A practical sequence when anxiety, depression, and trauma overlap
For a fictional client who has intrusive memories, depressed withdrawal, and fear of meetings, build one shared map rather than three disconnected target lists. Identify which episodes activate which processes. The assault memory may trigger intrusive images; a recent dismissal may activate defeat; a meeting interruption may activate humiliation. These experiences can overlap without being identical.
Formulation Script: “The intrusions, staying in bed, and freezing in meetings all matter. Which is creating the biggest obstacle this week? Which experience becomes active at that point? Let's choose a first target and also decide what we will keep supporting while we work on it.”
If the assault memory is the selected target, assess and process it through the EMDR phases, then separately review intrusions, daily activity, and meetings. Improvement in one area can create room for the next intervention without proving that every problem came from the same memory. If withdrawal persists, assess hopelessness-related episodes and maintain depression care. If the meeting response persists, identify its own present trigger and relevant history, then build a future template for participating.
Clinical focus: Sequence by the treatment job, not by a fixed hierarchy of diagnoses. The shared plan should name the current EMDR target, the symptom or function it is intended to change, the other care continuing alongside it, and the signal that would change the order. This makes coordinated treatment concrete and prevents one intervention from quietly displacing another.
A diagnosis list is not a treatment sequence
A client may meet criteria for PTSD, depression, panic disorder, and a substance-use disorder while also facing insecure housing. Writing all five concerns in a record does not tell the clinician what to do on Tuesday. Conversely, selecting one elegant trauma narrative does not make the other concerns disappear. A useful formulation explains the relationships among processes while preserving uncertainty about which relationships are causal.
Begin with the client's priorities, the risks that require action, and the mechanisms maintaining current impairment. One symptom can have several pathways. Avoiding a train may reduce reminders of an assault, prevent feared panic, or reduce exposure to an actually unsafe person. The same behavior needs different treatment depending on its function. Ask about a recent episode in enough detail to distinguish these possibilities.
Working distinction. Diagnosis organizes evidence and care pathways. Formulation connects this person's experience, context, behavior, and goals. Target planning specifies a candidate memory or other treatment focus within that formulation. None of these tasks replaces the others.
Build a process map with competing explanations
For each major difficulty, record the trigger, interpretation, emotional or bodily response, action, immediate consequence, and longer-term cost. Then mark connections that the client recognizes. An intrusive assault memory may lead to drinking; drinking may worsen sleep; poor sleep may increase vulnerability to both intrusions and panic. These connections are hypotheses to test, not arrows that prove an underlying trauma explains everything.
Include processes that are not memory driven: medication effects, poverty, chronic pain, sleep disruption, nutritional compromise, compulsive rituals, ongoing discrimination, or lack of practical support. If a client avoids appointments because accessible transport is unreliable, additional processing of “I am helpless” will not repair the transport system. Formulation should make environmental interventions visible.
Use two columns when needed: evidence supporting this explanation and evidence that would make us revise it. A hypothesis that cannot be contradicted will tend to absorb every treatment outcome. “Any lack of progress means we have not found the real trauma” is not a clinically useful test.
Choose a sequence by consequence, feasibility, and preference
A sequence should answer four questions. What needs immediate action? What can the person meaningfully engage in now? Which intervention has the strongest relevant evidence? What does the client choose after understanding alternatives? The answer may be parallel care, a short preparatory intervention, direct PTSD treatment, or treatment of a different condition first.
For PTSD with depression, NICE generally favors addressing PTSD first, while recognizing that severe depression or risk can make another sequence necessary. It also calls for individualized attention to barriers and practical circumstances in people with additional needs. [11] These are conditional recommendations, not an instruction to process memories regardless of current capacity.
The 2023 VA/DoD guideline advises that co-occurring disorders should not automatically preclude recommended PTSD psychotherapies. [30] This protects access without removing clinical responsibility. A diagnostic label is not a contraindication; an immediate medical crisis, inability to consent, or an unsafe delivery setting may require a different action today.
Avoid both premature processing and indefinite preparation
Some clients need targeted work on orientation, coping, trust, practical supports, or coordination before memory processing is feasible. Name the need precisely. “Client cannot currently remain oriented when recalling the agreed event” is more actionable than “Client is too complex.” The preparatory plan should specify what will be assessed, what improvement would enable a next step, and when the decision will be reviewed.
Do not infer that every person with childhood abuse requires a lengthy preliminary phase. In a randomized trial, adding STAIR before EMDR did not produce superior outcomes to immediate EMDR for the study's childhood-abuse-related PTSD sample. Important exclusions included acute suicidal crisis, ongoing abuse, substance misuse or dependence, and intellectual disability. This trial challenges a universal prerequisite; it does not establish one sequence for every complex presentation. [12]
Similarly, the absence of a preparatory phase in a study does not mean that assessment, consent, psychoeducation, or ordinary protocol preparation were omitted. Distinguish extended phase-based treatment from the preparation inherent in competent therapy.
Select a target that tests the central link
Suppose Leah has PTSD after an assault, recurrent panic, and depression. She describes panic on entering the stairwell where the assault occurred and also unexpected panic at home. The stairwell memory may be a suitable PTSD target. It is not yet an adequate formulation of the unexpected panic. Assess catastrophic interpretations of bodily sensations and the need for panic-specific treatment rather than assuming the same target will resolve both.
Original formulation language. “We think this remembered moment contributes to the stairwell alarm. We do not yet know how much it explains the panic at home. If the memory becomes less disturbing but panic continues, we will reassess that process rather than treating it as proof that you did the therapy incorrectly.”
This conversation makes a prediction that can be checked. It also reduces the pressure to report global improvement when only one domain changes. A well-selected target can be useful without being the single cause of all symptoms.
Parallel care needs named responsibilities
When more than one clinician is involved, record who monitors risk, who manages medication or medical concerns, who treats each condition, and how contradictory recommendations will be reconciled. Obtain appropriate consent for information sharing. “The team knows” is not a communication plan. A short shared summary can state the active goal, target rationale, current supports, signs requiring review, and the next coordination point.
Avoid simultaneous intensive interventions merely because each has an evidence base. Consider burden, scheduling, cognitive demands, and the client's preferences. Conversely, do not withhold useful care for one condition until every other condition has resolved. The plan should be coordinated, not competitively organized around professional ownership.
Read the outcome in more than one dimension
At reevaluation, compare the selected memory, PTSD symptoms, other conditions, daily functioning, and adverse effects. Improvement in intrusive memories with unchanged depression may indicate residual depression requiring its own treatment. Reduced drinking with unchanged nightmares may indicate successful substance-use care alongside ongoing PTSD. These are differentiated outcomes, not failures of the person.
Worsening requires prompt assessment, not an automatic explanation that treatment is “working deeply.” Consider new danger, illness, medication change, sleep loss, overload, alliance rupture, or an inaccurate formulation. A change of plan can mean a better target, modified delivery, added condition-specific care, consultation, transfer, or a different therapy. Chapter 24 offers a structured review process. Good comorbidity work is not the ability to fit every difficulty into EMDR; it is the ability to keep the entire person in view while using EMDR where it is justified.