this light.

The misuse of power leads to a wide range of threats to human safety, survival, and sense of self. Such threats may include the loss of loved ones or people one depends on. Being undermined or invalidated through criticism, hostility, humiliation, and having other people’s views or meanings imposed on you may threaten a person’s sense of self or safety. Intergenerational trauma may be passed down through parents and other relatives, which may be misinterpreted as a genetic influence. Poverty leads to a range of threats to the individual, including lack of housing, being unable to meet basic physical needs or accessing basic services.

The sense people make of these threats will be influenced by their context, their culture and community, and the narratives available for them to draw upon. One powerful example is the concept of the ‘symptom pool’ (Shorter, 1992), which shows how distress may be instantiated in different ‘symptoms’ at varying points in history. For example, hysteria in the 19th century or anorexia in the 1990s.

The PTMF proposes that threat responses are conscious or unconscious attempts to cope with the negative operations of power and what the individual needs to do to survive. This offers an alternative understanding of such experiences rather than merely symptoms of a mental illness. People may give up, exhibiting signs of ‘learned helplessness,’ apathy or low mood. Others may become hypervigilant, alert for future threats. They may cut off from unbearable psychic material through a process of dissociation and develop voices or unusual, unshared beliefs; for example, by becoming distrustful, suspicious or even paranoid (Colbert, 2024). Some may restrict their eating in an attempt to gain some form of control, while others might turn to alcohol, drugs or self-harm as ways to numb the pain.

In developing an understanding of how people respond to the misuse of power and the threat response they use to survive, the PTMF also considers strengths – the power resources someone might have access to. For example, an individual may be part of a community that offers a different understanding of their experiences, such as the Hearing Voices Network, or they may have financial resources, allowing them to pursue a legal response to the misuse of power by taking an employer to a tribunal.

Putting all these aspects of the PTMF together into a story (narrative), conveys the individual’s meaning-making and may offer opportunities for change, new ways to cope or new ideas to address the situation. Several studies have explored PTMF-informed narrative formation, including with psychosis (Ball et al., 2023), multiple complex needs, including homelessness, substance misuse, offending behaviour and emotional distress (Sapsford et al., 2023), climate-related distress (Barnwell et al., 2020), prison-based violence (Gallagher et al., 2023), school refusal (Devenney, 2021) and the experiences of mental health in caregivers (Paradiso & Quinlan, 2021).

According to the authors, a key purpose of the framework is to restore the links between threats and threat responses as an alternative to the diagnostic lens, which obscures them. This can also be thought of as ‘re-storying,’ reflecting the central role of the narrative. As already discussed, the medical model inserts an illness or disorder that obscures the links between what has happened to the individual and how they respond; for example, someone may come to believe that their low mood is due to clinical depression rather than being an understandable response to being made redundant and the threats to their status and lifestyle. Considering the elements of the PTMF may facilitate the reconnection of such meaning that has been lost.

At one level, this may be considered common sense. There are widely available narratives in the developed world that certain life experiences are challenging, and people may struggle. It is commonly accepted that people living in poverty are more likely to feel miserable, potentially leading to depression. Similarly, it is recognised that abuse and trauma make it more likely that people will dissociate, hear voices or experience low mood. This reflects the public belief that ‘bad things happen and can drive you crazy.’ (Haslam & Read, 2004).

There are, however, several factors that combine to conceal these links from the individual and from society more broadly. The threat or the operation of power may be less obvious because it takes a subtle, cumulative and/or socially acceptable form; for example, stop-and-search, social media influencers offering young girls different ways to lose weight and critical parenting. It may be hard to consider critical parenting. People may want to believe, “My childhood was happy; my parents did the best that they could,” when overly critical parenting can lead to overwhelming and humiliating experiences.

With childhood experiences in particular, the threat may be distant in time. It may be hard to recall, or people may not remember how they felt, even though the experience significantly impacted them. Threats may have been numerous, and the responses many and varied, causing the connections between them to become confused and obscured. Research has shown that people who have experienced one trauma are more likely to experience subsequent traumas (Benjet et al., 2016). There may be an accumulation of apparently minor threats and adversities over a very long period of time. An event such as being shouted at in the workplace may not seem terribly overwhelming as a one-off, but if this occurs on a daily basis, it can have a significant impact. These have been referred to as ‘micro’ traumas (Straussner & Calnan, 2014).

A threat response may take an unusual or extreme form that is less obviously linked to the threat, such as self-harm, self-starvation, experiencing voices or having unusual or unshared beliefs. Particularly in psychosis, the threat response may take a symbolic form, requiring decoding to link to the adverse experience. For example, one young man was forced by his mother to move out of home, as he no longer wanted to attend church. He developed beliefs about being monitored and spied upon, and the feeling of other people reading his thoughts. These threat responses might be difficult to initially understand until it comes to light that when he went home to see his mother, she would tell him where he had been and what he had been doing, as, unbeknownst to him, this information had been passed to her by church members who had seen him in the community.

The  person themselves may not be aware of the link between the threats and their responses to them. They may not remember what happened if they were too young or if they were so overwhelmed during the trauma that those memories were not laid down at the time. Forgetting or cutting off from unbearable psychic material – i.e., dissociative amnesia (Carlson & Putnam, 1993) – might be a part of people’s coping strategies, thus obscuring the link. The person in distress may overlook or ignore any possible links because acknowledging them felt dangerous, stigmatising or shaming. For example, during the recent trial in France, Gisèle Pelicot bravely fought against such stigma by insisting that shame must change sides (Harding, 2024). Victims may carry shame that more accurately belongs to perpetrators.

In societies in the developed world, a common way of understanding mental health can be described as the ‘brain or blame trap’ (Boyle, 2013). The logic is often framed as either:

‘You have a psychiatric condition, and therefore your distress is real, and no one is to blame for it’

Or,

‘Your difficulties are imaginary and/or your, or someone else’s fault, and you ought to pull yourself together.’

While understanding psychological distress in mental health/psychiatric terms might initially be seen as helpful by removing personal blame or fault, both sides of this dilemma require accepting something defective about you as a person. Either your brain is defective – you have ‘social anxiety disorder’ or ‘clinical depression’ – or your character is defective: it’s your fault for being weak or culpable; you cannot cope like others can. The use of diagnosis by professionals obscures the connection between threats and threat responses, imposing a narrative of individual defectiveness instead.

In addition to obscuring the link between adverse life experiences and distress, the medical model can give rise to a conceptual confusion, illustrated by the concept of ‘co-morbidity’. The response to traumatic or adverse life experiences can take many different forms, such as restricted eating and checking, or periods of elevated mood with a fear of going outside. These responses may not correspond neatly with diagnostic categories, and so an individual can acquire several diagnoses, such as anorexia and obsessive-compulsive disorder, or mania with agoraphobia. This can lead to an individual being prescribed a long list of medication in an attempt to address the different disorders. Psychotherapeutically, novice therapists may struggle to determine which model to use when working with a client, such as whether to use cognitive behavioural therapy for bipolar disorder or for panic disorder. In the EMDR field, they may also be uncertain whether to use the protocol for panic disorder (Horst & de Jongh, 2015) or for bipolar disorder (Amann et al., 2015). This conceptual confusion can give rise to a situation where some forms of distress are understood to arise from unprocessed trauma memories and are regarded as appropriate targets in EMDR, whereas other forms of distress are regarded to arise from a disorder or dysfunctional brain and are not targeted in EMDR.

For example, in a case study of EMDR addressing offence-related trauma, the client also had a diagnosis of paranoid schizophrenia (Clark et al., 2014). Trauma memory networks underlying distress associated with the offence were targeted in EMDR. During the reprocessing, a trauma memory associated with an assault the client experienced in prison came up and was also targeted. However, there did not seem to be any consideration of experiences the client may have had that could underlie his feelings of paranoia. Sadly, his experience of psychosis seemed not to be considered at all during the EMDR therapy, despite his success in reprocessing other trauma with EMDR. Moving beyond diagnostic categories to a narrative of events in his life may have elucidated other adverse experiences that were linked with his feelings of paranoia, which then could have been targeted in EMDR. 

Argument

This paper argues that the AIP model is more aligned with the concepts of the PTMF than the medical model, and practitioners can deliver EMDR from a PTMF perspective, rather than from a medical model perspective. There is substantial overlap between the AIP model and the PTMF. Considering the examples of the misuse of power given above (e.g., bullying, coercive control) and the threat responses employed (e.g., hypervigilance, dissociation), EMDR practitioners will be familiar with these experiences with their clients.

A recent qualitative study investigated participants’ accounts of undertaking EMDR for psychosis (Rainey et al., 2024). The misuse of power was evident in the narratives. For example, female participants, who had experienced intimate partner violence, described a combination of coercive and ideological power that maintained their oppression and feelings of powerlessness. One participant explained, “He would tell me about like witchcraft and demonization and things like that. So as soon as like, I got ill, I realized I had internalized all of that” (Rainey et al., 2024, p. 10). Another participant described the response of a community elder to the disclosure of abuse: “Our elder told us you have to be patient. You can’t just leave your marriage. Just, it’s like, in our communities, like it’s normal is [sic] known. If they abuse you that is normal” (Rainey et al., 2024, p. 10).

Both the AIP model and the PTMF regard humans as active meaning-makers, trying to make sense of their experiences. Both regard different forms of distress as the individual’s attempt to make sense of and cope with what is happening to them as adaptive responses. In EMDR, the negative cognition is established, reflecting what the client worries it might say about them as a person, that the trauma happened to them. This has resonances with meaning in the PTMF, the sense that the person made of their experiences and what they needed to do to survive. Consistent with the PTMF’s assertion that the meaning people make of their experiences influences the response they have to them, there was some suggestion that a combination of self-blame and feeling unsafe may leave participants feeling suspicious and vulnerable, whereas experiences of grandiosity may have been responses to themes of self-defectiveness (Rainey et al., 2024).

EMDR goes on to establish a positive cognition – what the individual would prefer to believe. This has resonances with re-storying, the narrative creation in the PTMF-guided discussion. As one woman who had engaged in EMDR for psychosis expressed, “Before I used to blame myself well yes, ‘you have the right to beat me up’. Well, no, it’s not my fault” (Rainey et al., 2024, p. 13).

In both approaches, an illness is not required to understand the link between adverse or traumatic experiences and distress. The concept of ‘comorbidity’ can be made redundant. The conceptual confusion that can arise from trying to fit people into diagnostic categories and then wondering what protocol to draw on can give way to attempts to link current distress to underlying memory networks developed from adverse life experiences. The answer to the question of why someone develops one response to trauma, such as flashbacks, rather than other responses to trauma, such as low mood or rumination, lies in this narrative understanding. Psychological formulation may be one such narrative, or in EMDR terms, case conceptualisation.

PTMF and EMDR share a focus on re-establishing the links between adverse experiences and distress. Given the many factors obscuring the link between adversity and distress, it is encouraging that participants described the role of EMDR as helping them to acknowledge and address distress arising from adversities associated with social or economic inequality (Rainey et al., 2024). Delivering EMDR from a PTMF perspective allows movement beyond the ‘brain or blame trap.’ When the links are re-established with adverse and traumatic life experiences, the problem is no longer located within the person. It is no longer required to accept some form of defectiveness. The response is not disordered; the mind is trying to do what it’s supposed to do: create meaning and generate an adaptive response aimed at facilitating survival and coping. People are also not regarded as being to blame for their difficulties. Struggling with psychological distress is not regarded as morally defective but rather an understandable response to life experiences. Consistent with this, a key transformative element of EMDR has been found to be the role in reducing personal responsibility and self-blame in relation to experiences of adversity (Hardwick et al., in preparation).

It may be important for EMDR practitioners to hold in mind that they are developing formulations, case conceptualisations, with clients within the broader societal ‘brain or blame trap’. There has been a long history of critique of psychiatric diagnosis (e.g., Szasz, 1960; Goffman, 1961; Laing, 1968). One response to such critiques is that some clients ask for a diagnosis or value their diagnosis. Social media and first-person accounts are replete with statements of how a diagnosis made everything make sense (e.g., Partridge, 2025) and meant that struggles were no longer regarded as their fault (e.g., Eads et al, 2021). This can be seen as moving from the ‘blame’ side to the ‘brain’ side of the trap.

Unfortunately, alternatives to diagnosis can sometimes be perceived as moving back to the ‘blame’ side. For example, the British Psychological Society’s Understanding Depression report argued that referring to depression as “an illness is only one way of thinking about it, with advantages and disadvantages” (British Psychological Society, 2020, p. 16), which appeared to some readers to suggest people should “pull yourself up by your bootstraps” (Hickox, 2021, p. 31). It may have been that the critique of the illness approach, the ‘brain’ side of the ‘trap’, was interpreted as reinforcing the ‘blame’ side of the ‘trap’, when that was clearly not the authors’ intention (Holttum et al., 2021).

Similarly, psychological formulations can be experienced as blaming when the psychological processes described are not clearly contextualised in the individual’s experiences, such as regarding maintenance cycles. “I never really thought about it being me maintaining the problems” (Spencer et al., 2023, p. 335). Developing a narrative that re-establishes the links between adverse life experiences and subsequent distress offers a viable exit from the trap. The PTMF focus on the misuse of power, and EMDR case conceptualisation’s emphasis on the links with unprocessed trauma memory networks may help clients feel the problem is not being located within them and they are not disordered.

With the focus on community and cultural understandings, the PTMF allows space for different forms of meaning-making of adverse life experiences. If EMDR is to be delivered in non-Western cultures, delivery from a PTMF perspective can embrace such alternative understandings and avoid imposing a Western medical model. At the 2024 EMDR UK Association Conference, Femke Bannink Mbazzi (2024) spoke on cultural adaptations in EMDR. One such adaptation was embracing a negative cognition referring to ‘we’ – the family – rather than ‘I’, e.g., ‘we are weak’, reflecting a collectivist rather than individualist society. The importance of this can be understood from the basis of meaning-making within a cultural context rather than from the medicalised perspective of an individual with a ‘mental illness.’ Furthermore, the PTMF aims to expand the narratives that are culturally available to people to include psychological explanations while also honouring spiritual and cultural understandings.   

One ancillary of delivering EMDR from a PTMF perspective would be replacing medicalised language, like ‘symptoms’, with psychological and experiential language, like ‘experiences.’ Throughout this paper, medicalised language has only been used when referring to the medical model and diagnostic labels. Psychological and experiential language has been employed when referring to people, our experiences and responses. This type of language facilitates a more accurate description of what has happened to someone and the psychological processes involved. This facilitates meaning-making and the creation of a comprehensible narrative rather than the obscuring function of medicalised language. There has been some evidence that using medicalised language may block a sense of curiosity about other perspectives (Hardwick et al., in preparation).

Conclusions and summary

It has been argued that there are many fruitful resonances between the PTMF and the AIP model, and delivering EMDR from a PTMF perspective may avoid some of the criticisms of the medical model. The PTMF’s focus on the misuse of power facilitates an overarching understanding of the consequences of adverse and traumatic experiences that can be addressed in EMDR. By focusing on the links between such experiences and subsequent forms of distress, an adaptive narrative can be created where the individual is no longer required to accept a view of themselves as defective. This process can also help identify useful targets for reprocessing.    

Author positionality statement

I am a white, heterosexual, middle-aged, lower-middle-class, dyslexic woman. These different aspects of my identity come to prominence in my mind at different times in response to situations and others I encounter. I have a long history of education, including a PhD in early intervention in psychosis and a doctorate in clinical psychology.

Being a psychosis psychologist for many years, I have been required to contend with iatrogenic harm arising from societal views of madness, the medical model and mental health practice. For me, the PTMF brought together a range of evidence and critiques I had drawn upon in my work over the years. Undertaking EMDR training, the AIP model resonated with my understanding of what it was to be human and gave me a powerful tool I could offer clients to consider for healing distress.

Hearing the criticisms that EMDR located the problem within the individual and neglected the trauma, injustice and oppression experienced, I was somewhat bewildered. This was not how I understood EMDR. I realised that the criticisms arose from the connection with the medical model, which I had long abandoned, and instead embraced ideas consistent with the PTMF. I wondered if this might resonate with others, hence the argument proposed in this paper.