Trauma-focused therapies aim directly at processing traumatic experiences. Well-known methods are:

• TF-CBT: Cognitive Behavioral Therapy with techniques such as imaginal exposure and cognitive restructuring.
• EMDR: Processing traumatic memories with the help of eye movements. Non-trauma-focused therapiesconcentrate on coping with symptoms and developing skills. Examples are:
• Stress inoculation training: Techniques for relaxation and stress management.
• Stabilizing group programs: Promoting safety and resources. Phase-based approaches combine both approaches. They often begin with stabilizing measures and then proceed to direct trauma processing. Examples are:
• STAIR/NT: Integrates emotion regulation and narrative exposure.
• DBT-PTSD: Combines DBT with trauma-focused techniques. For PTSD, trauma-focused therapy is the first choice. Non-trauma-focused therapies can be used complementarily, especially for complex trauma-related disorders. Phase-based approaches offer a flexible combination of both approaches.

Description of specialized psychotrauma therapy for traumatized patients Psychotrauma therapy is a specialized treatment field within psychotherapy that focuses on the healing and processing of traumatic experiences. Traumaticevents can profoundly influence a person's life and cause a variety of psychological and physical symptoms. Specialized psychotrauma therapy offers a structured and integrative approach to treating these deep wounds, to help patients improve their quality of life and restore their emotional and psychological health.

1. Safe therapeutic framework A fundamental aspect of psychotrauma therapy is creating a safe and trustworthy therapeutic framework. The therapist ensures that the patient feels safe and supported in therapy. This is crucial as it enables the patient to open up and share the traumatic experiences without fear of judgment or retraumatization.
2. Stabilization Before traumatic experiences are directly addressed, it is often necessary to stabilize the patient. Stabilization means that the patient learns techniques and strategies to cope with acute symptoms such as anxiety, panic attacks, flashbacks and dissociation. Stabilization techniques include:

• Breathing exercises and relaxation techniques: Methods such as deep abdominal breathing or progressive muscle relaxation help reduce the physiological stress response.
• Mindfulness exercises: These techniques promote presence in the here and now and help reduce intrusive thoughts and flashbacks.
• Grounding exercises: Techniques that help the patient feel grounded and safe, such as holding onto a solid object or consciously perceiving one's own environment.

1. Trauma processing Processing the trauma can be done through various therapeutic approaches, all of which aim to process the traumatic experience and reduce the associated emotional burdens. Some of the commonly used methods are:

• EMDR (Eye Movement Desensitization and Reprocessing): This method uses bilateral stimulations, such as eye movements, to support the processing of traumatic memories. The patient focuses on the traumatic experience while performing guided eye movements or other bilateral stimulations, which reduces emotional burden and integrates the memory into long-term memory.
• Cognitive Behavioral Therapy (CBT): This method helps identify and change dysfunctional thought patterns and behaviors. The patient learns to recognize negative beliefs that arose from the trauma and replace them with more realistic and positive thoughts.
• Trauma-focused cognitive behavioral therapy (TF-CBT): A specialized form of CBT that specifically targets the processing of traumatic experiences. It includes exposure exercises, cognitive restructuring and the development of coping strategies.
• Body-oriented approaches that aim to process traumatic experiences stored in the body. The patient learns to perceive physical sensations and understand how they are connected to the trauma, and develops techniques to regulate these sensations.
• Narrative Exposure Therapy (NET): This method focuses on reconstructing the patient's traumatic story in a coherent narrative. The patient tells their life story chronologically, integrating both positive and traumaticexperiences to develop a coherent and meaningful life story.

1. Emotional processing An important part of trauma processing is emotional processing. This includes:

• Experiencing and expressing emotions: The patient is encouraged to feel and express emotions associated with the trauma such as fear, anger, grief and shame. This can happen through conversation, art therapy or writing.
• Acceptance and validation: The therapist supports the patient in accepting and validating their emotions, which leads to emotional relief and a reduction in emotional intensity.

1. Cognitive reappraisal Cognitive reappraisal is a central component of trauma therapy and includes:

• Identification of negative thoughts: The patient learns to recognize negative and dysfunctional thought patterns that arose from the trauma.
• Cognitive restructuring: These negative thoughts are replaced with more realistic and positive beliefs. The patient develops a new understanding of the traumatic experience and its effects, which leads to a reduction in emotional burden.

1. Integration The integration of the traumatic experience into one's own life story is an essential step in trauma therapy. This means:

• Coherent narrative: The patient develops a coherent and understandable story of the traumatic event.
• Incorporating life story: The trauma is accepted as part of one's own life story without it dominating the entire identity. The patient recognizes that the trauma is part of their life, but does not define their entire life.

1. Reduction of flashbacks and intrusions Through techniques such as EMDR and mindfulness, the frequency and intensity of unwanted memories, flashbacks and intrusions are reduced. The patient learns to remain present in the moment and give less space to intrusive thoughts.
2. Somatic processing Somatic processing is another important component of trauma therapy and includes:

• Body awareness: The patient learns to perceive body sensations and understand how they are connected to the trauma.
• Body-oriented therapy: Methods help process and resolve physical reactions to the trauma.

1. Promoting safety and control A central aspect of trauma therapy is restoring a sense of safety and control over one's own life. This includes:

• Stabilization strategies: Techniques for calming and self-regulation, such as breathing exercises, relaxation techniques and mindfulness exercises.
• Building coping strategies: The patient develops and applies skills to deal with stress and trauma-related symptoms. This strengthens self-confidence and self-efficacy.

1. Social support and self-care The role of social support and self-care cannot be emphasized enough. The patient is encouraged to build a strong network of family, friends or self-help groups that provides emotional and practical support. Additionally, the importance of self-care is emphasized, including regular physical activity, healthy nutrition and adequate sleep.
2. Long-term aftercare and prevention After the intensive phase of trauma therapy, it is important to develop long-term aftercare and prevention strategies to avoid relapses and maintain the progress achieved. This may include regular therapeutic sessions, participation in self-help groups or continuous practice of coping strategies. Conclusion Specialized psychotrauma therapy for traumatized patients is a comprehensive and integrative approach that is tailored to the individual needs and experiences of each patient. It includes creating a safe therapeutic framework, stabilizing the patient, processing and integrating the trauma, emotional and cognitive reappraisal, reducing flashbacks and intrusions, somatic processing, promoting safety and control, the importance of social support and self-care, as well as long-term aftercare and prevention. Through this holistic approach, traumatized patients can learn to process their traumatic experiences and lead a fulfilling and functional life.

Chronological therapy course of trauma confrontation + integration DBT-PTSD Program Phase 1: Preparation and Stabilization

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  1. Setting Goals:
  • Enabling controlled confrontation with traumatic memories.
  • Exposure and experiencing of associated emotions.
  • Support in coping with intense emotions and avoiding flooding or dissociation.
  • Processing and reappraisal of traumatic memories.
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  1. Stabilization Techniques:
  • Mindfulness exercises for grounding: Conscious perception of the present moment, promoting a non-judgmental attitude.
  • Emotion regulation: Application of DBT skills for modulating intense feelings.
  • Distress tolerance training: Techniques such as TIPP skills (Temperature, Intense exercise, Progressive muscle relaxation, Paced breathing).
  • Identifying and naming feelings: Emotional differentiation and precise naming of different feelings.
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  1. Therapeutic Support:
  • Validation of the patient's experiences.
  • Coaching in the application of skills. Phase 2: Confrontation and Exposure
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  1. Exposure (controlled trauma confrontation):
  • Narrative exposure: The patient tells their traumatic experiences in detail.
  • Imaginative exposure: Guided reliving of the trauma in imagination.
  • Prolonged exposure: Repeated confrontation with trauma memories.
  • Dual-attention stimulation (EMDR): Bilateral stimulation during memory work.
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  1. Integration of exposure techniques:
  • Dosed confrontation: Use of skills to stay within the "window of tolerance" and avoid overwhelm.
  • Therapeutic support: Continuous accompaniment and support by the therapist. Phase 3: Processing and Integration
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  1. Processing traumatic memories:
  • Verbalization: Detailed telling of the traumatic experience, structuring and organizing memories.
  • Contextualization: Placing the trauma in temporal and biographical context, understanding circumstances and consequences.
  • Meaning-making: Search for meaning or lessons from the experience, development of a personal perspective.
•  
  1. Techniques to promote integration:
  • Narrative exposure: Chronological telling of life story, including the trauma, for placement in life course.
  • Timeline work: Visual representation of life story and positioning of trauma in context of other life events.
  • Journaling: Regular writing about experiences and feelings, promoting reflection and processing.
  • Cognitive restructuring: Review and adjustment of trauma-related beliefs, integration of new, more adaptive perspectives. Phase 4: Conclusion and Aftercare
•  
  1. Therapy conclusion:
  • Ensuring complete integration of experiences into autobiographical memory.
  • Reduction of avoidance behavior and promotion of stable emotional processing.
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  1. Aftercare:
  • Regular follow-up discussions to ensure long-term stability and integration.
  • Adjustment and reinforcement of emotion regulation and distress tolerance techniques in daily life.

1. Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) is a specialized form of therapy for treating trauma-related disorders, particularly Post-Traumatic Stress Disorder (PTSD). The therapy combines cognitive behavioral techniques with trauma-focused methods, which are chronologically organized in several phases. 1.1. Stabilization phase In this first phase, the patient learns techniques for coping with intense feelings and flashbacks. These include: 1.1.1. Mindfulness and relaxation exercises These exercises reduce arousal levels and help cope with strong emotions. 1.1.2. Affect regulation The patient learns to better control their emotional reactions. 1.2. Psychoeducation The patient is educated about trauma and PTSD to develop a better understanding of their own symptoms: 1.2.1. Knowledge transfer about trauma and PTSD Explanation of how traumas influence the brain and behavior: 1.2.1.1. Understanding biological reactions to trauma Traumatic experiences activate the brain in an intensive way. Particularly the limbic system, which is responsible for processing emotions, reacts strongly. These reactions lead to symptoms such as hypervigilance (excessive alertness), flashbacks and strong emotional reactions. The patient learns how the brain reacts to danger signals and why persistent stress reactions can occur after a trauma. 1.2.1.2. Explanation of memory changes A trauma can change the way memories are stored. Often traumatic experiences are stored in a fragmented and difficult-to-access way in memory, which can lead to recurring and intrusive memories (flashbacks). The patient learns that these memories do not appear arbitrarily, but are a normal reaction to the trauma.
2. Trauma processing In this central phase, traumatic experiences are directly processed, usually through exposure therapy: 2.1. Exposure therapy (Prolonged Exposure, PE) 2.1.1. Imaginative exposure (in sensu) The patient relives the trauma in their thoughts to weaken the emotional reaction. 2.1.2. In-vivo exposure The patient confronts themselves with real, non-dangerous stimuli that are connected to the trauma to reduce fears. 2.2. Cognitive restructuring Processing and changing dysfunctional beliefs and thoughts that arose from the trauma: 2.2.1. Identification and modification of dysfunctional cognitions Negative thoughts are identified and replaced with more realistic, less burdensome ones. 2.2.2. Changing traumatic beliefs Exaggerated or distorted beliefs are processed to reduce guilt and shame feelings. 2.3. Imagery Rescripting The patient imagines the traumatic experience to mentally change it, which leads to positive emotional restructuring. 2.4. Behavioral experiments The patient tests beliefs and assumptions related to the trauma through targeted behavioral changes in daily life.
3. Integration and relapse prevention In the concluding phase, the learned strategies are integrated into daily life: 3.1. Life integration The learned techniques are applied in daily life to achieve long-term improvement in quality of life. 3.2. Relapse prevention strategies Plans are developed to cope with possible relapses and permanently use the learned techniques. TF-CBT is individually tailored to the patient and combines the described methods to ensure sustainable treatment of trauma-related disorders.

Egon Molineus is certified as Psychological Psychotherapist / Trauma therapy with EMDR according to Shapiro

[Translate to English:] Der Wissenschaftliche Beirat Psychotherapie verabschiedete in der **Session of July 6, 2006 – The Following Expert Opinion on the Scientific Recognition of the EMDR Method (Eye Movement Desensitization and Reprocessing) for the Treatment of Post-Traumatic Stress Disorder**

**1. Basis of the Assessment**

This expert opinion is based on the following documents:

An application for an expert opinion submitted by EMDRIA Germany e.V. (Professional Association for EMDR in Germany) in January 2005,

supplemented by a total of 21 original studies on EMDR in adults, described as controlled and randomized, two controlled non-randomized original studies, and three uncontrolled original studies. The application was supplemented by four meta-analyses on the efficacy of EMDR in adults, two of which were published in journals with peer-review processes. Furthermore, four controlled and randomized as well as three additional studies on the application of the EMDR method in children and adolescents with post-traumatic stress disorder were submitted.

**2. Mandate of the Expert Opinion/Research Question**

According to the application for the expert opinion, the application is submitted by the professional association EMDRIA Germany e.V. in collaboration with the Section for Psychotraumatology at the University of Heidelberg to recognize the EMDR method as a scientifically founded procedure. The application is limited to the application of the EMDR method in patients with the diagnosis of post-traumatic stress disorder (PTSD; ICD-10: F43.1; DSM-IV: 309.81).

The Scientific Advisory Board for Psychotherapy under § 11 of the Psychotherapy Act has decided with resolution dated September 15, 2003, that for the decision on whether a procedure or method meets the criteria for scientific recognition, it examines the evidence of efficacy for defined areas of application in psychotherapy for adults or for children and adolescents. According to this, the evidence of efficacy for an area of application can generally be considered established if efficacy in disorders from this area has been demonstrated in at least three independent, methodologically adequate studies, and at least one study includes a follow-up examination at least six months after completion of therapy that demonstrates the therapeutic success at least six months after the end of therapy.

The examination usually carried out in a second step, whether a recommendation for approval as a procedure for in-depth training as a psychological psychotherapist in accordance with § 1 Paragraph 1 of the Training and Examination Regulations for Psychological Psychotherapists can be made, is not applicable in the case of the application assessed here, since scientific recognition is only requested for one area of application in psychotherapy for adults and one area of application in psychotherapy for children and adolescents (post-traumatic stress disorder).

**3. Definition**

According to the application for the expert opinion, EMDR is a psychotherapeutic method in which the processing of traumatically experienced events is enabled through bilateral stimulation. EMDR follows an eight-phase treatment concept, the core of which is a process in which the patient focuses on certain parts of his traumatic memory and simultaneously moves his eyes following the finger movements of the therapist. The processing process can also be induced by other forms of "bilateral stimulation" through rhythmic touching of both hands or through alternating sound stimulation of both ears. It is assumed that this triggers "an associative processing process usually associated with rapid relief," in which, through spontaneous connections of memory fragments from the traumatizing event with elements from the biographical memory ("contextualization") or simple fading of the traumatic memory, affective relief becomes noticeable for many patients.

**4. Indication Named by the Applicants**

The primary indication for the application of EMDR is the treatment of post-traumatic stress disorder (PTSD) in an individual setting.

According to the applicant, contraindications include "acute psychoses as well as comorbid severe dissociative symptoms and comorbid severe personality disorders." In addition, the application for the expert opinion names the following additional relative contraindications: "lack of social security, especially ongoing trauma exposure or ongoing contact with the perpetrator; insufficient stability in the physical, social, and mental areas; acute physical illnesses; acute psychiatric disorders; decompensated anxiety disorder; severe depressions with acute suicidality; active substance abuse."

**5. Theory**

According to the application, the theory of EMDR is based on etiological models of the development of post-traumatic symptoms that assume disturbed information processing as a result of traumatic events. The etiological models assume that traumatic events are accompanied by the experience of extreme helplessness and powerlessness, and the resulting stress leads to an overload of the mental coping and processing mechanisms. The models further assume that memories acquire a traumatic quality when their integration into semantic memory fails. This results in separately registered sensory elements of the experience that can be activated independently of the context to which they belong.

Models of the efficacy of the EMDR method are based on three different concepts: on the one hand, it is assumed that the EMDR treatment contributes to the deconditioning of effective trigger stimuli through repeated imaginary exposure to the distressing memory, which occurs repeatedly and in a controlled manner in the context of EMDR treatment. Furthermore, dysfunctional cognitions are processed in the treatment. Through relaxation induction via bilateral stimulation – according to the theory – an accelerated deconditioning should occur. Hypotheses on the efficacy of the EMDR method in this context are based on psychophysiological findings on the orienting reaction when confronted with new stimuli. The bilateral stimulation specific to the EMDR method should lead to a more prolonged orienting reaction, coupled with parasympathetic stimulation, whereby the aversive stimulus of the traumatic memory would then be coupled to a non-aggressive relaxation stimulus.

A third model assumes that repetitive parasympathetic stimulation accelerates information processing. The repeated saccadic eye movements in connection with the EMDR treatment should lead to vagus stimulation, which, through a reciprocal mechanism, initiates a processing mode similar to REM sleep.

**6. Diagnostics**

In addition to careful general diagnostics, which is generally common in psychotherapy (biographical history, social history, current psychopathological status, general medical-neurological examination), the applicants consider diagnostics of the type of traumatization and its coping or consequences, diagnostics of comorbidities, and disorder-specific diagnostics necessary, which has a reliable and valid diagnosis of PTSD or a partial syndrome of PTSD as its content. The following aspects are named as main subjects of process diagnostics: safety in physical and social terms, mental stability, stability of the working alliance, manifestation of transference (unintentional repetition of dysfunctional relationship patterns), tendency/inclination to resolve intrapersonal conflicts primarily through action. Continuous checking of the patient's stability and external safety is postulated as particularly important for EMDR treatment.

**7. Evidence of Efficacy in Adults**

Of a total of 21 independent randomized-controlled studies that relate to the area of application (stress disorders, F43), 13 cannot be recognized because either no effects were detectable, no randomization was carried out, or other limitations of methodological study quality were found (too small sample sizes, no real control group, no standardized instruments, patients do not exhibit PTSD) [1]. Five non-randomized comparative studies as well as three non-controlled studies cannot be recognized for these reasons either.

The efficacy of the EMDR method in patients with PTSD – in some studies comparable to the effects of exposure treatment – is demonstrated by eight studies (Nos. 5, 6, 9, 10, 11, 13, 18, 19). Since at least one study (No. 19) exists in which a follow-up of at least six months was conducted and the stability of the effects was demonstrated, the criteria established by the Scientific Advisory Board for recognition in the area of application 3 (stress disorders, F43) are met. However, it should be noted that the scientific evidence for the efficacy of the techniques specific to EMDR (especially bilateral stimulation) has not yet been conclusively provided. The two meta-analyses published in scientific journals (Nos. 33, 35) tend to conclude that the EMDR method is effective compared to control conditions and treatments without trauma exposure, but that no systematic difference from exposure treatments could be demonstrated.

**8. Evidence of Efficacy in Children and Adolescents**

Of the total of seven studies submitted on the efficacy of the EMDR method in children and adolescents with the diagnosis of post-traumatic stress disorder, only one study (No. 28) meets the methodological minimum criterion of a comparison group. The explanatory power of this study is limited by a small sample size. From a methodological point of view, it is further problematic in this study that although the clinical status of the patients as a result of sexual abuse is likely, no differentiated diagnostics were carried out. In this study of 14 Iranian girls, the EMDR method proved to be comparably effective to "cognitive-behavioral therapy" (CBT). Another study (No. 29) with a comparison group has so far only been published as a poster at a congress and cannot be evaluated as evidence of efficacy due to lack of detailed information. There are no follow-up studies that demonstrate the therapeutic success at least six months after the end of therapy. Overall, therefore, scientific recognition of the EMDR method in children and adolescents for this area of application cannot be established.

**9. Application in Practice**

In recent years, the EMDR method has spread in the German-speaking world and is used both in outpatient and inpatient facilities specializing in the treatment of trauma victims – embedded in a procedure-specific treatment plan.

**10. Training and Continuing Education**

Training institutes and training curricula for EMDR exist in Germany. To learn and apply the EMDR method responsibly, a completed, state-recognized training as a psychological psychotherapist, child and adolescent psychotherapist, or a completed medical psychotherapeutic continuing education is an indispensable prerequisite.

**11. Summary Statement**

The Scientific Advisory Board for Psychotherapy states in summary that the EMDR method in adults can be considered scientifically recognized as a method for the treatment of post-traumatic stress disorder.

The EMDR method cannot be recommended as a procedure for in-depth training as a psychological psychotherapist in accordance with § 1 Paragraph 1 of the Training and Examination Regulations for Psychological Psychotherapists, as it cannot be considered scientifically recognized for the required minimum number of five of the 12 areas of application in psychotherapy for adults of the Scientific Advisory Board for Psychotherapy or for at least four of the eight classical areas of application.

For the treatment of post-traumatic stress disorder in childhood and adolescence, there are indications of the efficacy of the EMDR method based on a recognized study. However, overall, the number of studies is not sufficient for scientific recognition of the EMDR method in children and adolescents for the area of post-traumatic stress disorders. In children and adolescents, scientific recognition of the EMDR method cannot be established for any area of application in psychotherapy.

The EMDR method cannot be recommended as a procedure for in-depth training as a child and adolescent psychotherapist in accordance with § 1 Paragraph 1 of the Training and Examination Regulations for Child and Adolescent Psychotherapists, as it cannot be considered scientifically recognized for the required minimum number of four of the eight areas of application in psychotherapy for children and adolescents of the Scientific Advisory Board for Psychotherapy or for at least three of the five classical areas of application.

Berlin, July 6, 2006

Prof. Dr. Gerd Rudolf  
(Chairperson)

Prof. Dr. Dietmar Schulte  
(Deputy Chairperson)

Correspondence addresses:

Federal Chamber of Psychotherapists  
Klosterstraße 64  
10179 Berlin  
(Management of the SAB of the second term of office)

Federal Medical Association  
Herbert-Lewin-Platz 1  
10623 Berlin

**Berlin, October 16, 2014** – For the treatment of statutorily insured patients suffering from post-traumatic stress disorder (PTSD), an additional psychotherapeutic method will be available in the future. The Joint Federal Committee (G-BA) passed a corresponding resolution on Thursday in Berlin, which provides that Eye Movement Desensitization and Reprocessing (EMDR) can be used as a treatment method within the framework of a comprehensive treatment concept of behavioral therapy, psychodynamically oriented psychotherapy, or analytical psychotherapy.

"Patients who have been traumatized by events and experiences such as rape, war, kidnapping, and torture now have an additional method available in outpatient psychotherapy with EMDR. Given the severe symptoms such as anxiety and suicidal thoughts, as well as significant psychological comorbidities that patients with PTSD suffer from, this is very welcome," said Dr. Harald Deisler, an impartial member of the G-BA and chairman of the Psychotherapy Subcommittee. "The benefit of EMDR in the treatment of adults with PTSD was found to be scientifically proven in the G-BA's evaluation procedure."

The EMDR treatment method may also be indicated for processing other traumatically experienced events and experiences, such as after accidents or the diagnosis of a life-threatening illness. According to its founder, the American Francine Shapiro, the core of the treatment is "desensitization." This involves briefly engaging with the distressing memory while simultaneously applying bilateral stimulation, such as rhythmic eye movements, sounds, or brief touches on the back of the hand, to lift the blockage and enable rapid processing of the distressing memory.

The G-BA evaluates psychotherapeutic treatment forms—like other medical methods—according to an established procedure. This involves assessing whether psychotherapeutic procedures, methods, or techniques are medically necessary and cost-effective, and whether they provide a scientifically proven benefit for patients.

The resolution will first be submitted to the Federal Ministry of Health (BMG) for review and will take effect after approval and publication in the Federal Gazette.