OCD-EMDR do you treat OCD or trauma memories - Where to go first?

Our latest Q&A series on Integrative EMDR for OCD 

This specific dilemma—in the EMDR treatment plan, do we target the "Big-T" trauma or the current OCD symptoms—is one of the most common hurdles for EMDR clinicians and clients alike.

In this instalment of our FAQ series, Dr. Joyce Blake and Linda Sunderland discuss how they navigate the options when a client presents with both trauma and OCD.

The Big Question: Trauma or OCD—Where to go first?

The Question: When a client comes in with trauma and OCD, do you tackle the trauma first to see if the OCD symptoms subside, or do you go for the OCD trigger with a "bridge back" (or a flash-forward)?

Dr. Joyce Blake: The Power of Client Autonomy

For Dr. Blake, the clinical decision-making process starts with a partnership. She prioritises the client’s internal compass to build a foundation of safety.

"I generally ask the client whether they would rather work on the known trauma or the OCD triggers and bridge back, as I think it is helpful to empower the client wherever they can," says Dr. Blake. "If they ask me to decide, I would generally start with the known traumas."

She also offers a word of caution regarding specific techniques: "I would not use flash-forwards in the early stages of processing"

Linda Sunderland: Choice as a Reparative Experience

Linda Sunderland agrees that the "right" path is the one the client feels ready to walk, noting that giving a client a choice is often a healing act in itself, especially for those who have had their agency taken away in the past.

"I will offer information so they can make an informed choice," Linda explains. "We discuss the EMDR three-pronged approach and adaptive information processing theory: we can follow the present symptoms and distress with a bridge back to where it needs to go. Sometimes it lands on the trauma; sometimes it goes somewhere completely unexpected."

Linda also highlights the nuance of "The Whale and the Boat" (T. Zimmerman) when deciding between targeting a major trauma (the Whale) or the OCD:

• The "Road to Rome": If a specific trauma clearly precipitated the OCD, it may seem like a direct route straight to the trauma—though Linda warns there can be an "OCD backlash" when jumping straight to "Big-T" events because the OCD may be working hard as a protective defense against experiencing what the trauma brings up.
• The Early Schema: Often, the best work happens at the "youngest part," where a child learned their needs would not be met, to suppress emotions, or maintain tight control. Processing these early formative experiences and associated beliefs, can help to light up the neural pathways making them ready to connect the adaptive information to the later traumas process – resulting in trauma processing going more smoothly.
• Stability First: "If Big-T was in childhood, and we approach the OCD as the protective part that came along as an adaptive response to childhood adversity, I consider: what size of boat do we have? Metaphor from T. Zimmerman. Is it steady enough to hook a whale?"
• Flash Foward? "I believe this can take us off down a rabbit hole with the OCD's clever magic tricks of distraction. I appreciate some EMDR colleagues do suggest this as the way to target OCD when using EMDR - If this is going to be used, the clinician and client really need to understand OCD presentations, and what they are creating as an image, and why they are doing this" - It's similar to ERP's approach as going to the imagined catastrophic thoughts and images to desensitise the symptoms, but doesn't address the question of "how did it come to be this way". I would recommend processing the formative experiences first, by bridging from the symptoms in the present prong, with the attachment lens in mind.

The Consensus: Follow the Client

While there are "many options," the OCD-EMDR team remains rooted in a singular philosophy: We attune to the client sitting in front of us and their specific experiences will inform the case conseptualisation and treatment plan. Whether you spend more time by stabilising the "boat" or “cross the bridge into the attachment wound” or follow any open road that goes directly to a known trauma, the goal is to ensure the client feels empowered, attuned to, informed, and safe throughout the processing journey.