For possible targets and assessment scripts across these and other presentations, see Chapter 5: EMDR Target Selection Across Clinical Presentations. The present chapter focuses on how metaphors and interweaves can help or misfire in complex clinical work.
Knowing what the question is doing
“What if I hurt someone?”
The sentence alone does not tell us what kind of help a person needs. One client may be describing an unwanted obsession that frightens them. Another may be disclosing intent, a plan, or a loss of behavioral control. Someone else may be remembering an event, responding to a voice, or trying to explain an experience they do not yet understand. The clinician needs to ask, listen, and assess before choosing language intended to change the experience.
The same care applies to “I am not safe,” “I cannot trust myself,” and “Something is wrong with me.” A familiar negative cognition does not establish a diagnosis, a treatment target, or readiness for reprocessing.
This chapter focuses first on obsessive compulsive disorder, then considers several other presentations that can require specialized assessment and coordinated care. Its examples primarily concern adult care; work with children, adolescents, or perinatal presentations requires population-specific guidance and expertise. It offers original metaphors and possible questions, with their context made explicit. It does not rank diagnoses by difficulty or supply treatment protocols for them. Complexity can arise from current symptoms, coexisting conditions, medical instability, developmental needs, social circumstances, and barriers to care. A diagnosis alone does not tell us how complex a particular person's treatment will be.
Chapter 26 explains the general limits of this guide. Here we apply those limits to particular clinical questions: Is the client seeking information or certainty? Are they sufficiently present to engage? Does the apparent block require an interweave, a different formulation, or another level of care?
Cognitive interweaves are part of the EMDR approach developed by Francine Shapiro. The examples below were written for this guide; they are not standardized scripts, independently validated interventions, or claims that Shapiro developed these particular metaphors. A question used in preparation or ordinary clinical conversation should not be described as an EMDR cognitive interweave merely because it appears in this book. [1]
Three contexts for the language in this chapter
Assessment and planning language helps clarify the client's experience, function of a behavior, current needs, and treatment options. It is not a substitute for a full assessment.
Preparation and reflective language may help a client describe an experience, discuss support, or consider a skill within an agreed treatment plan. It should not be slipped into active reprocessing as an unplanned series of explanations.
A possible interweave during blocked reprocessing is a brief, selective intervention within an appropriately formulated EMDR treatment. In this chapter, these examples concern a specific trauma-related block in a client who may also have another condition. They are not instructions to use EMDR to treat every symptom of that condition.
The clinical task comes before the image. If the task is unclear, the next step is clarification, not a more compelling metaphor.
Obsessive compulsive disorder
When thinking becomes an attempt to obtain certainty
OCD can involve visible compulsions, mental rituals, avoidance, reassurance seeking, or combinations of these. A person may repeatedly review a memory, analyze their intentions, test their feelings, confess, or ask someone else for an answer. Whether a behavior functions as a compulsion depends on its pattern and purpose, not on how it looks from the outside.
NICE recommends cognitive behavioral therapy that includes exposure and response prevention, with treatment choices and intensity matched to need. Its recommendations specifically address mental rituals and neutralizing strategies and advise reducing family members’ and carers’ involvement in reassurance seeking sensitively and supportively. The details of an ERP plan require competence in OCD treatment; this chapter does not provide one. [36]
For a clinician using metaphors, the central concern is function. An image intended to reduce shame can become something the client repeats until they feel certain. A question intended to open perspective can become another request to prove innocence. Relief after a prompt does not by itself show that the underlying process has changed.
“You would never do that” may feel compassionate, but repeated certainty-giving can become part of a reassurance pattern. Conversely, abruptly refusing all questions can feel punitive and can interfere with ordinary assessment or communication. The clinician needs a shared formulation, a collaborative plan, and a way to remain warm without turning every encounter into a verdict.
Assess risk without treating a thought as a confession
Unwanted intrusive thoughts with violent, sexual, or death-related content can occur in OCD. Their presence alone does not establish intent. NICE advises consultation with an OCD specialist when clinicians are uncertain about risk associated with such thoughts. [36]
NICE also recommends assessing self-harm and suicide risk, consequences of compulsions, and relevant comorbid and psychosocial factors. [36] That distinction does not justify dismissing new intent, planning, access to means, behavioral changes, or other relevant risk information. Assess the actual presentation. In a parent reporting harm thoughts, for example, do not infer either dangerousness or safety from the diagnosis alone. Acute changes after childbirth, impaired reality testing, or expressed intent require their own assessment. Reassurance avoidance must never become a reason to omit necessary safeguarding or clinical care.
Metaphor one The service desk that keeps reopening the ticket
Metaphor: Imagine a service desk that closes a ticket only when it receives complete certainty. Each answer settles the ticket briefly. Then a new version arrives: “But did you consider this detail?” The desk becomes increasingly busy without reaching a lasting resolution.
The comparison may help describe a repetitive question-and-answer pattern. It does not mean that the person's concern is silly or that every request for information should be ignored.
Context: Assessment and treatment planning, especially when a reassurance pattern has been identified collaboratively.
Choose one question for the stated context:
- Assessment / Preparation Question: “After we answer this question, what usually happens next?”
- Assessment / Preparation Question: “Are we learning something new, or being asked to close the same ticket again?”
- Assessment / Preparation Question: “What would support look like if I stayed with you without providing another certainty verdict?”
Caution: Do not use the metaphor to label the client's question before understanding it. A new factual concern, actual exposure, or change in risk deserves assessment. The phrase “another ticket” should not become a dismissive shorthand between clinician and client.
Metaphor two The proof printer with no final page
Metaphor: Imagine a printer producing a report intended to prove, beyond all possible doubt, that a feared outcome cannot happen. Each page raises another question, so the printer adds an appendix. The person becomes exhausted trying to read far enough to reach the final page.
This image concerns the demand for absolute proof. It does not tell the person that a feared outcome is impossible, and it does not ask them to stop thinking by force.
Context: Preparation or reflective work within an OCD-informed treatment plan.
Choose one question for the stated context:
- Assessment / Preparation Question: “What level of proof is your mind asking for?”
- Assessment / Preparation Question: “Has another page been giving you lasting information or a short period of relief?”
- Assessment / Preparation Question: “How would you recognize that this discussion had become another attempt to obtain the final page?”
Caution: A client can turn “there is no final page” into a reassurance phrase or a rule they repeat until it feels right. Notice how the language is used. Do not prescribe repetition of the metaphor, a special number of statements, or a requirement to feel calm before continuing with life.
Metaphor three The borrowed verdict
Metaphor: A person may borrow a verdict from someone they trust: “My therapist said I am a good person.” The verdict helps briefly, but then doubt asks whether the therapist knew every detail. The person returns for a revised verdict. The relationship becomes organized around proving something neither person can settle to an absolute standard.
Context: Collaborative discussion of reassurance and the therapeutic relationship.
Choose one question for the stated context:
- Assessment / Preparation Question: “What are you hoping my answer will settle?”
- Assessment / Preparation Question: “How long does that answer tend to feel settled?”
- Assessment / Preparation Question: “How can I communicate care without becoming the person who must certify every thought?”
Caution: Do not imply that support must be withdrawn. Emotional validation, accurate information, ordinary kindness, and a collaborative treatment plan remain available. Any change in how the clinician responds should be explained rather than used as a surprise test.
Trauma and OCD can coexist
A person may have both PTSD and OCD. A painful memory can become the subject of compulsive review, while a genuine trauma target may also need treatment. The clinician must distinguish the processes rather than assume that all repetition is either reprocessing or ritual.
EMDR has been studied for OCD, including a feasibility randomized trial with 55 participants. This small study does not establish therapeutic equivalence or justify replacing guideline-supported OCD treatment. Evidence and planning for a coexisting trauma disorder should not be presented as proof that trauma processing will resolve compulsions. [37]
A useful consultation question is: “When we return to this event, are we engaging a trauma target, mentally checking it, or moving between both?” Treatment sequencing and coordination should follow the assessment, the client's priorities, risk, and relevant expertise. A recent small pilot explored sequential and integrated ERP and prolonged-exposure approaches in veterans; it illustrates possibilities but does not establish a universally preferred order or an EMDR sequencing protocol. [43] There is no universal “trauma first” rule in this chapter.
Cognitive Interweave: If a client with OCD is processing an established childhood trauma and becomes stuck on adult expectations of their younger self, a brief question might be, “What responsibilities belonged to the adults at that time?” Its purpose is to address that target's responsibility block. If it starts another round of proving the client's innocence, stop and reassess its function rather than adding more persuasive examples.
A fictional exchange
Client: “Can you tell me one more time that having the thought does not make me dangerous?”
Therapist: “I hear how much you want an answer that stays settled. Before I give another answer, can we look at what happened after the last one?”
Client: “I felt better for a few minutes, then I remembered another detail.”
Therapist: “That sounds like the pattern we have been discussing. Would it help to talk about how I can support you without making this another certainty check?”
This is a planning conversation, not an EMDR set or an ERP exercise. It does not replace risk assessment. If the client discloses new intent or a meaningful change in circumstances, the therapist assesses that information directly.
Dissociative presentations
Presence matters more than the elegance of the image
Dissociative experiences vary. A brief feeling of unreality, a marked loss of present orientation, amnesia, and a diagnosed dissociative disorder should not be treated as interchangeable. A quiet client is not necessarily dissociating, and a low distress rating does not establish that processing has completed.
Specialist training addresses adaptations for significant dissociation. The existence of those adaptations does not make them available through a metaphor collection. Clinicians need appropriate assessment, competence, consultation, and individualized planning. [35]
Metaphor The connection that needs checking
Metaphor: A conversation can become harder to follow when a connection is unreliable. Speaking faster or adding more content does not repair it. First, the people involved need to determine whether they can hear one another.
Context: Optional preparation language after the client has described an experience of losing connection. Direct, concrete language may be preferable.
Choose one question for the stated context:
- Assessment / Preparation Question: “Are you able to follow our conversation right now?”
- Assessment / Preparation Question: “Would fewer words, a pause, or a different way of communicating help?”
- Assessment / Preparation Question: “What have we agreed to do when you begin to feel less present?”
Caution: These are orientation and collaboration questions, not cognitive interweaves. Do not use “connection” to impose a model of parts, recover memories, or suggest hidden experiences. If present orientation or ongoing consent is insufficient, follow the established clinical plan rather than inviting deeper imagery. Sudden confusion may also need medical assessment.
Psychosis and experiences that are difficult to verify
Validate distress without confirming an explanation
A person experiencing psychosis can also experience trauma and benefit from appropriate care. NICE recommends assessing trauma-related symptoms in people with psychosis and following PTSD guidance when indicated. Psychosis therefore should not become an automatic reason to deny trauma-informed assessment or treatment. At the same time, acute symptoms, safety, engagement, and coordination with the treating team matter. [38]
A metaphor can be unhelpful if it appears to confirm surveillance, external control, a special identity, or a hidden message. The clinician should not turn uncertainty about an experience into certainty about its cause.
Metaphor Two columns on the same page
Metaphor: Imagine a page with one column for what a person is experiencing and another for explanations that have been considered. The experience can be distressing even when the explanation remains uncertain.
Context: Collaborative assessment or reflective discussion, only if the client finds the distinction respectful and useful.
Choose one question for the stated context:
- Assessment / Preparation Question: “What is the experience like for you?”
- Assessment / Preparation Question: “What do we know directly, and what are we still trying to understand?”
- Assessment / Preparation Question: “What support would help with the distress while we work on understanding it?”
Caution: Do not turn the columns into an interrogation or demand that the client renounce a belief to receive care. Avoid leading imagery, debating every detail, or treating a symbolic story as evidence. Command experiences, severe disorganization, inability to meet basic needs, or immediate risk require direct assessment and appropriate escalation, not a more elaborate metaphor.
Bipolar disorder and major shifts in mood or activation
The current state changes the clinical task
A person with bipolar disorder is not always manic, depressed, or unstable. Their diagnosis alone does not determine whether trauma work is appropriate. The current presentation matters: changes in sleep, activity, judgment, mood, impulsivity, or reality testing may require reassessment and coordination with psychiatric care. NICE recommends urgent specialist assessment when mania or severe depression is suspected or there is danger to self or others. [39]
Metaphor The dashboard before the long drive
Metaphor: A driver can be capable and experienced, while still needing to check changing conditions before beginning a demanding journey. The check is about today's situation, not a permanent judgment about the driver.
Context: Shared treatment planning, preferably linked to the person's existing relapse or wellness plan.
Choose one question for the stated context:
- Assessment / Preparation Question: “What changes in sleep, energy, or decision-making have you noticed since we last met?”
- Assessment / Preparation Question: “What does your existing plan say to do when these changes appear?”
- Assessment / Preparation Question: “Who needs to be involved in deciding what is appropriate today?”
Caution: Do not use the image to diagnose a mood episode, change medication, or interpret reduced sleep and increased confidence as proof of healing. Mania, mixed symptoms, or severe depression call for the relevant assessment and care. No interweave in this chapter is offered as a way to process through an acute episode.
Severe depression and suicide risk
A belief about worth and an immediate safety need are different tasks
A client may experience profound hopelessness, shame, slowed thinking, or thoughts of death. The clinician should understand these experiences directly rather than attempt to replace them with an uplifting image.
For PTSD with depression, NICE generally recommends treating PTSD first because depression may improve, but recommends treating depression first when its severity makes PTSD treatment difficult or when there is risk of harm. This is a qualified clinical recommendation, not permission to disregard current risk. [24]
Assessment of suicide risk, collaborative safety planning when appropriate, and escalation to emergency or specialist care should follow established professional procedures. No metaphor, verbal promise, or reduction in distress during a session establishes safety by itself. Do not use risk scales to predict future suicide or decide who receives treatment or is discharged. Use individualized psychosocial assessment and risk formulation. [40]
Metaphor The ledger that omits the conditions
Metaphor: Imagine judging a person's work from a ledger that records what was unfinished but omits the illness, losses, limited resources, and effort present that day. The record is incomplete even when some entries are factually correct.
Context: Reflective discussion of global self-condemnation when the person can engage and the immediate clinical needs have been addressed.
Choose one question for the stated context:
- Reflective Question: “What conditions are missing from the way you are judging yourself?”
- Reflective Question: “What would a more complete account include?”
- Reflective Question: “Is there one practical support that belongs in the plan rather than another demand on yourself?”
Caution: Do not ask the client to produce positive evidence until they feel better, make them defend their reasons for living, or use the metaphor instead of direct safety questions. If a specific trauma target is being processed later, address its actual block rather than treating the diagnosis itself as the target.
Borderline personality disorder and enduring interpersonal difficulties
Hold warmth and consistency together
A diagnosis involving enduring patterns of emotion, identity, or relationships should not become a character judgment. Clinicians should avoid shorthand such as “manipulative” when a more precise account of behavior, context, function, and risk is possible. Trauma history should be assessed rather than assumed.
Structured psychological care, shared treatment plans, and consultation are important. NICE recommends considering a comprehensive dialectical behavior therapy program for women with borderline personality disorder when reducing recurrent self-harm is a priority; that population-specific recommendation is not a claim that one approach fits every person. NICE also recommends treating coexisting PTSD within a well-structured treatment program for borderline personality disorder. [41]
Metaphor The handrail and the path
Metaphor: A handrail can offer steady support while the person chooses how to move. Consistency in the support matters. It should not disappear as punishment for distress or become a promise that no difficult step will occur.
Context: Collaborative discussion of the therapeutic relationship, boundaries, and between-session plans.
Choose one question for the stated context:
- Assessment / Preparation Question: “What helps our plan feel predictable?”
- Assessment / Preparation Question: “When separation or uncertainty feels intense, what have we agreed you can use or reach for?”
- Assessment / Preparation Question: “Is there something about my wording or our plan that needs clarification?”
Caution: The metaphor does not justify promises of unlimited availability, punitive withdrawal, or unilateral changes in contact arrangements. Address ruptures directly. Do not interpret all fear of abandonment as irrational; actual losses, inconsistent care, and current circumstances matter.
Cognitive Interweave: “What options did you have at that age?” may address a specific helplessness block when the client is engaged in appropriately planned processing. It is not a treatment for the diagnosis, a way to settle a current disagreement with the therapist, or a substitute for structured care.
Substance use and coexisting trauma
Avoid both exclusion and unsafe timing
Substance use can serve different functions, and substance use disorders vary in severity. NICE advises not excluding a person from PTSD treatment solely because of drug or alcohol misuse. That does not mean conducting demanding memory work during acute intoxication, clinically significant withdrawal, or medical instability. Assess present conditions and coordinate care. [24]
Metaphor The borrowed shelter
Metaphor: A person may have found shelter that offered short-term relief while creating other difficulties. Understanding why they entered it can coexist with examining its costs and building other supports.
Context: Nonjudgmental formulation and treatment planning, not acute withdrawal management.
Choose one question for the stated context:
- Assessment / Preparation Question: “What did using help you get through at the time?”
- Assessment / Preparation Question: “What costs or risks are you noticing now?”
- Assessment / Preparation Question: “What support would make another option more available?”
Caution: Do not presume that trauma explains all use, romanticize a dangerous behavior, or suggest that abstinence alone establishes readiness. Do not recommend abruptly stopping substances that may require medically managed withdrawal. Treatment for the substance use disorder and trauma-related needs may both be necessary; neither should be reduced to a single metaphor.
Eating disorders and medical vulnerability
The body requires direct care
Eating disorders involve psychological and physical needs. Medical risk cannot be inferred safely from appearance or body size. NICE advises against using a single measure such as BMI to determine access to treatment and recommends acute medical care for severe physical compromise, including severe electrolyte imbalance, malnutrition, dehydration, or signs of incipient organ failure. [42]
Trauma-informed care should not make food, weight, or body symptoms merely symbolic. Nutritional rehabilitation, medical monitoring, and disorder-specific psychological treatment require appropriate expertise and coordination.
Metaphor The rulebook with one narrow score
Metaphor: Imagine a rulebook that assigns a person's value from a single narrow score while excluding relationships, interests, effort, and health. The score can become powerful without being a complete account of a person.
Context: Optional reflective work about self-worth within coordinated eating-disorder care.
Choose one question for the stated context:
- Reflective Question: “What does this rulebook leave out about you?”
- Reflective Question: “Whose standards shaped these rules?”
- Reflective Question: “How can this conversation support the treatment plan your team is helping you follow?”
Caution: Avoid numbers, body comparison, moral judgments about food, or an invitation to negotiate medical and nutritional requirements through imagery. The metaphor is not a meal plan, an exposure exercise, or evidence that medical risk has passed. If it encourages further comparison or rigid rules, stop using it.
More than one process in the same room
A client may have trauma symptoms, OCD, depression, and substance use at the same time. The clinician cannot resolve the complexity by assigning each sentence to a different diagnosis or by assuming one diagnosis explains everything.
Before offering a prompt, identify the immediate task. Is the client disclosing something new? Asking for a repeated verdict? Losing present orientation? Describing a current threat? Responding to a specific trauma target? What has changed since the treatment plan was made?
Consider a fictional client, Avery, who has an OCD treatment plan and is beginning assessment for trauma-related symptoms. Avery says, “I need to replay the event until I know exactly what I meant.” A therapist who hears only guilt may supply increasingly strong innocence metaphors. A therapist who hears only OCD may overlook an actual traumatic event. A better next step is to clarify the experience and consult across the relevant areas of care.
The clinician might say, “I want to understand what replaying does for you. What are you hoping to know at the end, and what tends to happen after you review it?” This question gathers information. It does not decide the diagnosis or initiate reprocessing.
Later, if an established trauma target is being processed and Avery becomes stuck on an unrealistic expectation of their younger self, a brief responsibility interweave may be appropriate. If the same question begins to function as a certainty check, the clinician returns to the formulation rather than repeating it. The distinction depends on the pattern, context, and response, not on the wording alone.
Consultation that changes the plan
Bring a specific question to consultation. “What metaphor should I use for OCD?” is less useful than “I am unsure whether my response is supporting trauma processing or providing reassurance.” Similarly, “Can I treat someone with bipolar disorder?” is less precise than describing the person's current state, treatment team, relevant history, consent, and proposed target.
A useful consultation summary includes the client's own words, the assessed diagnoses and uncertainties, current safety and medical considerations, the treatment goal, what intervention was offered, and what happened afterward. Discuss cultural meanings, developmental needs, and practical constraints. Share only what is appropriate under confidentiality requirements and consent.
Referral or shared care should be explained as an effort to match treatment to need, not as a verdict that the client is too difficult. Clear responsibility for follow-up, communication, and urgent concerns matters more than an impressive list of providers.
Before choosing the next sentence
- What am I trying to understand or help with right now?
- Have I distinguished a processing block from another clinical need?
- Could this response become reassurance, neutralization, avoidance, or confirmation of an unverified belief?
- Is the client sufficiently present and able to participate in ongoing consent?
- Are current safety, medical, and condition-specific needs being addressed?
- Does this intervention fit the shared treatment plan and my competence?
- What will I do if the client disagrees, becomes less present, or uses the image in a way that maintains the problem?
Complexity does not require a more complicated sentence. It requires a more accurate understanding of what the sentence is being asked to do. Sometimes the helpful next step is a brief interweave. Sometimes it is a direct question, a practical plan, specialist consultation, or stopping memory work for the day. The client's needs determine that choice.
These sources support the clinical boundaries described here. They do not validate the original metaphors, establish effectiveness for every presentation, or replace current local guidance and specialist training. All named clients and exchanges are fictional teaching examples.