How the problem presents
A client may dread a follow-up scan, hear an alarm in ordinary background noise, avoid discussing a birth, or feel estranged from a body changed by surgery, illness, disability, or injury. Another describes persistent pain without intrusive memories. These presentations overlap but are not interchangeable.
Ask which part of the experience matters most: threat to life, pain, helplessness, lack of consent, separation, disbelief, humiliation, uncertainty, or enduring change. An intervention considered routine by staff may have been frightening to the patient. Conversely, a medically serious event does not establish PTSD. The subjective account and an appropriate clinical assessment both matter.
Assessment and treatment context
Clarify current health status, ongoing treatment, functional restrictions, medication effects, sleep, and the clinical plan for new or changing symptoms. With permission, coordinate with relevant medical clinicians. Memory work must not delay necessary care or imply that persistent symptoms are imaginary. Distinguish current pain or threat from memories of pain or threat, while recognizing that a client may experience both at once.
For PTSD after traumatic birth, miscarriage, stillbirth, or neonatal death, NICE recommends trauma-focused CBT or EMDR in line with PTSD guidance. It advises against single-session high-intensity interventions explicitly focused on reliving traumatic birth. [27] This recommendation concerns PTSD, not a requirement that everyone distressed by birth undergo trauma processing.
For chronic primary pain, NICE includes ACT or CBT for pain among treatment options and emphasizes person-centered assessment across chronic pain presentations. Chronic secondary pain requires attention to its underlying condition. [28] Do not present EMDR as a proven cure for pain, a replacement for rehabilitation, or evidence that trauma caused an unexplained symptom.
Candidate targets conditional on the history
Threat and helplessness during care. A particular procedure, emergency, frightening interaction, or period of apparent inability to communicate may be relevant. Record what is remembered directly and what was later learned from others.
Loss of agency or dignity. A recalled dismissal, unwanted exposure, coercion, or lack of explanation may have a different meaning from the medical danger itself. Assess ongoing safety and consent concerns rather than placing all responsibility for adaptation on the patient.
A moment of bodily change. Seeing a scar, receiving a diagnosis, or learning that an ability will not return may carry grief or shame. The aim is not to deny the change or impose gratitude for survival.
Present triggers and future procedures. Sensations, appointments, and anticipated treatments belong on the formulation map. They are not all past memories, and some signal current clinical needs.
Assessment Script
“What happened from your point of view, and what do you know from records or other people's accounts? Which parts are clear, uncertain, or missing? We do not need to fill in gaps.”
“What is most difficult now: remembering the event, feeling something in your body, needing further care, living with a change, or something else? When the difficulty appears, what seems to be happening in that moment?”
“What medical care or accommodations are currently needed? Have symptoms changed in a way your medical team needs to know about? How have previous clinicians responded when you raised concerns?”
“If we considered a specific memory, what would you want help with? What should remain entirely your choice? What would useful progress look like if some pain, disability, uncertainty, or sadness remained?”
The interview should not imply that uncertain recollections are inaccurate, nor that vividness proves factual completeness.
A fictional past present and future map
Presenting situation. Sana, a fictional client, experiences intrusive recollections after an emergency birth. Her baby is receiving follow-up care, and Sana has ongoing pelvic pain under medical assessment. She wants to attend appointments without feeling transported back to the operating room. The clinician separately assesses PTSD, depression, pain-related needs, and safety.
Past candidate. Sana identifies the moment staff began moving quickly while she could not understand what was being said. Her meaning is “My voice does not matter.” She has gaps surrounding anesthesia. The clinician does not encourage her to imagine what must have happened during those gaps.
Present cues. Staff speaking over one another and the smell of a clinic evoke the remembered helplessness. Her current pain is documented as a present symptom requiring continuing medical care, not treated as proof that the birth memory remains unprocessed.
Future aim. Sana wants to bring questions to a follow-up visit, ask for explanations, and use an agreed support person if she chooses. She wants care that respects consent, not merely greater tolerance of distress.
Rationale. If PTSD is established and she prefers EMDR, the identified moment provides a specific candidate within that treatment. Pain management, recovery, infant care, and practical support remain parallel needs. Progress might include less intrusive recollection and greater participation even if physical symptoms have not changed.
Putting EMDR to work before the next medical appointment
Fictional clinical walkthrough. Sana distinguishes three possible targets: staff moving rapidly without explaining what was happening, the moment of separation from her baby, and a later dismissal of her pain. Each could carry a different meaning. She chooses the first because overlapping voices in appointments bring back that remembered helplessness. Missing periods around anesthesia remain missing; they are not supplied through imagination.
Make the target concrete. Ask, “Which remembered moment best represents not being heard?” Sana selects a clinician turning away while she tries to ask a question. Her negative cognition is “My voice does not matter”; her preferred cognition is “I can ask for what I need.” In this fictional assessment she reports fear and anger, disturbance of 8/10, a tight throat, and rigid shoulders. The preferred cognition feels 2/7. Current pelvic pain, its baseline, and the medical follow-up plan are documented separately.
Adapt delivery so she can participate. Before reprocessing, agree a comfortable position, an accessible stop signal, and a bilateral-stimulation method consistent with her needs and the clinician's training. Ask whether she needs a break for feeding, pain management, or fatigue. These accommodations support the actual treatment rather than requiring her to tolerate an inaccessible session.
Process the remembered loss of agency. Activate the target's assessed components and follow the trained protocol. Use brief invitations to report what changes. If Sana notices anger, allow it to develop without steering her toward gratitude that she survived. If she recalls a staff member who did explain something, follow her association without using it to invalidate the earlier experience. An emerging memory of later dismissal may warrant its own assessment if distress remains after the selected scene changes.
After appropriate target resolution, reassess whether her preferred cognition still fits, complete installation and the body scan, and close the session. During bodily review, ask what is happening now rather than declaring all discomfort residual trauma. Continuing pelvic pain does not invalidate improvement in the remembered fear, and a lower target rating does not resolve the medical problem.
Reevaluate at home and in care. Ask whether the original scene still intrudes, how she responds to overlapping voices, and whether she has been able to attend necessary appointments. Review new or changing physical symptoms through the medical plan, not through a target-distress score.
Rehearse an achievable appointment. Future-template work can include entering the clinic, hearing staff talk, opening her written questions, and saying, “Please explain that before we continue.” Include requesting her support person or a pause where medically feasible. Between sessions, Sana practices making one agreed request. Assess whether she can participate and communicate more freely, even if the appointment remains uncertain or physically uncomfortable.
When to reconsider the formulation
Reassess when symptoms change, treatment decisions are pending, pain increases, or the client is avoiding urgent care. Medical review may take priority. Ongoing illness does not automatically preclude psychological treatment, but it changes what can credibly be described as past and what remains uncertain now.
Review the target when the chief difficulty is current disability discrimination, inaccessible services, persistent inadequate pain control, or repeated nonconsensual care. These require practical and systemic responses as well as support. If the client fears that improvement will make clinicians stop believing their pain, discuss that concern directly. Therapy should not become another setting in which they must prove suffering to receive care.
Preparation and pacing
Adapt sessions to fatigue, positioning, sensory needs, medication effects, mobility, and caregiving responsibilities. Ask before using body-focused attention; a person may find it helpful, overwhelming, painful, or irrelevant. Agree options that fit their health and preferences rather than applying a standard exercise unquestioningly.
Plan around procedures and recovery without assuming that all memory work must await complete medical resolution. Explain the rationale for timing and coordinate with consent. For birth-related presentations, consider feeding, sleep disruption, infant care, partner dynamics, and reproductive loss without imposing a particular parental identity or emotional response. Feeling grateful, angry, relieved, or disconnected need not be forced into a single narrative.
Future Planning Script
“Consider the next appointment or daily activity that matters to you. What information and accommodations would help? How could you communicate a question, a limit, or a request for explanation? If a memory intrudes, what would help you recognize where you are and decide what to do next? If a new physical symptom appears, what is the medical plan? What would count as meaningful participation even if discomfort or uncertainty remains? Who will help make that plan possible?”
Rehearsal supports agency and coordination. It cannot guarantee a painless procedure, a particular medical result, or a respectful response from every clinician.
Common errors
Calling unexplained pain psychological. Absence of an explanation does not establish a trauma cause.
Equating survival with a positive outcome. Attend to loss, disability, consent, and ongoing burden.
Filling memory gaps. Distinguish recollection, records, reports, and imagination.
Treating all bodily attention as helpful. Adapt to pain, access needs, and consent.
Making treatment success depend on symptom elimination. Track agency, participation, trauma symptoms, and medical outcomes separately.
Consultation and companion connection
Seek relevant medical, pain, rehabilitation, perinatal, or trauma consultation when the formulation crosses competencies. Share only authorized information. Bring explicit questions about current risk, functional limits, coordination, and the proposed memory focus rather than asking another clinician to endorse a global psychological explanation.
Use Metaphors That Open Doors, Book Two, only when its language respects the client's actual body and circumstances. Avoid suggesting that the body has betrayed them, that pain is merely an alarm, or that recovery requires returning to a former version of themselves.