A diagnosis can help a clinician recognize a pattern. It does not tell the clinician which memory to process, whether memory processing is appropriate today, or what the client wants to change.
Two people diagnosed with PTSD may need different starting points. Two people who say “I cannot stop thinking about it” may be describing a flashback, an obsession followed by mental checking, depressive rumination, grief, or an unresolved practical problem. A useful target plan begins by understanding the experience rather than assigning a memory to a diagnostic label.
This chapter provides a structured way to explore possible targets across common clinical presentations. It includes original assessment scripts, brief metaphors, and selected cognitive interweaves. These are teaching examples, not validated scripts, diagnostic instruments, disorder-specific EMDR protocols, or instructions for self-treatment. Use established training, consultation, informed consent, and the client's own formulation to determine what fits. The examples primarily concern adult clinical work. Child and adolescent assessment, consent, caregiver involvement, safeguarding, and treatment adaptations require age-specific guidance and competence.
Francine Shapiro developed EMDR therapy and its foundational cognitive interweave approach. The organizing language and examples below were written for this guide; they should not be attributed to Shapiro or interpreted as her endorsement. [1]
A diagnosis does not supply a target
A useful distinction is between the condition being treated, the problem the client wants help with, and the experience selected for processing.
Diagnosis or presentation: A recognized pattern such as PTSD, OCD, depression, panic, or a trauma-related difficulty that does not meet a diagnostic threshold.
Treatment goal: A meaningful change in daily life, such as traveling to work, sleeping with fewer trauma-related interruptions, responding to a disagreement without shutting down, or participating in an agreed OCD treatment plan.
Possible target: A specific remembered experience, a current trigger, or an anticipated situation linked to that goal within the treatment formulation. A target is not simply the word “anxiety,” a diagnostic category, or a therapist's theory about the client's childhood.
Treatment task: What is needed now. It might be memory processing, assessment, safety planning, skills practice, exposure-based treatment, behavioral activation, a medical evaluation, or coordination with another professional.
Trauma is an experience category, and domestic violence is a pattern of harm and control; neither is interchangeable with a PTSD diagnosis. Distressing experiences can matter clinically without automatically establishing PTSD. Conversely, a trauma history does not establish that every current symptom is maintained by a traumatic memory.
EMDR has a well-established place in PTSD treatment. Evidence and guideline recommendations for other diagnoses differ. This chapter does not extend the evidence for PTSD to every diagnosis discussed. The examples show questions a clinician might explore when considering an EMDR formulation, not proof that EMDR should be the primary treatment. [2–4]
Start with a formulation and a readiness assessment
Before selecting a memory, clarify the person's goals, current functioning, diagnostic picture, relevant medical factors, supports, and immediate risks. Attend to consent, present orientation, capacity to remain engaged with the therapist, and the ability to communicate a need to stop. An assessment of dissociation is more than asking whether a client sometimes feels distracted.
Before reprocessing, plan how the session will close, what support and coping options are available between sessions, and how the work will be reassessed. Establish how the client can report difficulties afterward without implying continuous therapist availability.
A difficult diagnosis is not an automatic exclusion from trauma treatment. Equally, willingness to try EMDR is not sufficient evidence of readiness for reprocessing. The question is whether this person, in these circumstances, can participate safely and meaningfully in the proposed work with the support available. Preparation needs vary. Avoid universal promises that everyone must process immediately or spend a fixed number of months preparing. [2,4]
Assessment Script: “What would you most like to be different in your daily life? Before we decide whether to work with a memory, I want to understand what happens, what helps, what makes it harder, and what you need to stay engaged in the session.”
Assessment Script: “Is there anything happening now that makes you or someone dependent on you unsafe? Are there medical, sleep, substance-related, or other changes we need to understand before focusing on a past experience?”
These questions begin an assessment. They do not replace a risk evaluation, safeguarding procedures, or diagnosis-specific assessment. If there is immediate danger, acute medical instability, significant intoxication or withdrawal, or a psychiatric state that prevents meaningful participation, the immediate response follows the relevant clinical pathway. A metaphor cannot make those conditions safe.
Organize the work across past present and future
EMDR's three-pronged framework attends to earlier experiences, current triggers, and future challenges. The eight phases provide the wider treatment structure. A clinician's target map should connect these elements rather than become a list of upsetting things to process indiscriminately. [2]
Past: Which experiences does the client identify as relevant to the current pattern? These might include a particular assault, a humiliating incident, a frightening medical event, or repeated experiences represented by a specific example. Do not assume the earliest or most distressing memory is always the correct first target.
Present: What activates the pattern now? Identify a recent concrete example, the situation, the client's interpretation, bodily experience, and what they do next. Determine whether the trigger resembles a past threat, involves a current threat, or belongs to another process such as compulsive checking.
Future: What realistic situation would the client like to navigate differently? Consider required skills and external supports. A future template is not a promise that feared events will not happen or a way to install a flawless performance.
Assessment Script: “Tell me about a recent time this problem showed up. What happened just before it, what did you notice, and what did you do next?”
Assessment Script: “Does that experience remind you of anything you already remember? It is also okay if no earlier experience comes to mind.”
Future Planning Script: “What is one upcoming situation in which you would like to respond differently? What would a workable response look like, including what you could do if it became difficult?”
Do not press a client to produce an origin story. An image, feeling, dream, or sensation is not verification of a historical event. Memory uncertainty should remain uncertainty. [22] Do not ask a client to imagine abuse in order to explain a symptom, or treat an apparent processing shift as proof that a suspected event occurred.
Move from a broad problem to a specific agreed focus
The following sequence is an editorial aid for assessment, not a replacement for the standard EMDR protocol.
Assessment Script: “You have described several experiences. Which one seems most connected to the problem you want help with? We can also decide that more assessment or preparation is needed before choosing.”
Assessment Script: “What part of that experience is most relevant to what is troubling you now? You do not need to give me every detail for us to discuss a possible focus.”
Assessment Script: “When you bring that part to mind, what does it seem to say about you? What feelings and bodily responses do you notice?”
Assessment Script: “What would you prefer to believe about yourself in relation to that experience, if it felt genuinely true to you?”
Then use the assessment procedures, measures, and protocol taught in your EMDR training. A clinician may need an image, another representative aspect of a memory, or an adapted approach that matches the person's experience and communication. Do not force a visual picture when the client does not experience memories visually. The VA explains that a detailed spoken account is generally not required for EMDR, although the person does attend to the target during treatment. [3]
A negative cognition and positive cognition should reflect the client's experience and the actual situation. “I can choose my next step” may be more realistic than “I control everything.” “I can seek support” may fit better than “I can do it all alone.” Present safety must be assessed before suggesting a belief about being safe now.
How to read the examples
Every label names a different clinical activity.
Assessment Script: Questions used to understand the pattern and consider a target. They are not cognitive interweaves merely because they invite reflection.
Metaphor: An optional image for explaining or exploring a distinction. Ask whether it fits. It does not establish a diagnosis or the truth of a memory.
Reflective Question: A question for collaborative discussion, preparation, or treatment planning. It should not automatically be inserted into active reprocessing.
Cognitive Interweave: A brief intervention considered only when reprocessing is genuinely blocked and the question fits the specific block. Offer one relevant intervention, observe the response, and return to processing according to training. A list of examples is not a sequence to deliver. [5]
Future Planning Script: Language for defining a realistic desired response. Use the actual future-template protocol from training when appropriate, rather than treating this wording as the protocol itself.
PTSD after a single event
What to assess: The event, intrusion and avoidance patterns, changes in threat perception and meaning, functional impairment, current safety, and other symptoms that may require separate care. A person may be most disturbed by the impact, the moments of helplessness, seeing another person injured, or what happened afterward. Do not assume the clinician's choice of the “worst moment” matches the client's.
Possible targets to explore: A clearly identified part of the event that remains disturbing; an associated moment of perceived responsibility; a later experience of being blamed or unsupported; current reminders that remain problematic. Selection depends on the formulation and agreed treatment plan.
Assessment Script: “When the event intrudes now, which part comes back? What is happening in that moment, and what does it mean to you?”
Assessment Script: “What situations do you avoid because they bring this back? Are those situations currently unsafe, or are they reminders of the event?”
Metaphor: A photograph can capture one moment without showing what happened before or afterward. The image may be important without containing the whole story.
Cognitive Interweave: If processing is blocked by retrospective blame: “What information did you have at that moment, before you knew the outcome?”
Future Planning Script: “Picture an ordinary situation you want to return to, such as taking a familiar route. What would help you respond to a reminder while also noticing the actual conditions around you?”
Clinical boundary: Do not use a readiness exercise as evidence that driving, work, or another activity is medically or practically safe. A low disturbance rating for one memory does not establish recovery across the entire presentation. PTSD guidance recommends structured trauma-focused treatment, not isolated processing detached from assessment and follow-up. [4]
Repeated trauma and complex PTSD presentations
What to assess: Repeated or prolonged adversity, emotion regulation, relationships, self-concept, dissociation, current living conditions, trust, and capacity to remain engaged. Complex PTSD and a dissociative disorder are not interchangeable diagnoses. Repeated trauma also does not mean every memory must be individually processed.
Possible targets to explore: Client-identified experiences that represent a current pattern, such as being punished for seeking help, being unable to leave, or repeatedly being treated as unworthy. Map themes and specific events without imposing an explanation that all problems come from one hidden memory.
Assessment Script: “When you say, ‘I disappear when someone is upset,’ what does disappearing feel like? What happens to your awareness of the room, time, and our conversation?”
Assessment Script: “Are there experiences you already remember that seem related? Which feels manageable enough to discuss as a possible starting point, and what would tell us to slow down?”
Metaphor: A map can mark several routes through a region without requiring the traveler to visit every place at once.
Reflective Question: “Which part of this map matters most to your current goals, and what support would make approaching it possible?”
Cognitive Interweave: For a specific blocked childhood responsibility belief, when the facts support it: “What responsibilities belonged to the adults in that situation?”
Clinical boundary: Do not interpret silence, numbness, or a falling rating alone as resolution. If the client loses sufficient present orientation, pause and reassess rather than adding more evocative imagery. Specialized dissociation competence and consultation may be needed. ISSTD's 2011 guideline concerns dissociative identity disorder and similar disorders; it should not be generalized to every client with a trauma history. [6]
Domestic violence and coercive control
What to assess: Current threats, surveillance, stalking, access to money or transport, safe communication, dependents, medical needs, and the consequences of disclosure or boundary-setting. Ask without directing the client toward confrontation or a particular relationship decision. Use an appropriate safeguarding and violence-response framework. WHO's handbook, developed for care of women subjected to partner or sexual violence, emphasizes immediate needs, ongoing safety, and support. Apply population-appropriate guidance rather than assuming one resource covers every survivor. [7]
Possible targets to explore: Once the plan supports trauma work, a specific assault, threat, incident of entrapment, humiliation, or blame that the client identifies as connected to current distress. Also consider experiences of not being believed. Processing a past event must not be used to reduce an accurate response to ongoing danger.
Assessment Script: “Before we work with that memory, what is happening in the relationship now? Is it safe for you to receive messages or attend these sessions? What do you want me to understand about the consequences of speaking up?”
Assessment Script: “Which remembered situation continues to affect you even when you are away from the immediate threat?”
Metaphor: An alarm may respond to a remembered fire or a present fire. Its meaning cannot be decided from its volume alone.
Cognitive Interweave: If a processed incident is blocked by responsibility for another person's violence: “Who made the decision to use violence in that moment?”
Future Planning Script: “Within the safety plan you choose, what is one situation you want to prepare for, and what options are genuinely available if conditions change?”
Clinical boundary: The future goal is not to tolerate abuse, become less reactive to threats, or prove that leaving is easy. Practical support and trauma treatment may proceed in coordination; ongoing danger requires individualized decisions, not an automatic rule that treatment is always possible or always prohibited.
OCD and intrusive thoughts
What to assess: Obsessions, overt and mental compulsions, reassurance seeking, avoidance, time spent, impairment, insight, coexisting conditions, and the function of repeated questions. Intrusive harm-related thoughts require a thoughtful assessment; their content alone does not establish intent. Conversely, assuming every concerning statement is “just OCD” can miss risk.
CBT with exposure and response prevention is a central guideline-supported treatment for OCD. Mental rituals and neutralizing behaviors matter even when there is no visible checking. EMDR should not be presented as a substitute for OCD-specific care or as a method for proving that an obsession is false. [8]
Possible EMDR targets to explore: A clearly remembered traumatic or adverse experience that remains independently disturbing and is clinically relevant, such as a past assault in a person who also has OCD. This requires a formulation distinguishing the trauma response from the obsession-compulsion cycle. Do not search for a trauma that must have “caused” OCD or treat every obsessional image as a memory.
Assessment Script: “After the thought appears, what do you do to feel safer or more certain, including things you do in your mind? How long does the relief last?”
Assessment Script: “Is this a remembered event, a feared possibility, or uncertainty about what might have happened? We do not need to turn uncertainty into a memory.”
Assessment Script: “If we work on this known event, how will we tell whether we are addressing its impact rather than giving the doubt another checking ritual?”
Metaphor: A question box can keep producing new slips after every answer. The important information may be what answering does to the cycle, rather than whether the next answer sounds more convincing.
Reflective Question: “What happens to the demand for certainty after you answer it?” This is formulation language, not an instruction to conduct ERP without training.
Cognitive Interweave: For a specific trauma target with a clearly formulated trauma-related responsibility belief, an appropriate question might be, “Who held responsibility for caring for you then?” It must not become a repeated statement used to neutralize obsessional doubt.
Future Planning Script: “How would you like to respond to this situation in a way that supports your agreed OCD treatment plan, even if uncertainty is present?”
Clinical boundary: Do not use bilateral stimulation, a positive cognition, or a metaphor as a ritual that must make an intrusive thought disappear before the client can continue living. Coordinate with an OCD-trained clinician where needed. A feared future catastrophe is not automatically a suitable target for an unfamiliar specialized EMDR procedure.
Generalized anxiety and chronic worry
What to assess: The range and function of worry, actual current stressors, avoidance, sleep, physical symptoms, uncertainty, and practical problems. Distinguish widespread worry from trauma reminders, obsessive rituals, panic, and a realistic need to plan. NICE recommends a stepped approach to GAD, including disorder-specific psychological treatments. [9]
Possible targets to explore: If the formulation supports a memory link, specific experiences of unpredictability, loss, criticism, or helplessness that the client identifies as continuing to drive present reactions. These are possibilities, not presumed origins of anxiety.
Assessment Script: “Take one recent worry episode. What started it, what were you trying to prevent, and what did worrying lead you to do?”
Assessment Script: “Is there a concrete problem we can address now, an uncertain possibility, or a reminder of something you have already lived through?”
Metaphor: A planning notebook has a page for actions that can be taken now and space for things that are not yet knowable. Filling the second space repeatedly may not create new information.
Reflective Question: “Which part needs a practical step, and which part is asking you to know the future?”
Cognitive Interweave: For a blocked memory of having been unprepared: “What resources are available to you now that were not available then?” Do not claim resources exist without checking.
Future Planning Script: “What would a useful response to an ordinary uncertainty look like, including a reasonable action and room for not knowing everything?”
Clinical boundary: The target of care is not elimination of all uncertainty. Do not keep revisiting memories solely because the client still has ordinary concerns.
Panic and agoraphobic avoidance
What to assess: The pattern of attacks, feared consequences of sensations, anticipatory anxiety, avoidance, safety behaviors, medical evaluation, medication and substance factors, and functional restriction. New or concerning physical symptoms require appropriate medical assessment. Panic-focused CBT is guideline supported; interoceptive or situational exposure requires relevant competence. [9]
Possible targets to explore: A first or particularly impactful panic episode if it remains a disturbing memory; an experience of humiliation or helplessness during an attack; another clearly relevant traumatic event. A first episode is not automatically the best starting target.
Assessment Script: “When you notice that sensation, what are you afraid will happen? What do you do next, and what happens when you avoid the situation?”
Assessment Script: “Is there a particular episode you remember that still feels as though it is happening when these sensations return?”
Metaphor: A dashboard light needs to be understood in context. Its appearance alone does not identify the mechanical problem, and ignoring a new warning is not the same as learning about a familiar alarm.
Cognitive Interweave: If a past episode is blocked by global self-blame: “What was happening in your body before you had a chance to make a deliberate choice?”
Future Planning Script: “Within your treatment plan, how would you like to respond to familiar sensations while doing an activity that matters to you?”
Clinical boundary: Do not reassure away potentially urgent symptoms or use memory work as a replacement for panic-specific assessment and treatment.
Specific phobias and social anxiety
These presentations share avoidance but require different formulations. For a specific phobia, clarify the feared object or situation, actual hazards, previous learning, and avoidance. For social anxiety, examine feared evaluation, self-focused attention, safety behaviors, and the situations in which impairment occurs. NICE's social anxiety guidance recommends disorder-specific CBT. [10]
Possible targets to explore: A remembered frightening encounter, humiliating event, bullying incident, or episode of ridicule that remains linked to the current difficulty. Some people cannot identify a single learning event. The absence of such a memory is not a reason to invent one or delay appropriate condition-specific care.
Assessment Script: “What do you predict will happen in that situation, and what do you do to prevent it? Is there a particular experience you already remember that seems connected?”
Assessment Script: “When you imagine being judged, whose response are you anticipating? Does that relate to a known event, or is it mainly a prediction?”
Metaphor: An old review can be carried into every new performance, even when the audience and circumstances have changed.
Cognitive Interweave: If processing a specific humiliating memory is blocked by equating another person's judgment with total personal worth: “What else was true about you at that time, beyond that person's reaction?”
Future Planning Script: “What would participating look like if success meant doing something meaningful rather than controlling every sensation or everyone's opinion?”
Clinical boundary: Avoid guarantees that others will approve or that the feared object can never cause harm. Exposure-based work, when indicated, is planned with the appropriate skills and safety assessment; a future template does not replace it.
Depression and persistent negative self beliefs
What to assess: Mood course, anhedonia, functioning, sleep and appetite, losses, guilt, hopelessness, suicide risk, medical contributors, substance use, and any history suggesting mania or hypomania. Do not infer unipolar depression from low mood alone. Depression has multiple possible contributors and established treatments; a painful memory formulation is one part of assessment, not a complete causal explanation. [11]
Possible targets to explore: Specific experiences of humiliation, rejection, loss, failure, or helplessness that the client identifies as linked to a persistent self-belief. Distinguish a bounded memory from a repetitive review of everything the client believes they have done wrong. Co-occurring PTSD may affect treatment priorities.
Assessment Script: “When ‘I am a failure’ feels strongest, what has just happened? Does a particular remembered experience come up, or is this more like an ongoing commentary?”
Assessment Script: “What have you stopped doing because of the depression, and what support would help you take a manageable step while we decide on the broader treatment plan?”
Metaphor: A verdict written across an entire folder can hide the differences among the documents inside it.
Cognitive Interweave: If a specific event is blocked by global condemnation: “Does this one event describe everything about you, or is there more to the record?”
Future Planning Script: “Picture one achievable activity consistent with your goals. What would help you begin, and what could you do if motivation remains low?”
Clinical boundary: Do not promise that processing a rejection will resolve a depressive disorder. Acute risk or severe impairment may alter priorities. Behavioral, social, medical, and other psychological treatments may remain necessary even when a memory becomes less distressing.
Bereavement and prolonged grief presentations
What to assess: The relationship, circumstances of the death, cultural and spiritual context, duration and impact of grief, functioning, support, trauma symptoms, and any risk concerns. Distinguish grief from a traumatic memory of the death without assuming they are entirely separate. Grief has no single emotional sequence that every client must complete. Prolonged grief disorder requires its own assessment and treatment planning. [12]
Possible targets to explore: A specific distressing scene, receiving the news, a medical encounter, or an event connected to persistent guilt. The fact that the person died is not a memory defect to remove, and continuing love or sadness is not evidence that processing has failed.
Assessment Script: “What part feels most difficult now: missing them, a particular scene that keeps returning, guilt, the way life has changed, or something else?”
Assessment Script: “If we work with that scene, what would you hope becomes easier without requiring you to stop caring about the person?”
Metaphor: One page may be painful to read without being the whole relationship.
Cognitive Interweave: For a hindsight responsibility block: “What did you know at that time, and what became clear only afterward?”
Future Planning Script: “How would you like to approach this anniversary or family event while making room for grief and the support you choose?”
Clinical boundary: Do not use an imagined message from the deceased as factual authority. Do not require gratitude, forgiveness, closure, or a positive interpretation of the death.
Medical trauma pain and body related distress
What to assess: Medical status, current symptoms, the experience of treatment, consent or control concerns, disability access, pain-related functioning, fear of recurrence, and coordination with medical providers. Pain and other bodily symptoms should not be assumed to be psychological because testing has been inconclusive. A medical trauma formulation does not explain the cause of a disease.
Possible targets to explore: A known procedure, emergency, frightening symptom episode, loss of control, perceived dismissal, or difficult birth experience that remains disturbing. Select a specific psychological impact rather than promising to eliminate pain or prevent recurrence.
Assessment Script: “What part of the medical experience continues to trouble you: the sensations, a particular moment, how you were treated, or what you fear might happen next?”
Assessment Script: “What remains medically uncertain, and what information or support do you need from your healthcare team before we plan the next step?”
Metaphor: A medical chart and a personal account describe different parts of the same experience. Both deserve attention.
Cognitive Interweave: For a past loss-of-control block, where current options genuinely differ: “What choices can you discuss with your care team now that were not available in that emergency?”
Future Planning Script: “Picture an upcoming appointment. How would you like to ask questions, express preferences, or request support, within what is actually possible?”
Clinical boundary: Do not interpret bodily changes during processing as medical clearance. Evidence for EMDR in PTSD does not establish effectiveness for every pain or somatic condition. Chronic pain guidance emphasizes assessment and individualized planning; it is not an EMDR protocol. [13]
Eating disorders binge eating and emotional eating
What to assess: Eating patterns, restriction, binge episodes, compensatory behaviors, body image, shame, medical risk, food availability, medications, and relevant physiological factors. “Overeating” is not a sufficient formulation. A person may be responding to restriction, hunger, stress, an eating disorder, or several factors. Eating-disorder-specific assessment and care must not be displaced by a trauma explanation. [14]
Possible targets to explore: A clearly identified experience of weight-based humiliation, coercion, abuse, or another traumatic event associated with current distress, when memory work fits the coordinated plan. A craving is not proof of a hidden trauma. Food should not be framed as morally good or bad.
Assessment Script: “Walk me through a recent episode, including what you had eaten earlier, the situation, your feelings, and what happened afterward.”
Assessment Script: “Are there experiences around food or your body that you already remember and that remain upsetting? How do they connect, if at all, to the difficulty we are discussing?”
Metaphor: Several inputs can influence a signal. Understanding hunger, restriction, emotion, and context is different from trying to silence the signal altogether.
Cognitive Interweave: If processing a specific memory of body-based humiliation is blocked by treating someone else's standard as a verdict on personal worth: “Whose standards were being imposed on you in that moment?”
Future Planning Script: “Within your eating-disorder or nutrition care plan, what would responding to a difficult meal or body-image trigger look like with support?”
Clinical boundary: Do not use EMDR to install disgust toward food, suppress necessary hunger, guarantee weight loss, or encourage restriction. Medical instability requires appropriate care. Processing shame does not replace nutritional rehabilitation or disorder-specific psychotherapy.
Substance use and addictive behavior
What to assess: Pattern and function of use, intoxication or withdrawal risk, overdose risk, trauma symptoms, coping resources, treatment engagement, and medical or psychiatric comorbidity. Distinguish a trauma reminder from craving, habit, withdrawal, and environmental access. PTSD and substance use disorders can both require treatment; one diagnosis alone is not a reason to deny evidence-based PTSD care. [15]
Possible targets to explore: Known traumatic memories associated with distress that contributes to use, and particular experiences of shame or threat when clinically relevant. This does not mean trauma processing by itself treats addiction or that urges should be approached with an unfamiliar specialized protocol.
Assessment Script: “What happens before you use, what does it change in the short term, and what happens afterward? Which parts relate to a memory and which relate to craving, withdrawal, or the situation around you?”
Metaphor: A route can become familiar because it brings short-term relief, even when it leads somewhere the person does not want to remain.
Reflective Question: “What other supports need to be available before we approach the experiences this route has helped you avoid?”
Cognitive Interweave: For a specific trauma memory blocked by global shame: “What circumstances are missing when you describe yourself only with that label?” This is not an excuse for harm or a substitute for accountability.
Future Planning Script: “Within your recovery and safety plan, how would you respond to a known trigger, including contacting support or changing the situation?”
Clinical boundary: Do not begin or continue reprocessing when intoxication, withdrawal, or impaired participation makes it unsafe. Coordinate care rather than requiring an arbitrary universal period of abstinence or implying that processing will remove relapse risk.
Relationship difficulties attachment concerns and abandonment fears
What to assess: Current relationship patterns, violence or coercion, communication, practical stressors, previous experiences, and the client's goals. “Attachment trauma” should not be used as a substitute for a specific history or diagnostic assessment. Fear of being left may reflect real instability, a trauma reminder, grief, personality-related difficulties, or more than one process.
Possible targets to explore: A remembered separation, betrayal, rejection, or caregiving experience that the client links to current reactions. Establish whose treatment is being provided and avoid treating one partner's account as a complete factual record of the relationship.
Assessment Script: “When the possibility of being left comes up, what are you most afraid it would mean or require? What concerns are practical, and what feels connected to earlier experiences?”
Assessment Script: “If you were caring for the children without your partner, which supports exist, which are uncertain, and which would need to be developed?”
Metaphor: A bridge can be planned one section at a time, but the materials and support need to be real.
Cognitive Interweave: During blocked processing of an earlier abandonment experience, when current options genuinely exist: “What options do you have as an adult that you did not have then?”
Future Planning Script: “Picture a realistic challenge, such as asking for help or making a parenting decision. How would you like to respond, including what you could do if support is limited?”
Clinical boundary: Do not promise the partner will stay, tell the client they can manage everything alone, or use a future template to push a decision about separation. A positive cognition such as “I can learn and seek support” must be chosen by the client and grounded in their circumstances.
Personality related difficulties and recurrent interpersonal crises
What to assess: The individual pattern of emotion, identity, relationships, impulsivity, coping, risk, and functioning over time. A personality disorder label does not identify a single cause or establish that a client's report is unreliable. Assess trauma when relevant without assuming all difficulties are trauma-based. Structured treatment and coordinated planning remain important; NICE's borderline personality disorder guidance addresses this broader care context. [16]
Possible targets to explore: Specific, client-identified traumatic or adverse experiences linked to an agreed problem, within a plan that addresses current patterns and risk. A crisis is not automatically an invitation to process the most painful memory immediately.
Assessment Script: “What happened between the trigger and the point where things became overwhelming? What did you need, what did you do, and what were the consequences?”
Metaphor: A close-up view can show the intensity of one moment while a wider view reveals the sequence around it.
Reflective Question: “Which part of the sequence needs a skill or support, and which part appears to bring an earlier experience into the present?”
Cognitive Interweave: For a defined memory blocked by a global identity judgment: “Is that a description of what you did in that moment, or everything about who you are?”
Clinical boundary: Preserve accountability without shaming. Do not use a metaphor to force attachment to the therapist, bypass boundaries, or substitute for a coherent treatment plan.
Bipolar psychotic and significant dissociative presentations
These are distinct presentations, not one category with one treatment. They are grouped here only because target selection may require particularly close attention to current state, specialist competence, coordination, and the limits of this guide.
What to assess: For bipolar presentations, consider mood state, sleep, activation, judgment, risk, and treatment engagement. For psychosis, assess experiences, distress, functioning, reality testing, current risks, and the person's understanding without endorsing unverified beliefs. For dissociative presentations, assess awareness, orientation, memory difficulties, identity-related experiences where relevant, and ability to maintain sufficient connection with the present. Follow appropriate specialist guidance. [6,17,18]
Possible targets to explore: A known traumatic event and its current impact, if a suitably qualified clinician's assessment supports trauma-focused work. The diagnosis itself is not a target. Do not select a delusional explanation as verified history or interpret a dissociative experience as proof of a particular event.
Assessment Script: “What is most distressing about the experience, and how is it affecting sleep, daily life, and your ability to feel present with me?”
Assessment Script: “Before deciding about memory work, what does your current care plan say about changes in sleep, activation, unusual experiences, or losing time? Who should we coordinate with?”
Metaphor: Different instruments on a dashboard provide different information. One reading cannot stand in for the whole assessment.
Reflective Question: “What information do we still need before choosing the next treatment task?”
Clinical boundary: This section intentionally does not provide a generic reprocessing script for acute mania, psychosis, or significant dissociation. Trauma treatment may be appropriate for some people with these diagnoses, but requires assessment and expertise beyond a list of prompts. Acute symptoms that impair consent, orientation, or safe participation call for the appropriate assessment and care response.
Other common concerns that require a different first question
Insomnia: Ask about sleep timing, opportunity, habits, substances, medications, breathing-related symptoms, mood changes, and trauma-linked nightmares. A disturbing bedtime memory may be relevant, but insomnia should not automatically become a trauma target. Evidence-based insomnia treatment such as CBT-I may be indicated. [19]
Assessment Script: “What happens from the time you prepare for bed until morning? Are you avoiding sleep because of a specific memory or nightmare, or is another pattern keeping you awake?”
Anger and irritability: Assess threats, violence risk, substance use, sleep, mood, and consequences. A remembered humiliation may be relevant, but treatment must also address present behavior and responsibility.
Assessment Script: “What happened immediately before the anger rose, what did you believe it meant, and what did you do? Is there a specific earlier experience that seems connected?”
ADHD autism and learning or communication differences: Do not frame a neurodevelopmental condition as damage to erase through trauma processing. Assess trauma when indicated and adapt communication, sensory conditions, pacing, and supports to the person. Use literal language when it works better than a metaphor. A traumatic school experience may be a target; attention differences and autistic identity are not problems to erase through reprocessing. EMDR does not erase the historical event being addressed. [20,21]
Assessment Script: “What about this situation is distressing: the sensory demands, unclear expectations, a remembered experience, or something else? What adjustments help you participate?”
Adjustment difficulties and life transitions: Explore the actual stressor, losses, resources, coping, and functional impact before looking for a historical target. Some people need problem-solving, grief support, or practical assistance more than memory work.
Assessment Script: “Which part of this change is hardest to manage now, and what would useful support look like?”
A future template should rehearse a workable response
The future component connects processing to life. It should reflect the client's goals, actual circumstances, and needed skills. If the client cannot imagine coping because a skill or resource is genuinely missing, do not treat that as resistance or keep repeating a positive statement.
Future Planning Script: “Choose one specific situation you reasonably expect to face. How would you like to respond? What support, information, or practice would you need?”
Future Planning Script: “If a difficult feeling or an unexpected problem appeared, what could you do next? Let us make room for a workable response rather than a perfect outcome.”
Use the trained protocol for future-template work. Do not use this chapter's planning questions as a substitute for that procedure. Some anticipated situations require practical rehearsal, medical guidance, specialist treatment, or a safety plan before imagery-based work is appropriate.
A worked example of choosing rather than assuming
The following is fictional. It illustrates formulation, not a complete assessment or a treatment outcome.
Present problem: An adult avoids the route to work following a collision. They also reread insurance correspondence late at night and ask family members repeatedly whether they could have prevented the crash.
Assessment Script: “When you avoid the road, what comes up? When you reread the letters, what are you trying to find out? Do those experiences feel like the same problem or different ones?”
The client describes an intrusive image of the impact on the road. Rereading letters sometimes addresses a real unresolved insurance question, but sometimes becomes a repeated attempt to feel completely certain about blame. These observations suggest different tasks, not a single automatic target.
Competing explanations: Road avoidance may relate to PTSD symptoms, pain, actual driving limitations, or several factors. Repeated reviewing may be a trauma-related coping pattern, an OCD process, or a practical problem. Assessment remains open rather than diagnosing from one behavior.
Possible selected target: If the assessment supports it and readiness is established, the client and clinician might agree to work with the remembered moment of impact because it is directly linked to the current intrusion and an important functional goal. The agreed goal is a workable return to necessary travel, not an instruction to feel no fear under any circumstances.
Why another target is not selected automatically: The clinician does not begin searching childhood for the origin of every worry, process the insurance letter merely because it is recent, or use an interweave to settle legal responsibility. The practical insurance question needs an appropriate factual response. A possible compulsion needs its own formulation and care plan.
Reevaluation: Later assessment would consider the memory response, remaining route-related triggers, actual travel behavior, pain or medical restrictions, and the reviewing pattern. Improvement in one does not prove resolution of the others. The future plan can include realistic coping and support, with the relevant driving and health considerations addressed separately.
Record why the target makes sense
A concise target plan can record the following without unnecessary graphic detail:
- The current problem and the client's functional goal.
- The diagnostic or formulation questions that remain open.
- The specific experience, trigger, or future situation under consideration.
- The client's own explanation of its connection to the current problem.
- Relevant meaning, emotions, body responses, and contextual facts.
- The reason for choosing this focus now rather than another treatment task.
- Readiness, consent, safety considerations, and needed adaptations or consultation.
- How change will be evaluated beyond a single in-session rating.
For example: “Client identifies a remembered collision as linked to avoiding the route to work. Current driving and medical considerations reviewed. Plan addresses the memory, remaining route-related triggers, and a realistic return-to-driving goal, with reassessment of functioning and tolerance.” This is a fictional documentation illustration, not a template that should be copied when those assessments have not occurred.
Reevaluate the plan. If a target becomes less distressing but avoidance, compulsions, mood symptoms, medical concerns, or danger remain, those findings deserve attention. They do not automatically mean the clinician selected the wrong memory, nor do they establish that another memory must be found.
The question to carry into the room
Before asking, “What should I target for this diagnosis?” ask:
“What is maintaining this person's difficulty, what matters to them, and what treatment task is appropriate now?”
That question leaves room for a memory target, a present trigger, or a future challenge. It also leaves room to recognize that the next helpful step may be something other than EMDR reprocessing.
References
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