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Eye Movement Desensitisation Reprocessing (EMDR) for Childhood Sexual Abuse: A Case Series

Updated: Aug 16, 2023

Man holding sign 'love shouldn't hurt' to protest Post Traumatic Stress Disorder; Childhood Sexual Abuse; Eye Movement Desensitisation Reprocessing; Attention, Memory and Executive Functioning; Emotional and Behavioural Functioning

Research Ratified: 10 December 2021

Abstract: This case series investigates the perceived experiences of six young adult female survivors of Childhood Sexual Abuse (CSA) in their Eye Movement Desensitisation Reprocessing (EMDR) treatment. The study explores two key aspects: neuropsychological, emotional, behavioural functioning, and quality of life issues using descriptive statistics via outcome measures, and client perspectives through qualitative interviewing at one-month follow-up using Reflective Thematic Analysis (RTA). The research was conducted within the UK National Health Service (NHS) framework for Improving Access to Psychological Therapies (IAPT). This service is now known as NHS Talking Therapies. The results suggest positive and moderate outcomes in most cases, but with variable differences in neuropsychological processing from pre- to post-treatment. Qualitative analysis revealed three key themes: 'Unhelpful' process, 'Helpful' aspects of therapy, and 'Mixed Responses' due to the COVID-19 pandemic. This study addresses a gap in the literature concerning neuropsychological functioning in young adult CSA survivors undergoing EMDR within real-world clinical settings.

Keywords: Post Traumatic Stress Disorder; Childhood Sexual Abuse; Eye Movement Desensitisation Reprocessing; Attention, Memory and Executive Functioning; Emotional and Behavioural Functioning

INTRODUCTION Eye Movement Desensitisation and Reprocessing (EMDR) is a therapeutic approach developed by Francine Shapiro in 1989 to address traumatic memories and associated distressing symptoms. The eight-phase protocol, incorporating bilateral stimulation such as horizontal saccadic eye movements, aims to desensitise the distress stemming from traumatic memories and facilitate reprocessing and integration within the client's general biographical memories (Shapiro, 2005).

LITERATURE REVIEW To date, a considerable body of literature has investigated the efficacy of EMDR for the treatment of adult survivors of childhood sexual abuse (CSA). A PRISMA review of EMDR literature was conducted on 18th March 2021 (Moher et al., 2009) and identified eleven relevant papers, including case-studies, case-series, randomized controlled trials (RCTs), and quantitative comparative studies. Among these, four studies compared the effectiveness of EMDR with Prolonged Exposure (PE) therapy, one study explored the combination of Imagery Rescripting and EMDR (Shields, 2015), and the remainder focused on the overall efficacy of EMDR (Aranda et al., 2015; Edmond and Rubin, 2004; Hutchins and Mason, 2017; Jamshidi et al., 2020; Wright and Warner, 2020).

The review revealed that EMDR demonstrated significant effectiveness in case-study designs and was also advantageous in both RCTs and comparative studies. However, a notable gap in the literature pertained to the examination of neuropsychological functioning, particularly in an adolescent/young adult sample within real-world clinical settings such as the IAPT program. Only two identified studies considered neuropsychological evaluations. For instance, Aranda et al. (2015) examined attention, memory, and executive functioning in an 18-year-old adolescent CSA survivor, showing pre-EMDR treatment impairments that improved after the intervention. Another study by Gerardi et al. (2010) investigated changes in salivary cortisol levels in female rape victims, indicating improvements in PTSD symptoms for both the EMDR and PE groups compared to a wait-list control.

Moreover, the literature consistently highlighted common issues associated with CSA, including problems with self-perception, attachment failure, self-destructive behaviour, dissociation, and interpersonal difficulties (Help for Adult Victims of Child Abuse, 2021; Kliethermes et al., 2014). Therefore, achieving a functional end-state in therapy was highlighted as a crucial goal. Furthermore, improvements in attention, emotional and psychosocial adjustment, and other factors like anxiety, depression, and self-esteem appeared to be vital indicators of successful treatment for CSA survivors (Chen et al., 2018; Smith et al., 2016; Schwarz et al., 2020; Griffioen et al., 2017).

Client choice was emphasised as paramount in therapy, especially in time-limited therapies, and further research (Elliott and James, 1989; Riede, 2018) suggests that the establishment of a healthy working relationship between the client and mental health professional is a significant source of support. However, a limitation of the current review was the heterogeneity in sample populations across studies, with the index event occurring at various ages, leading to challenges in selecting relevant research. To address this limitation, this study focused on an 18–25-year-old sample, reflecting the demographic accessing public services for EMDR within routine clinical IAPT settings.

This study aimed to contribute to the field of EMDR therapy by examining the experiences of young adult survivors of CSA who underwent EMDR treatment, exploring symptom improvement and client perceptions. This research was particularly timely due to the increase in individuals seeking trauma-focused therapeutic help during the ongoing COVID-19 pandemic (Lenferink et al., 2020) and the changing landscape of therapy delivery in public services. Furthermore, given the rising prevalence of sexual abuse cases (National Crime Agency, 2020), this study was significant in contributing to the professional practice of EMDR and offering guidance for everyday clinical practice.


Study Design A case series design was employed, incorporating both qualitative methods (one-month follow-up interviews) and descriptive statistics (self-report outcome measures) to assess the effectiveness of Eye Movement Desensitisation and Reprocessing (EMDR) treatment in adult survivors of childhood sexual trauma.

Ethical Approval Ethical approval for the study was obtained from the NHS National Research Ethics Service (NRES) under reference number 19/YH/0241. Additionally, approval was granted by both the Greater Manchester Mental Health (GMMH) NHS Trust and the University of Salford, School of Health and Society Ethics Panel.

Participant Selection Participants for the study were partially selected from the EMDR waiting list based on specific age range and inclusion criteria. Invitations to participate were posted to potential participants meeting the following inclusion criteria:

a) Experienced sexual trauma before the age of 16, as defined by the WHO Consultation on Child Abuse Prevention (1999). b) Exhibited trauma symptomology, as identified by the baseline Impact of Events Scale 'IESR' measure, which was used both as an assessment tool and to measure change in trauma symptomology. c) Reported that trauma symptomology persisted for over three months and primarily originated from pre-16 aged trauma. d) Were available for treatment sessions on a weekly basis for up to 16 sessions. e) Possessed a good understanding of the English language to avoid language barriers or the need for interpreters. f) If taking medication, had a stable medication regimen for at least 2 months. g) Underwent EMDR as the sole treatment for trauma from baseline until follow-up, to avoid any potential conflicts of interest arising from different therapeutic approaches.

Participants with significant psychiatric comorbidity, comorbid psychotic disorder, bipolar disorder type 1, alcohol or drug dependence, acute suicide risk, pregnancy, acute PTSD from trauma within the past 6 months, or who had undergone trauma-focused treatment within the past 3 months or were scheduled to begin another form of trauma treatment during the study were excluded. Additionally, individuals involved in the current research or who had recently participated in prior research studies were excluded. No exclusions were imposed based on gender or ethnicity, but recruitment was limited to English-speaking adults aged between 18-25 and drawn from the NHS IAPT service.

Participant Screening and Consent Participants were initially screened via the GMMH Central Mental Health Referral HUB using a standard therapist assessment protocol conducted over the telephone. This screening aimed to identify any potential risks, concerns, and safeguarding issues, which were addressed before triage into IAPT services. Ethical and consent issues were addressed according to organisational, National Institute for Health and Care Excellence (NICE), and EMDR Europe (2018) policies and procedures during further assessment. Measures were taken to ensure the security of personal data, recordings, anonymisation of transcripts, and proper retention and disposal of the data in accordance with relevant policies and procedures. Participants were informed of their right to withdraw from the study at any time up to 1 month after being interviewed, without fear of reprisal, in accordance with the Code of Human Research Ethics (British Psychological Society, 2014). Participants The study recruited six young adult participants (mean age: 22.5) from the IAPT waiting list for trauma focused EMDR treatment. The sample size was determined by participant availability and sensitivity to the subject matter. The purposive sampling strategy addressed the research question and gaps in the literature effectively.

Qualitative Data

Description of Case K1:

Baseline DES score for dissociation 13.39%

Number of Sessions with Research Therapist 8

EMDR phases completed (out of 8) 8

Previous Therapy N/A

Comorbidities Possible OCD, Health Anxiety, GAD and depressive symptoms

Moderating life stressors Work-related exams, physical ill health

Age at onset and end of abuse 8-9

Description of Case K2:

Baseline DES score for dissociation 10%

Number of Sessions with Research Therapist 9

EMDR phases completed (out of 8) 8

Previous Therapy Counselling

Comorbidities GAD and Depression

Moderating life stressors Studies, cared for both mum and younger sister

Age at onset and end of abuse 10-13

Description of Case K3:

Baseline DES score for dissociation 34.57%

Number of Sessions with Research Therapist 6

EMDR phases completed (out of 8) 2

Previous Therapy Counselling

Comorbidities Anxiety, depressive symptoms

Moderating life stressors Studies, financial constraints, uncertain UK residency status, unsupportive immediate family, resided with ‘critical' Aunt

Age at onset and end of abuse 15-16

Description of Case B1:

Baseline DES score for dissociation 16.78%

Number of Sessions with Research Therapist 20

EMDR phases completed (out of 8) 2

Previous Therapy Psychotherapy as child/adolescent, brief DBT, CFT and CBT

Comorbidities IBS due to previous eating disorder, OCD traits, health and social anxiety, low self-worth due to childhood bullying, panic attacks

Moderating life stressors Studies, voluntary work, full-time employment, IBS/reflux, changes in routine due to COVID-19, possible ADHD/ASD

Age at onset and end of abuse 11-17

Description of Case B2:

Baseline DES score for dissociation 39.07%

Number of Sessions with Research Therapist 19

EMDR phases completed (out of 8) 8

Previous Therapy Victim and drop-in service support on three occasions

Comorbidities Low mood, issues sleeping and anxiety

Moderating life stressors Isolation during COVID-19, house move, witnessed a traumatic event during EMDR, worked with sensitive family issues

Age at onset and end of abuse 3

Description of Case B3:

Baseline DES score for dissociation 22.82%

Number of Sessions with Research Therapist 13

EMDR phases completed (out of 8) 1-2

Previous Therapy School counselling

Comorbidities Insulin dependent diabetes, celiac, migraines as brain malformation

Moderating life stressors Lack of employment, recent benefits application

Age at onset and end of abuse 5

Quantitative Measures

Participants were required to enter IAPT assessment and treatment (approximately up to x16 EMDR therapy sessions at 60-90mins each) as per NICE (June 2018) and GMMH IAPT service guidance. IAPT services commonly use numerous outcome measures, from assessment through to end of treatment, two of which were used in this study (GAD7 and PHQ9) to assess anxiety and depressive symptoms. Additional IAPT measures were excluded due to irrelevance to the subject under study and avoidance of more client time in completion. However, mindful of the research question, both these measures alone would not have been sufficient in capturing gaps as highlighted in literature to explore (e.g., self-esteem, quality of life stressors and neuropsychological functioning). Therefore, as described below, more outcome measures were introduced to investigate these elements of change, as equivalent time would have otherwise been spent on the standard IAPT-dataset.

Baseline Measures

Dissociative Experiences Scale ‘DES’ (Bernstein and Putnam, 1986 and Sidran, for Children/Adolescent use)

Conducted as an assessment tool, at baseline, a dissociation screening tool.

Impact of Events Scale-Revised ‘IESR’ (Weiss and Marmar, 1997)

Conducted at baseline and post-treatment, capped scores were used for a first understanding of trauma symptomology and gauge of participant eligibility onto the study, and any changes in trauma symptoms at post-treatment.

Measures for Neuropsychological Functioning

The Psychology Experiment Building Language ‘PEBL’ (Mueller, 2010; Mueller, 2012; Mueller and Piper, 2014) battery test software

Conducted at baseline (and planned to be undertaken at post-treatment however unable due to COVID-19). Baseline results were included in data as they interconnected with specific questions on the WPS-CR measure. Hence, progression in these domains could be analysed by such data. Three PEBL subtests were conducted, as follows:

PEBL Attentional Network Test (PANT) – designed to assess alerting, orienting, and executive attention.

PEBL Corsi Blocks Test (PCBT) – a traditional spatial working memory task.

PEBL Iowa Gambling Task (PIGT) – to establish whether participants learnt to make better decisions when playing a simple routine card game, through process of trial and error.

Measures for Emotional and Behavioural Functioning

Generalized Anxiety Disorder 7 ‘GAD-7’ (Spitzer, et al, 2006)

Conducted each therapy session to measure levels of anxiety.

Patient Health Questionnaire 9 ‘PHQ-9’ (Kroenke et al, 2001)

Conducted each therapy session to measure levels of Depressive symptoms.

Weekly Problems Rating Scale (WPS-CR child-revised version as per Wilson, 2009; with addition of three questions, in absence of the PEBL sub-test at post-treatment)

Completed each session to identify participant feelings, interactions, and gauge general emotional, behavioural and neuropsychological functioning. Questions 12-14 were erased on this measure to reflect the young adult sample. Also, three items were added relating to the neuro-PEBL aspect of this research: assessing attention, memory and executive functioning.

Rosenberg Self-Esteem Scale ‘RSES’ (Rosenberg, 1965)

Conducted at baseline and post-treatment to measure global self-worth by measuring both positive and negative feelings about the self.

Measure for Quality of Life

The Valued Living Questionnaire ‘VLQ’ (Wilson and Groom, 2002)

Conducted each session to assess 9 valued domains of living (the ‘parenting’ question was not included due to missing data).

One Month Follow-Up Interview

Helpful Aspects of Therapy ‘HAT form’ Interview (Llewelyn, 1988)

Conducted at one-month follow-up. The first seven questions of which used an adapted version of the HAT form to identify helpful/unhelpful aspects of therapy. The eighth question specifically focused on changes in neuropsychological factors, consistent with the PEBL assessment and WPS-CR measure. This was especially useful in absence of PEBL-post-treatment scores due to COVID-19. The final three questions concentrated on therapy ending and any recommendations for treatment.

Qualitative Data Analysis Procedures One-month follow-up interviews were completed by the principal researcher employed by GMMH to maintain confidentiality and assess risk. The designated therapist inputted sessional outcome measures following standard IAPT procedure. The principal researcher managed pre- and post-treatment measures and transcriptions of follow-up interviews for precise data analysis. Braun and Clarke's (2006) Reflexive Thematic Analysis (RTA) model was used to explore emergent themes, convergence, divergence, and nuance, with the assistance of Nvivo software. RTA was chosen for its flexibility across various epistemologies, aligning with the interpretivist philosophical approach. The analysis was conducted within a Big Q qualitative orientation, situated within an interpretivist paradigm (Braun and Clarke, 2019; Clarke and Braun, 2018).

Quantitative Data Analysis Procedures The case series analysis used repeated outcome measures with a non-experimental design and no manipulation, randomization, or control group, influenced by Chambless and Hollon's (1998) approach. Elements of Elliott's Hermeneutic Single-Case Efficacy Adjudicated Design (HSCED) (Elliott, 2002) were incorporated. Two Independent Research Raters (IRR's), external to the local IAPT work environment with ability in ethics and research analysis, independently cross-examined the data. They evaluated individual change through a single-subject design (Baseline; Treatment; Follow-up) with a "small n" sample from GMMH IAPT services, adhering to NICE guidelines and GMMH policy. The IRR's identified categories of change (Positive Improvement, Moderate Improvement, No Improvement) and explored moderating and mediating factors. Independent member-checking was conducted to confirm the analysis and enhance credibility and authenticity of the findings. Treatment A naturalistic case-study design was adopted to ensure internal and external validity, reflecting real-world clinical settings and diverse client presentations in IAPT practice (McLeod and Elliott, 2011). Two experienced research therapists, each with over 5 years of EMDR experience and core qualifications in Clinical Psychology, were employed. To minimise therapist bias and introduce variance in approach, both therapists operated independently from the principal researcher and belonged to different teams (Falkenström et al., 2020; Crooke and Olswang, 2015).

Due to subject sensitivity and the naturalistic nature of the study, no treatment session recordings were made. Therapists followed a "therapy as usual" format and aimed to adhere to the standard 8-stage EMDR protocol (Shapiro, 2001; 2017; Shapiro and Forrest, 2004) with adherence to the EMDR Fidelity Rating Scale (EFRS) (Korn et al., 2018), assessed by an EMDR Consultant Rater (ECR). The most recent version of the EFRS (Version 2: Korn et al., 2018) was used, as recommended by EMDR International Association (2019). Both therapists received monthly standard clinical supervision from an external accredited EMDR Consultant employed by GMMH, in line with EMDR Association Accreditation Guidance (2018).


Reflexive Thematic Analysis: Three Key Themes

Figure 1: Theme One - Helpful Factors of EMDR

Figure 1: Helpful factors of EMDR

The descriptive statistical results revealed that broader quality of life issues, such as socio-economic status and lack of support network, significantly influenced participants' engagement in sessions and improvements in their clinical outcomes (Sprenkle and Blow, 2004). All participants emphasised the importance of feeling safe during therapy, both in their therapist's approach and the treatment environment (Marich et al., 2020). Despite participants with more severe quality-of-life issues showing lesser improvement in statistical data, they still exhibited overall enhancements in their clinical presentations. Interview feedback highlighted how individual therapist attributes, such as a sense of belonging, elevated levels of empathy, and a shared connection, played a crucial role in fostering the therapeutic alliance and promoting recovery (Jones-Smith, 2018; Omylinska-Thurston and Cooper, 2014).

The idiosyncratic approach to therapy could not be fully captured in quantitative data, but it was a significant aspect worth considering. Many participants reported positive changes resulting from techniques acquired from various modalities, particularly during the preparation phase. For instance, one participant (B1) found a "symptoms" approach, focusing on her present and past experiences, more beneficial than a "diagnostic" approach. This approach helped her understand herself better, including potential barriers in her communication style and responses, likely linked to underlying issues of neurodiversity. Consequently, this enhanced her readiness to proceed with the remaining phases of EMDR.

Figure 2: Theme Two - Unhelpful factors of EMDR

Figure 2: Unhelpful factors of EMDR

IAPT restrictions and time limitations were not addressed in the descriptive statistics. Participants in this study received between 6-20 sessions, with a third expressing anxiety about limited session availability and wait times, particularly during transitions between EMDR phases. This highlights the need for practice-based evidence to support time-limited therapies in primary care. Many participants had sought alternative therapies before starting EMDR, and half of the participants were re-referred for additional sessions after completing their initial EMDR contract. This raises questions about the necessity of re-referrals if longer time had been initially allocated. Additionally, interview feedback suggested that the 1–2-week interval between IAPT measures was not sufficient to capture changes in presentation, indicating the need for fewer measures and longer timeframes between recordings.

Another theme not captured in the descriptive statistics was the fear of emotional processing associated with EMDR themes, such as 'safety' and 'threat' when recalling traumatic memories. Participants found it difficult to let go of inner fears, leading to peaks and troughs in their progress. The anxiety of undertaking the process was further exacerbated by the uncertainty caused by the COVID-19 pandemic. Confidentiality concerns were also raised, with over 50% of participants expressing resistance in sharing information due to the fear of confidentiality breaches, especially when sessions moved from face-to-face to remote settings, potentially risking unintentional breaks in confidentiality.

Figure 3: Theme Three - COVID-19: Mixed Responses

Figure 3: COVID Mixed Responses to EMDR

Descriptive statistics did not consider changes in session delivery, transitioning from in-person to remote sessions. Only one participant expressed interest in remote sessions and chose to use both eye movements and tapping as part of their bilateral stimulation (BLS), ultimately preferring eye movements due to triggering experiences with tapping. However, the limited data does not allow for definitive conclusions on the effectiveness of either method. Most participants raised concerns about confidentiality and the blurring of personal and safe life with the exploration of potentially unsafe traumatic memories. Other factors influencing their preference for face-to-face sessions included the sense of connectedness with the therapist, and a third of participants reported that being in a different environment was helpful (K2).

Case Presentations with Descriptive Statistics

CASE K1: K1, the only participant with no prior therapy experience, showed significant improvement in trauma symptoms and self-esteem following EMDR treatment.

CASE K2: K2 completed all 8 phases of EMDR with interruptions due to the COVID-19 pandemic and medication issues, but still demonstrated overall improvements.

CASE K3: K3 displayed ongoing traumatic threat responses and moderate to severe anxiety symptoms, with some positive changes in managing dissociation through Mindfulness techniques.

CASE B1: B1 completed 2 phases of EMDR due to interpersonal issues and possible underlying ASD, with focus on overcoming barriers in communication and preparation for future reprocessing.

CASE B2: B2 had limited prior therapy support and reprocessed 5 target memories, showing an increase in self-compassion and significant improvement in executive functioning.

CASE B3: B3 was afraid of confidentiality breaks, and her therapy prioritised risk and stability. Though slight improvement in depressive symptoms, she reported positive changes in mood regulation and confidence. Summary of Descriptive Statistic Results Participants who completed all eight phases of EMDR showed significant reductions in trauma symptoms (IESR scores) and the greatest improvements in self-esteem and overall quality of life. They also reported better sleep patterns and reductions in anxiety and depressive symptoms (GAD7 and PHQ9 scores). These participants also observed improvements in neuropsychological functioning, particularly in executive functioning, as indicated by WPS-CR responses.

In contrast, participants who only completed phases 1-2 of EMDR showed some reduction in trauma symptoms and improvements in self-esteem and quality of life, but to a lesser extent than those who completed all eight phases. Their improvements in executive functioning were less pronounced, and some participants reported worsening memory and attention. The findings are consistent with previous research, highlighting the importance of completing the full EMDR protocol for optimal therapeutic outcomes. However, individual responses varied, and some participants faced challenges related to moderating life stressors and comorbidities. Participant K3 exhibited unique patterns, showing no improvement in attention and memory but experiencing improved executive functioning. Overall, the results suggest that completing all eight phases of EMDR leads to more robust improvements in trauma symptoms, self-esteem, quality of life, and neuropsychological functioning compared to completing only phases 1-2.

Standard Deviation: Measures and SUDS Scores

When working on the predominant memory, statistically significant improvements in the Subjective Units of Distress (SUDS) scores (often a benchmark to assess progression in treatment), 6.9 at pre- and 1.9 at post-EMDR, were displayed (t [9] = 4.19, p = .002).

Equally, there was a statistically significant difference (above all other tests) between the pre and post IESR scores of Pvalue .004, suggesting the efficacy of EMDR in reducing predominantly trauma symptomology, when working with survivors of CSA.

Independent Research Raters (IRR's) Analysis

As illustrated in the below table, two voluntary Independent Research Raters (IRR's) were employed to rate outcome measures and analyse qualitative data, following the approach outlined by Elliott et al. (2009). The IRR's took different stances in their evaluation of the data; one adopted an 'Affirmative' perspective, indicating substantial and constructive participant change resulting from therapy, while the other took a 'Sceptic' stance, posing 'good faith' queries to challenge the affirmative interpretation. The 'Sceptic' case aimed to explore whether the reported positive changes were truly a result of treatment and whether other factors, such as mediator/moderator effects, could explain the reported changes. Each case outcome was then independently reviewed by the respective client and clinician to ensure accuracy in the write-up and to provide an objective opinion on the data analysis.

Results table of independent ratings for EMDR

DISCUSSION The analysis of cases in this study demonstrated a significant reduction in trauma symptoms for half of the participants, with RTA data supporting the long-term efficacy of EMDR. These findings align with previous research indicating a reduction in trauma symptoms following EMDR treatment (Edmond and Rubin, 2004; Hutchins and Mason, 2017; Jamshidi et al, 2020; Rothbaum et al, 2005; Shields, 2015; Wright and Warner, 2020). Client views in this study were consistent with recent systematic reviews (Whitehouse, 2019; Shipley et al, 2022) that highlight EMDR as a transformative intervention, although not all participants had unanimously positive experiences. Participants who completed all eight phases of EMDR reported the greatest positive changes in various outcome measures, including neuropsychological functioning, anxiety, and depressive symptoms. However, those who only completed phases 1-2 showed some improvement but also displayed enduring moderate to severe symptoms. The COVID-19 pandemic had a negative impact on treatment continuation and outcomes, with some participants opting out of online treatment or experiencing negative effects of social distancing on their physical and mental health. Methodological limitations in previous studies, including lack of data from third parties and limited sample diversity, were addressed in the current research. The study focused specifically on a young adult sample (18-25 years old) and explored the significance of therapeutic alliance and client expectation for treatment outcomes. Despite initial pessimism towards therapy, participants reported positive changes in their views on EMDR following rapport building and the initial phases of treatment. The verbalisation of future goals in therapy allowed participants to develop adaptive responses and strengthen specific skills and behaviours. Participants who experienced the full 8-phase EMDR protocol and maintained optimism in their expectations of therapy and future aspirations observed the greatest outcomes. Therefore, the study emphasises the importance of thoroughly conducting the future template prong of EMDR to manage constructive yet realistic expectations both within and outside therapy settings.

Study Limitations The current research had several limitations. First, the COVID-19 pandemic had a significant impact on the study, causing disruptions in therapy sessions and limiting the ability to conduct post-treatment PEBL assessments in participants' home environments, leading to possible bias.

Second, three participants were unable to continue beyond EMDR phase 2 due to the complexity of their presentations. This limitation reflects the challenges faced by clinicians in real-life clinical settings when dealing with individuals with complex needs.

Additionally, the transition from face-to-face to remote therapy sessions posed challenges for some participants, while others found remote sessions more convenient. This limitation highlights the importance of considering individual preferences and needs when implementing remote therapy.

As a result of the COVID-19 restrictions, the option to re-refer for the remaining EMDR protocol after phase 2 was not feasible for these participants. This limitation underscores the impact of external factors on the completion of therapy.

Due to the limitations posed by the COVID-19 pandemic, post-treatment PEBL data could not be collected. Instead, changes in memory, attention, and executive functioning were assessed through participant interviews and WPS-CR responses. While these methods provide valuable insights, the absence of post-PEBL data may limit the comprehensive evaluation of neuropsychological changes.

Despite these limitations, the study still provides valuable insights into the effectiveness of EMDR in a real-world clinical setting with a young adult population, and the findings contribute to the growing body of research on trauma-focused therapies. Future research should aim to address these limitations and further explore the impact of the COVID-19 pandemic on mental health interventions.

Implications for Clinical Practice

The findings of this study have important implications for clinical practice. The results support the general guidance that PTSD treatment should consider EMDR as an equally effective trauma treatment compared to TF-CBT, in line with recommendations from the World Health Organization and the International Society for Traumatic Stress Studies. However, it is noteworthy that the current study's findings differ from the NICE Guidance (December 2018), which may indicate the need for further research and consideration of diverse treatment options for PTSD.

The study also highlights the importance of addressing insufficiency in session time within IAPT services, particularly for individuals with complex presentations. Participants who struggled with the limited session time and were potentially re-referred exhibited poorer outcomes. This emphasises the need for more comprehensive and tailored treatment pathways, especially for trauma clients who may benefit from a trauma-specific approach rather than being amalgamated onto a mainstream treatment waiting list.

Another significant implication is the importance of the therapeutic alliance in determining treatment outcomes. Variances in outcomes were observed due to factors such as financial constraints and secondary gains, which can impact the client's quality of life. Broader routine-clinical issues, such as lack of funding for public services leading to time limitations and pressures on both clients and clinicians, should also be considered when treatment planning.

Therefore, it is recommended to enhance therapy preparedness and consider individual treatment choices for this young adult client group. This may involve tailoring treatment approaches to address unique characteristics and needs, even if a trauma-specific pathway is not readily available. By recognising and accommodating these aspects, clinicians can improve the effectiveness of treatment and ultimately enhance the well-being of young adult clients undergoing trauma-focused therapies.

Future Research Direction

Future research should aim to build upon the current study's methodology, starting with practice-based evidence and then progressing to a randomized controlled trial (RCT) to establish evidence-based practice. Conducting an RCT would allow for a more rigorous evaluation of the modified EMDR protocol based on the clients' phenomenological experiences.

To enhance the generalisability of the findings, replication of this study in other treatment facilities and under different circumstances, preferably outside the context of the pandemic, would be beneficial. This would help to understand whether the clients experience may be influenced by external factors.

A critical aspect for future research is to address the issue of treatment fidelity. The ECR results indicated some adherence but also inadequacy in treatment fidelity due to the lack of session recordings, emergence of risk and complexity in cases, and abrupt changes or endings to treatment caused by the COVID-19 outbreak. Including treatment recordings in the methodology would improve quality assurance and ensure that the treatment protocol is consistently followed across different cases (Miller and Rollnick, 2014).

Overall, future research should strive to advance our understanding of the efficacy and applicability of the modified EMDR protocol, incorporating both quantitative and qualitative measures, and ensuring robustness in methodology and data collection. This will contribute to the continued improvement of trauma-focused therapies and provide valuable insights for clinical practice.

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