Combining EMDR and Polyvagal Therapy for Complex Posttraumatic Stress Disorder

What is Eye Movement Desensitization and Reprocessing?

Eye Movement Desensitization and Reprocessing (EMDR) was developed by Francine Shapiro in 1989 as a method of treatment for Posttraumatic Stress Disorder (PTSD).

Over time, researchers and therapists expanded the use of EMDR to include several other mental health diagnoses besides PTSD. It was discovered that not only did EMDR eliminate the impacts of acute memories leading to PTSD, but it also eliminated the negative impacts and irrational self-perceptions caused by nonacute memories and bad experiences in general. This is particularity true with individuals who have a history of repeated abuse or repeated traumatic incidences causing Complex Posttraumatic Stress Disorder (Complex PTSD).

Due to the many complexities found in the assessment and treatment of Complex PTSD, EMDR treatment required added interventions and assessment tools. These tools can be found in Polyvagal Therapy. This article explains how EMDR and Polyvagal Therapy can be combined for increased speed and effectiveness for treatment of individuals suffering from Complex PTSD.

EMDR and Neurobiology

EMDR is a treatment method used to eliminate the negative impacts of traumatic memory quickly and effectively. EMDR is a neurobiological intervention that makes use of eye movements to facilitate a physiological impact on brain functioning which creates permanent emotional and cognitive change in an individual when thinking about or visualizing a traumatic memory.

Recent studies on brain scans of individuals indicate that traumatic experience and traumatic recall negatively impact brain functioning and that EMDR corrects it. Specifically, during trauma a part of the brain called the amygdala, which controls many of our emotions and is responsible for autonomic responses associated with fear and fear conditioning, becomes over activated and this creates an impasse between itself and the hippocampus. The hippocampus plays an important role in the consolidation of information from short term memory to long term memory and spatial memory which is responsible for recording information about one’s environment and spatial orientation.

It is recognized that this impasse between the hippocampus and the amygdala creates symptoms found in generalized anxiety, panic attacks and posttraumatic stress disorder. During EMDR, this impasse is corrected as eye movements will both enlarge and activate the hippocampus so it can receive the overwhelming amount of information from the amygdala and then sort it. The hippocampus then completes the proper brain processing by sending information to the anterior cingulate cortex, which is involved in aspects such as attention, decision making, reward anticipation, ethics, morality, impulse control and emotion. The impact of opening this impasse and restoring proper brain functioning means that a negative memory, once too overwhelming to manage, is put into the proper context of time and space, has affective and cognitive aspects of the memory merged, is viewed with more rational thought, reason and control and exists in a clear distinction between the past and the present.

EMDR and the Two Primary Positive Treatment Reactions

During EMDR treatment, which is administered by a psychotherapist, a client responds to the neurobiological process described above and experiences two primary reactions to a traumatic memory. First, there is a distancing from the memory

that includes an elimination of the negative emotional reactions related to the trauma. Second, the client experiences an increased level of rational perception related to the memory. This increased rational thinking is called Adaptive Information Processing (AIP). AIP is the result of successful EMDR reprocessing and allows the client to hold a more rational view of personal safety, personal responsibility and personal choice while visualizing or discussing a traumatic memory. AIP also allows the client to hold an accurate positive self-perception or cognition while visualizing the trauma. This assists the client in problem solving how he or she would react, or prefer to react, differently in a similar situation. Repeating the EMDR procedure over a series of planned interventions targeting traumatic memories relieves the person of the negative impacts the memories have created. Due to its neurobiological quality, the changes from successful EMDR reprocessing are permanent and generates dramatic symptom reduction across the spectrum of most all mental health diagnosis.

Polyvagal Theory and Psychotherapy

Polyvagal Theory was developed by Dr Stephen Porges PhD in 1994 as a method of understanding the relationship between individual heart rate variability and the Autonomic Nervous System. In recent years the field of psychotherapy has had great interest in Polyvagal Theory as Polyvagal Theory has been able to provide neurophysiological explanations for several of the experiences described by individuals who have experienced trauma. This is particularity true with individuals who have a history of repeated abuse or repeated traumatic incidences causing Complex Posttraumatic Disorder. This interest has led to numerous psychotherapeutic exercises assisting people with self-regulation, relational management and an articulation of the subjective experiences of danger and safety.

Polyvagal Theory and The Perception of Safety and Danger

Polyvagal Theory assumes, of course, that there are both dangerous and safe situations, but that people will have emotional, physical, cognitive and relational hardship if their perception of those safe or dangerous situations is inaccurate. It is important that people approach relationships and daily tasks with an accurate assessment of both the safety and the danger involved in those settings. In some cases, people who have a history of abuse, neglect or trauma will misread situations and inaccurately see a situation either as more dangerous than it is or safer than it is. Exaggerating danger might be shown by being easily offended, having difficulty accepting criticism or having irrational fears like phobias, generalized anxiety or panic. Also, people might misread situations as being safer than what they are. This happens when people stay in abusive relationships, voluntarily frequent threatening environments or allow verbal, physical or emotional boundary violations.

The Three States of the Autonomic Nervous System

Polyvagal Theory argues that people are regularly moving through three different autonomic states throughout their daily lives. This movement is caused by reactions to life events and the attempt to survive emotionally or physically, to restore oneself, or connect with others. These three states are the ventral vagal state (safe and social), the sympathetic state (mobilized for fight or flight) and the dorsal vagal state (immobilized and collapsed). Each state is managed by a specific set of nerves and each state serves a specific set of biological and social needs.

1.Ventral Vagal State – The ventral vagal state is a physical, emotional and cognitive experience facilitated by a set of nerves in the upper part of the body connecting the brain to the heart, neck, face, mouth, eyes and ears. The ventral vagal state, also known as the “safe and social state”, is responsible for detecting, accepting, evaluating and reciprocating states of social safety. Also, it regulates the other two defensive autonomic states listed below. Being in a safe situation and then actively looking for and seeing safety will activate the ventral vagal state. The activation of the ventral vagal state facilitates self-regulation and eliminates unnecessary defensive thoughts, feelings and behaviors. In a relational sense, people in the ventral vagal state feel safe which leads to a sense of connection, trust, comfort, restoration and happiness. It is best that individuals solve relational problem(s) in the ventral vagal state. If they do not, they will switch involuntarily to the sympathetic state and attempt to solve their problem(s).

2.The Sympathetic State – The sympathetic state is a physical, emotional and cognitive experience facilitated by a set of nerves coming from the center of the spine and connecting to various organs. This set of nerves alerts and activates people when they detect danger and prepares the body to act. The sympathetic state, also known as “mobilized for fight or flight state”, moves through various levels of intensity measured by both the level of fear experienced and the related amount of physical and mental energy that is given to deal with the event. When someone is in this state, they are pulled out of the ventral vagal state, lose the benefits of feeling safe and begin to disconnect from people. Relationally it is a state of conflict and fear. Clinically the sympathetic state parallels anxiety, anger, posttraumatic stress, relational discord, obsessions and cognitive distortions leading to self-questioning. Physical symptoms include headaches, high blood pressure, heart disease and joint pain. If the problem or event is not solved in the sympathetic state, the person will then involuntarily activate the next state which is the dorsal vagal state.

3.The Dorsal Vagal State – The dorsal vagal state is a physical, emotional and cognitive experience facilitated by a set of nerves that extend from the Vegas Nerve to the organs located below the diaphragm. When the dorsal vagal state, also known as “the immobilized and collapsed state”, is activated an individual will shut down. Often this will follow the overwhelm of energy and fear caused by the sympathetic state. This overwhelm can be physical, emotional, or cognitive. The body will grow cold, weak, slow and lacking in energy. Socially the individual feels disconnected from others. Clinically this state triggers symptoms of depression, dissociation, performance anxiety, paranoia and cognitive distortions leading to challenged self-concept. Physical symptoms consist of low blood pressure, immune system disorders, stomach problems, obesity, fibromyalgia and irritable bowel syndrome.

The Vagal Brake and The Window of Tolerance

The vagal brake is a term created by Stephen Porges PhD to describe the process of stopping physiological reactivity to life events that lead either to the sympathetic or dorsal vagal defensive state. It is important that individuals accurately read the level of both safety and danger in life events in order to not overuse a defensive state position. People who have a history of trauma and nonacute trauma found in PTSD and Complex PTDS have histories where it was necessary to maintain states of high defense. However, in different life settings, or in adulthood, the level of threat generally is less and the need for a defensive state is less. An unnecessary overactivation of a defense state will create emotional, physical and cognitive overwhelm and a relational management style that is ineffective. The activation of the vagal brake, at the right time, will ease a defense reaction and leave the individual in a position to self-regulate and return to a ventral vagal state of safety. The development of an accurate vagal brake response can be done by polyvagal exercises as well as by the reprocessing of traumatic memory through the EMDR protocol. These interventions are central to the treatment of Complex PTDS.

The window of tolerance is a clinical term used to describe the parameters of one’s state of non-defense. It is necessary to recognize one’s own window of tolerance since it will determine what are manageable tasks, thoughts, memories, relationships and topics in and out of therapy. Thus, the awareness of one’s window of tolerance will assist in self-regulation and with creating the most likely positive results from the use of internal resources and therapeutic suggestions. A goal of treatment is for the client’s window of tolerance to increase over time so one can actively problem solve needed topics of change while maintaining a ventral vagal state position. As this relates to the vagal brake, the window of tolerance will expand as one can more quickly use their vagal brake to inhibit defense response, maintain a state of safety and “tolerate” life events. The window of tolerance is expanded by Polyvagal exercises and EMDR since both will decrease the automatic activations of unnecessary defensive states.

What is Coregulation?

Coregulation is the moment to moment act of managing a relationship to self regulate. Coregulation is based on attachment theory which argues that the regulation of a child doesn’t simply come from the “good enough” behavior of the parent but is a process by which the child feels calm in reaction to the parent’s self-regulation which is in response to the child’s initial signs of self-soothing. In relationships, coregulation is the processes of keeping a relationship safe in an effort of bring oneself to state of regulation. In Polyvagal terms, the individual has an awareness of both their window of tolerance and sensitivity to their vagal brake and will use methods to manage the relationship in order to remain in or return to a ventral vagal state. This often requires the need to defuse the defensive states of sympathetic defense and dorsal vagal defense that occur both in oneself, but also in others. Often individuals with a history of abuse or neglect leading to PTSD or Complex PTSD have a history of strained and conflictual relationships and do not have a background of guided experience leading to self-regulation through relational management.

The Polyvagal Hybrid States

Polyvagal Theory argues that the three states of the autonomic nervous system listed above, the ventral vagal, sympathetic, and dorsal vagal states, are not mutually exclusive nor antagonistic but rather comingle and coexist to create a full spectrum of cognitive, relational, behavioral and emotional experiences. These coactivated states are called “hybrid states” states. There are two hybrid states which are the combined ventral vagal and sympathetic state and the combined ventral vagal and dorsal vagal state. Polyvagal hybrid states represent how polyvagal awareness and creative application can facilitate the process of using internal client resources for self-regulation and solving problems. For more information on this topic and useful exercises see “Polyvagal Hybrid States and Complex Posttraumatic Stress Disorder” by author.

Combining EMDR and Polyvagal Therapy for Complex PTSD

Combining EMDR with Polyvagal Therapy makes use of the strengths of both methods. Polyvagal Therapy is a unique method of evaluating autonomic states and state shifts as well as a helpful framework for understanding reactivity and resolve in relationships. EMDR is a highly effective method of treatment that makes use of neurobiological mechanisms to eliminate the negative impacts of traumatic memory. Additionally, EMDR has a significant impact on increasing the rational perception of events. This lends itself to be a method of individual resource for the process of change, particularly related to cognitions and imagery. Combining these two methods assists someone dealing with Complex PTSD to have quicker and more effect resolve. Follow these six steps below.

1.Complete the polyvagal profile map first – To begin combining EMDR with Polyvagal Therapy first complete the polyvagal profile map. This will be an introduction to polyvagal theory and will begin to assist in recognizing the subjective experience of the various states, the triggers for those states and a recognition of the internal resources needed to avoid states of defense. Additionally, it will prepare one to target memories more effectively for EMDR reprocessing and will be a vehicle of the narrative of change following EMDR reprocessing. See the article “Polyvagal Profile Maps for Complex Posttraumatic Stress Disorder” by author for directives on this process.

2. Use EMDR for PTSD memories first – Complex PTSD can consist of both major traumatic memories as well as memories of repetitive nonacute occurrences. Following the initial assessment, it should be determined if there are symptoms of PTSD. If it is the case, those memories leading to PTDS should be reprocessed first using EMDR. This is done for two reasons. First, eliminating the negative impacts of traumatic memory leading to PTDS will bring the most amount of relief in the fastest way. This relief will then allow for better functioning in and out of sessions as well as more ego strength to manage the treatment process. Second, PTSD generates a specific set of symptoms that are debilitating and will interfere with reprocessing memories that are nonacute. Eliminating these symptoms will assist in better listing and reprocessing nonacute memories found in Complex PTSD.

3. Use EMDR for nonacute traumatic memories – The impacts of repetitive abuse in a relationship or in childhood will have a profound negative and confusing impact on a person’s cognitive, social, and emotional life. These impacts will significantly impact one’s level of defense and reactivity. Also, many of the triggers related to switching to more defensive states in the polyvagal profile are triggered by memories. The elimination of these triggers will allow for better use of the polyvagal exercises, decreasing defense in conflicts and finding more restoration in relationships.

4. Do polyvagal problem solving following PTDS memory reprocessing – After one has completed the list of acute and nonacute traumas using EMDR, they will be in a much better position cognitively, emotionally and behavioral to make use of polyvagal problem solving. Polyvagal problem solving is a process of managing and changing day to day relational hardship and requires using the gains of EMDR in combination with a growing understanding of an autonomic state. Thus, it pulls together growth and understanding on a consistent basis while solving daily problems. Polyvagal problem solving then increases one’s window of tolerance since their capacities to manage stressful situations increases and the need for defense is less. For directives on completing Polyvagal problem solving see “Polyvagal Problem Solving for Complex Posttraumatic Stress Disorder” by author.

5.Use EMDR to reprocesses polyvagal problem-solving examples – As one begins to consistently use polyvagal problem solving, they can begin to use EMDR and treat each problem as if it were a trauma. The therapist should use the standard EMDR protocol for this procedure. This process will assist in further distancing the memory but will also allow one to use the EMDR positive cognition resource to activate states of ventral vagal safety more quickly and consistently.

6. Use EMDR as a resource installation technique for polyvagal hybrid states – Polyvagal hybrid states are unique combination states coactivating the ventral vagal state with the two defensive states to create states of safe mobilization and safe immobilization. One should first complete the exercise found in “Polyvagal Hybrid States and Complex Posttraumatic Stress Disorder”. EMDR can be used primarily as a resource installation technique. For example, an individual completing the hybrid exercise might envision decreasing a personal conflict found in a sympathetic state by introducing the concepts of competitive play which is a safe and social ventral vagal position. The standard EMDR procedure could be done on the conflict itself while the positive cognition would be developed based on an imagery of someone involved in play. In this way, EMDR is used as an installation technique to reprocesses a negative memory using a polyvagal framework. Another example might consist of someone who has been triggered and is in the dorsal vagal, immobilized shutdown state. Again, using the concept of play, the person might envision play tactics of teasing, flirtatiousness, friendly competition, and playful touch in order to challenge the shutdown state and create a state of collective immobilization leading to closeness and intimacy. Again, EMDR can be used to treat the attempted connection as a trauma using the standard protocol and the EMDR resource installation would allow for  distancing from the picture combined with the rational thinking facilitated by EMDR and the increased capacity to form intimate bonds through states of nondefense.  


The Pocket Guide to Polyvagal Theory: The Transformative Power of Feeling Safe by Stephen Porges (2017)

The Polyvagal Theory in Therapy by Deb Dana (2018)

The Polyvagal Theory: Neurophysiological Foundations of Emotions, Attachment Communication and Self-Regulation by Stephen Porges PhD (2011)

Traumatic Stress: The Effects of Overwhelming Experience on The Mind, Body and Societ y by Bessel Vander Klok, Alexander Mc Farlane, and Lars Weisaeth (2007)

Yoga Therapy and Polyvagal Theory: The Convergence of Traditional Wisdom and Contemporary Neuroscience for Self-Regulation and Resilience by Sullivan, Erb, Schmalzi, Moonaz, Tylor, and Porges from Frontiers in Human Neuroscience February 2018.

Eye Movement Desensitization and Reprocessing: Basic Principles, Protocols and Procedures by Francine Shapiro PhD (2001)

EMDR as an Integrative Psychotherapy Approach: Experts from Diverse Orientations Explore the Paradigm Prism Edited by Francine Shapiro PhD (2002)

Getting Past Your Past: Take Control of Your Life with Self Help Techniques from EMDR Therapy by Francine Shapiro PhD (2012)  

Schema Therapy – A Practitioner’s Guide by Jeffrey Young PhD, Janet Klosko PhD and Marjorie Weishaar PhD (2003)

Reinventing Your Life by Jeffrey Young PhD and Janet Klosko PhD (1993)

Schema Therapy by Eshkol Rafaeli, David Bernstein and Jeffrey Young (2011)

Negative Thinking Patterns: A Schema Therapy Self – Help and Support Book by Gitta Jacob, Hannie Van Genderen and Laura Seebauer

Cognitive Therapy – Basic and Beyond by Judith Beck (1995)

Cognitive Therapy for Personality Disorders – A Schema Focused Approach by Jeffry Young (1999)

Cognitive Therapy of Personality Disorders by Aaron Beck, Arthur Freeman and Denise Davis (2004)

Leave a Reply

Your email address will not be published. Required fields are marked *