Quick summary: People often arrive wanting EMDR as a procedure that will dissolve trauma without them having to face it, which creates disappointment particularly when the difficulty is complex childhood experience rather than a single event. EMDR works well on bounded incidents such as accidents but delivers less for accumulated early trauma, where externalising the material and establishing stability first tend to serve better. In mental health practice the most useful response is to assess carefully and combine the person’s knowledge of their own life with professional judgement, since recovery depends on owning the work rather than receiving a preselected treatment.
Most people who contact me about EMDR have already decided. They have read about it, or a psychiatrist has told them it is what they need, and the first sentence is often simply, “I want EMDR.”
It is worth listening to that sentence for a moment, because it uses the grammar of buying something. I want this product, and what I would like to know is what I get for my money and what the result will be. I do not say this to mock anyone. It is how we have been taught to approach almost everything, and it would be strange if our minds were the one area we approached differently. Something has quietly happened inside that sentence all the same, and it is worth naming.
When the patient takes the clinician’s chair
Arriving with the treatment already chosen places you in the position of the professional. You have decided what the problem is and which intervention it requires. You are not a mental health professional or a trauma specialist, though. You have read something online, perhaps a few papers, and you may well have an intuition about yourself that deserves to be taken seriously. An inkling about your own history is often the most valuable thing a person brings. It is best followed with the guidance of someone who does this every day, and it makes a poor basis for a prescription you write yourself.
Underneath the choice there is often a hope that something will be done to you. In that version, EMDR is a procedure that the therapist performs, the trauma dissolves, and years of difficulty are resolved without the person having to go anywhere near them. The patient becomes a recipient. This is the medical model transplanted into psychotherapy, with the wish being “cure me”. There is nothing shameful in wanting that, since it is exactly what we want from a surgeon or an antibiotic, and the alternative of going into the material yourself is frightening. It is still magical thinking, and in a trauma patient it is never a neutral error. It sets up a disappointment that afterwards reads as one more thing that did not work.
Trauma and PTSD are different things
Before going further, a distinction that the public conversation has almost entirely lost deserves restating. Something traumatic happening to you is different from developing post-traumatic stress disorder. Most people who go through something terrible do not develop PTSD, because the psyche has considerable capacity to metabolise a dreadful event and usually does.
What tells the two apart is time, because time is the first thing to collapse. A person with PTSD who was attacked ten years ago will speak about it as if it happened this morning, and will be organised around the certainty that it will happen again tomorrow. The past and the future have folded into a permanent present. That collapse is the disorder itself, and it matters more than the severity of what happened, because it means the event has never been allowed to become the past.
What EMDR does well
I was trained in EMDR in 2006 and have practised it for twenty years. I use it constantly, and I am not writing against it. It works extremely well on a single bounded event, such as a car crash, a bombing or watching someone die in front of you. These are specific events, located in time, with a before and an after, and in such cases EMDR can be remarkable and faster than people expect.
Where the trauma is a cluster accumulated through childhood, EMDR tends to be less effective. It is no harder to carry out, but it delivers less. The evidence points the same way. Survivors of complex childhood trauma have poorer outcomes than survivors of single events, and the systematic reviews of EMDR in complex childhood trauma rest on a small number of heterogeneous trials with modest effect sizes. EMDR remains among the better interventions we have, yet it is a different proposition for someone whose childhood was a weather system than for someone who was in a crash.
Why I keep returning to images
I am an art psychotherapist as well as an analyst, and for trauma I think art earns its place for one specific reason. If you build the traumatic situation in a sand tray or put it on paper, you take it out of yourself and set it down in front of you. It now has edges. It has a certain size, it sits in a particular corner of the tray, and you are looking at it from the outside instead of being inside it.
That is containment, and it cannot be achieved while the experience is held within you. A person cannot hold their own trauma because they are the container and the contents at once, and externalising it, even crudely or with a badly drawn picture, changes the geometry of the problem.
It also reaches people who cannot put the experience into speech at all. Ask them what happened and you may get blankness, a kind of going away, or simply “I cannot describe it”. This is no evasion. Some experience never arrives in a form that converts into sentences. Where there are no words there may still be an image, a shape, a colour or a place in the tray, and the medium does not require the one thing the patient lacks.
How the word trauma has inflated
We are living through a period in which trauma has become something close to a cult. Almost everyone who comes to see me now arrives with the word already attached, as in “I have been traumatised”, “this happened to me” or “I am traumatised by it”. The term entered general use relatively recently and largely through Vietnam. The soldier came home, something of him was still out there, and the profession had to find language for it. For years afterwards, much of the argument concerned whether a given experience counted as trauma at all.
Given that history, I would far rather people use the word and get help than withhold it and suffer quietly. If calling it trauma is what gets someone through the door, then call it trauma. The inflation has a cost, though, and it falls on the people doing the inflating. A father shouting at a child does not mean that the child is damaged for life. Treating every painful experience as a permanent injury teaches people they are broken in a way they are not, and then sends them out to buy the procedure that will fix it.
When trauma has a job to do
This is the most delicate thing I want to say, so I will say it carefully. Sometimes being traumatised acquires a function, and the function is explanation. Nobody chooses this. It is a defence, and defences exist because at some point they were needed. A defence that keeps running long after the danger has passed starts to cost more than it protects, and this one costs a great deal.
I should say plainly who I am describing. I see the people in whom this is live, because those who suffer something terrible, metabolise it and get on with their lives do not make an appointment with me. This is an account of a consulting room and says nothing about trauma survivors in general, most of whom it does not describe at all.
What the explanation accounts for are the things that did not happen, and those are more often relationships than careers. I have sat with many men who tell me they no longer have any relationship with their children, that they were not good fathers, and that this is because of what their own fathers did to them. All of that may be perfectly true. What tends to be missing from the account is the affair, or the years of evenings in the pub, or whatever else is in the room and unmentioned. When you ask about those, the answer returns to the same place, which is that it was the trauma. At that point you are looking at an amnesty, and the account has stopped describing a cause.
Where the chicken is and where the egg is, I frequently cannot say, and I am wary of anyone who claims they can. What I am sure of is the distinction underneath. We are not responsible for what was done to us, and we are entirely responsible for our recovery and our conduct. Something can be genuinely not your fault and still be your work.
Trauma has no special status here, since it is simply the explanation currently to hand. It could as easily be the upbringing, the ex-wife, the employer, the diagnosis or the circumstances. The mechanism is the same whatever gets put in the slot, and so is the cost, which is that responsibility is placed somewhere outside you and left there.
Recovery from anything begins in the same place, and the word for it is owning. This does not mean confessing, and it does not mean taking the blame for what was done to you. It means taking the thing back into your own hands, where it can actually be worked with. What stays entirely someone else’s cannot be worked on, because you have given away the only position from which anything moves. When trauma stops being something to heal and becomes something to keep, no treatment reaches it, EMDR included.
What complex PTSD describes
There is a real condition that loose usage obscures, and it deserves its name back. Complex posttraumatic stress disorder describes what happens when a person can neither fight nor flee. That inability to escape is the defining condition, and the severity of any single event matters less. A child at the mercy of a parent cannot leave, and neither can a woman in a violent home who is frightened for her life. The nervous system has nowhere to put what is happening, so it adapts around it for years. This is a different clinical animal from a single overwhelming event, and it is exactly the territory where a quick procedure is least likely to deliver.
What I do when someone asks for EMDR
When someone asks me for EMDR, I do not refuse. I assess. The first session establishes what happened, what is still alive and whether this approach is the right method for this person now. Sometimes it plainly is, and we begin. Sometimes it is the right method at the wrong moment, because there is not yet enough stability in the person’s life to do the work safely, and we build the ground first. Sometimes it is the wrong answer, something else will serve better, and I say so.
I can say so because I am a psychotherapist who also practises EMDR, rather than someone who practises only EMDR. That matters more than it sounds. A great many practitioners offering EMDR are trained in EMDR and nothing else, and when it is the only tool you have, every presentation seems to call for it. The patient has no way of knowing that this is happening.
What people are really asking for
I mean it seriously when I say that nobody actually wants EMDR. It is not something any human being desires. What the person sitting opposite me wants is peace. They want to stop being at war with something, and in the end they want to feel at home inside themselves. The procedure is only the shape the wish has taken, since a named treatment is far easier to ask for than peace.
To anyone who arrives having already decided, I would say that the professional across from you wants the same thing for you. We are not in disagreement about where you are going, and the only question is the route. Sometimes the route you have chosen is not the one that arrives.
My suggestion is a modest one. You are the specialist in your own experience, and nobody else has been inside your life or can report from there. I am a specialist in the human science of how people recover. Neither kind of knowledge is sufficient alone, and in my experience the work goes best when the two are brought together.
Dr Philippe Jacquet is a Harley Street and online Jungian analyst and art psychotherapist, registered with the HCPC, UKCP and the British Psychoanalytic Council. He has over 25 years of experience in addiction, eating disorders, trauma and men’s mental health, and holds a doctorate from the University of Essex.
