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. 2025 Oct 29;16(1):2573616. doi: 10.1080/20008066.2025.2573616

Treating complex PTSD with Schema Therapy, ImRs and EMDR: a review and case study

Tratamiento del TEPT Complejo con Terapia de Esquemas, ImRs y EMDR: una revision y studio de caso

Mellony TC van Hemert a, Paula M de Jong a, Tessa R Brouwer a,CONTACT, Luciano Zoon a, Ellen Gunst b, Laurence Claes c, Manuel Morrens b
PMCID: PMC12573552  PMID: 41160015

ABSTRACT

Introduction: Complex PTSD (CPTSD) often results from prolonged trauma, such as childhood abuse or domestic violence. Cognitive Behavioral Therapy (CBT) and Eye Movement Desensitization and Reprocessing (EMDR) are recommended for treating PTSD. However, their limited effectiveness for CPTSD highlights the need for alternatives such as Schema Therapy (ST) and Imagery Rescripting. This case study evaluates the effectiveness of a combined therapy approach integrating ST, ImRs, and EMDR for treating CPTSD.

Method: A combination of Schema Therapy and EMDR was used. Treatment progressed in phases: Sessions 1–20 focused on building trust, case conceptualization (1–10) and reducing dysfunctional coping and Implementing Experiential Treatment (11–20). Sessions 21–40 were focused on trauma-focused therapy using a combination of ImRs and EMDR. The final phase (41–50) emphasized relapse prevention and was used as follow-up.

Results: Results showed notable reductions in maladaptive schemas, such as Unrelenting Standards/Hypercriticism and Detached Self-Soother and a decrease in the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5) score from severe to below the clinical cut-off for PTSD.

Conclusion: While the patient's case demonstrates promising outcomes, further research is needed to establish the efficacy of integrating ST, EMDR and ImRs for CPTSD. A randomized controlled trial is essential to compare this combined approach with each treatment separately and to explore the impact of treatment sequencing. Ultimately, optimizing therapy for CPTSD will require a personalized approach based on individual needs and responses.

KEYWORDS: Complex PTSD, PTSD, Schema Therapy, EMDR, imagery rescripting, personalized treatment approach, trauma-focused therapy

HIGHLIGHTS

  • Effective Combined Therapy: This case study demonstrates the promising effectiveness of combining Schema Therapy (ST), Imagery Rescripting (ImRs), and EMDR to treat Complex PTSD (CPTSD), resulting in significant reductions in maladaptive schemas and a marked decrease in PTSD symptoms as measured by the CAPS-5.

  • Importance of Personalized Treatment: The study underscores the need for a personalized approach to CPTSD, highlighting the value of adapting therapy based on the individual’s unique trauma history, emotional needs, and readiness for trauma-focused treatment.

1. Introduction

1.1. Complex PTSD

Post-traumatic stress disorder (PTSD) can develop after exposure to traumatic events involving actual or threatened death, serious injury, or sexual violence (APA, 2013). Symptoms vary depending on the trauma’s type and timing, with differences between single-incident trauma, repeated exposure, and trauma in adulthood versus childhood (Terr, 2003). In the ICD-11, PTSD is defined by core symptoms of re-experiencing the trauma, avoidance, and a persistent sense of threat (WHO, 2022). To reflect differences seen particularly after prolonged or repeated trauma, the ICD-11 also introduced Complex PTSD (CPTSD), which expands on PTSD by including persistent issues with emotion regulation, identity, and relationships (Maercker, 2021; WHO, 2022). Key risk factors for CPTSD include being female, childhood abuse (sexual or physical), ongoing physical abuse, and emotional neglect (Leiva-Bianchi et al., 2023). While both PTSD and CPTSD can stem from adult trauma, childhood trauma is more strongly linked to CPTSD (Cloitre et al., 2019). Reflecting its clinical relevance, global CPTSD prevalence is estimated at 2.6% to 7.7% (Ben-Ezra et al., 2018; Cloitre et al., 2019; Hyland et al., 2020).

The impact of CPTSD is profound. Individuals experience higher psychiatric comorbidity, such as major depressive disorder (MDD) and generalized anxiety disorder (GAD), and lower psychological well-being compared to those with PTSD alone (Cloitre et al., 2019). Survivors of childhood sexual abuse are more likely to report poor general health, more mentally and physically unhealthy days per month, and lower health-related quality of life (Downing et al., 2021). Economically, PTSD incurs substantial costs, estimated at $232.2 billion annually in the U.S. and up to one billion Euros in the Netherlands, mainly due to healthcare use, lost productivity, and reduced quality of life (Davis et al., 2022; Dijk & Kiernan, 2023). These figures likely underestimate the full societal burden of CPTSD, given its greater suffering, underdiagnosis, limited care access, and long-term consequences.

1.2. Treatment for PTSD and CPTSD

Given their profound individual and societal impact, effective treatment for PTSD and CPTSD is essential. Trauma-focused Cognitive Behavioral Therapy (TF-CBT) and Eye Movement Desensitization and Reprocessing (EMDR) are recommended by both the APA (2017) and NICE (2018). While both therapies outperform waitlists or usual care, their effect sizes are modest compared to non-trauma-focused treatments and show no clear superiority over other trauma-focused approaches (Hudays et al., 2022; McLean et al., 2022). Meta-analyses show that about 40% of TF-CBT completers still meet PTSD criteria, and even those no longer diagnosed often report residual symptoms (Bradley et al., 2005). Research indicates that childhood abuse can negatively moderate treatment outcomes, with individuals more severely affected by early abuse showing less improvement (Karatzias et al., 2019). Although childhood trauma is a significant risk factor, CPTSD can also result from other forms of prolonged or repeated trauma, underscoring the need to adapt treatments to the diverse presentations of CPTSD. Despite TF-CBT and EMDR’s efficacy, concerns exist regarding study quality, publication bias, and limited advantage over placebo (Bhattacharya et al., 2022; Cuijpers et al., 2020). Cloitre et al. (2010) reported even higher dropout among individuals with PTSD related to childhood trauma, underscoring the difficulty of sustaining treatment engagement in this population. Moreover, research on CPTSD-specific treatments remains limited (Bisson & Andrew, 2013; Davis et al., 2022; Dijk & Kiernan, 2023). Schema Therapy (ST), particularly Imaginary Rescripting (ImRs), has emerged as a promising alternative for PTSD. A systematic review found preliminary evidence that ImRs may reduce PTSD, anxiety, OCD symptoms, and maladaptive schemas, though methodological limitations prevent firm conclusions (Peeters et al., 2022). For CPTSD, early findings suggest ST and ImRs may be effective as stand-alone treatments or as add-ons (Arntz et al., 2007; Boterhoven de Haan et al., 2020; Jung & Steil, 2013; Raabe et al., 2022). While promising, these results need confirmation in larger, high-quality studies.

1.3. The need for personalized treatment approaches

Personalized treatments are increasingly recognized for improving therapy outcomes across psychological disorders (Nye et al., 2023). Personalized treatment refers to tailoring therapeutic approaches to the individual characteristics, needs, and context of each patient, rather than applying a uniform protocol. A meta-analysis of 66 studies with 8,803 PTSD patients found significant variability in treatment effects, suggesting personalization could boost effectiveness by up to 12% (Herzog & Kaiser, 2022).

This variability partly fuels the debate around best practices for CPTSD. Current guidelines favour a phased approach, beginning with stabilization before trauma-focused therapy (Cloitre et al., 2012). However, some argue this is not evidence-based. De Jongh et al. (2016) argue that CPTSD patients, even with severe comorbidities or childhood trauma, can safely begin trauma-focused therapy without prior stabilization. Supporting this, Van Vliet et al. (2021) found no outcome differences between phase-based and immediate approaches. Similarly, Ter Heide et al. (2011) found EMDR as effective as stabilization alone, with no higher dropout. Bongaerts et al. (2017) also showed intensive EMDR effectively reduced PTSD symptoms in CPTSD patients, with most maintaining gains after three months, though a few dropped out or showed limited improvement. Still, some experts, like Willis et al. (2023), emphasize that stabilization may benefit certain individuals.

In this case study, the therapist aimed to personalize treatment by taking additional time to build a strong therapeutic alliance and foster trust, as well as providing greater emphasis on stabilization before moving to trauma-focused interventions. The approach considered factors such as the client’s unstable self-esteem, her stage as a young adult, and her ongoing residence in an unsafe home with her mother. Although trauma-focused treatment seemed most suitable, the client initially declined, showing significant avoidance.

1.4. Treating complex PTSD with Schema Therapy, ImRs and EMDR

ST targets deeply ingrained patterns, or ‘schemas,’ that develop early in life, helping clients recognize maladaptive coping strategies and gradually replace them with healthier alternatives (Young et al., 2003). ImRs enables clients to revisit distressing memories and modify them through guided imagery, introducing protective or empowering elements to reduce emotional impact (Arntz, 2012). EMDR involves recalling traumatic experiences while engaging in bilateral stimulation, such as guided eye movements, to facilitate memory reprocessing and decrease emotional distress (Shapiro, 2018). In practice, a therapist may select ImRs for working on memories that require cognitive-emotional restructuring, and EMDR for addressing highly vivid or intrusive traumatic memories.

In this case study, a combination of ST, ImRs, and EMDR was applied to address the client’s complex needs. These interventions were tailored to the client’s particular history and presenting problems. While both ImRs and EMDR were used during the trauma-processing phase in this case study, they served slightly different purposes. ImRs could be particularly useful for addressing distressing memories that involve strong shame, guilt, or relational trauma, as it allows the patient to actively modify the imagery and experience a sense of mastery or protection. EMDR, on the other hand, may be more suitable for memories that are highly intrusive or emotionally intense, where bilateral stimulation can facilitate rapid reprocessing and reduction of distress. For the purposes of this case study, we propose that ImRs and other Schema Therapy techniques may be used to ‘prepare’ the patient and enhance self-esteem before directly confronting intrusive memories with EMDR.

1.5. Objective

This study aims to assess the effectiveness of a combined therapy approach integrating ST with ImRs and EMDR for treating CPTSD. Given the limited research on optimal treatments, this study presents a detailed case of an outpatient, ‘Marie,’ to explore the benefits, challenges, and outcomes of combining these therapies.

2. Case report

Marie, an 18-year-old woman born and raised in the Netherlands to parents from Kosovo, sought treatment for worsening panic attacks during a stressful period at school. Having never received psychological treatment before, she attributed her distress to home responsibilities and frequent conflicts with her mother. As a child, Marie witnessed domestic violence between her parents before their divorce when she was six. Her father returned to Kosovo, while she, her mother, and her two brothers remained in the Netherlands, living without legal documentation and hiding from immigration authorities for years. At eight, her mother entered a new relationship and had a daughter. Marie recalls being treated differently from her half-sister, particularly by her stepfather, often facing criticism and neglect.

Despite these challenges, Marie had completed high school, worked four days a week in a store, and enjoyed a large social circle, playing volleyball, and visiting museums. While she had experienced anxiety before, she had always managed to suppress it. During intake, she disclosed a history of childhood trauma, including neglect and exposure to violence, identifying it as a key factor in her symptoms. She described experiencing flashbacks, avoidant behaviour, irritability, anger, sleep disturbances and low self-esteem. It also became evident that the client lacked a well-developed sense of identity, and her ongoing panic symptoms appeared to be connected to repressed emotions. She also expressed distrust in others and little hope that therapy would help. Following the intake, the client met the DSM-5 criteria for PTSD, with symptom severity above the diagnostic threshold across all symptom clusters. In addition, she exhibited symptoms consistent with complex PTSD (CPTSD) as described in ICD-11, including affect dysregulation, negative self-concept, and relational difficulties, as well as panic attacks, although she did not meet full criteria for a panic disorder (Figure 1 and Table 1).

Figure 1.

Figure 1.

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Flowchart of treatment phases and assessment timepoints.

Table 1.

Diagnostic and outcome measures administered from intake to session 50.

    Intake Session 20 Session 40 Session 50
Diagnostic measures Structured Clinical Interview for DSM-5 Disorders – Clinician Version (SCID-5-CV; First et al., 2016) x      
Experiences in Close Relationships-Revised (ECR-R; Fraley et al., 2000) Adult Attachment Questionnaire x      
Outcome measures Clinician-Administered PTSD Scale for DSM-5 (CAPS-5; Weathers et al., 2013) x x x x
Young Schema Questionnaire-Long Form 3 (YSQ-L3; Young et al., 2003) x x x x
The Schema Mode Inventory (SMI; Young et al., 2007) x x x x
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Note: The working alliance was assessed by means of The Working Alliance Inventory (WAI; Stinckens et al., 2009) in each session for the first 23 sessions.

3. Method

3.1. Clinical diagnostic measures

The Dutch versions of the following instruments were used to assess clinical diagnoses.

3.1.1. Structured Clinical Interview for DSM-5 Disorders

The Structured Clinical Interview for DSM-5 Disorders – Clinician Version (SCID-5-CV; First et al., 2016) is a semi-structured interview widely used to assess DSM-5 disorders. It covers a broad range of mental health conditions and has shown high positive agreement with clinical diagnoses (73%–97%) and sensitivity/specificity values above 0.70. Most diagnoses show strong reliability, with kappa values greater than 0.70, and its test-retest reliability is adequate. The SCID-5-CV has proven validity and adaptability for clinical practice (Osório et al., 2019).

The Experiences in Close Relationships-Revised (ECR-R) Adult Attachment Questionnaire (Fraley et al., 2000) is a 36-item self-report scale designed to assess adult attachment style, specifically attachment anxiety and avoidance. The items are rated on a 7-point Likert scale ranging from 1 (strongly disagree) to 7 (strongly agree). The ECR-R evaluates two dimensions: attachment anxiety and attachment avoidance. The ECR-R shows excellent test-retest reliability (α = .91–.94) and good construct validity, correlating with interpersonal functioning, emotional regulation, and mental health symptoms (Kooiman et al., 2012; Sibley & Liu, 2004). This instrument is widely validated and has stable psychometric properties, making it a valid and reliable tool for assessing attachment-related issues in adult populations.

3.2. Clinical outcome measures

The Dutch versions of the following instruments were used to assess diagnostic outcomes:

3.2.1. Clinician-Administered PTSD Scale for DSM-5

The Clinician-Administered PTSD Scale for DSM-5 (CAPS-5; Weathers et al., 2013) is a 30-item structured interview used to assess PTSD symptoms and diagnose PTSD, including both current (past month) and lifetime PTSD, as well as symptoms from the past week. The items are clinician-rated based on the DSM-5 criteria for PTSD. The Dutch version of the CAPS-5 has demonstrated adequate psychometric properties, including support for refined factor models (six and seven factors) specific to DSM-5 PTSD (Boeschoten et al., 2018). A score below 33 on the CAPS-5 is considered below the clinical cut-off for diagnosing PTSD (Weathers et al., 2018). Scores above 33 indicate clinically significant PTSD symptoms, with higher ranges corresponding to severity: moderate (33–48), severe (49–67), and extreme/severe (68+) PTSD, based on established CAPS-5 severity guidelines (Weathers et al., 2018). However, a formal PTSD diagnosis requires not only a total score above the clinical threshold but also meeting DSM-5 criteria for each symptom cluster (intrusion, avoidance, negative alterations in cognition and mood, and alterations in arousal and reactivity). Each cluster must have a sufficient number of symptoms rated at the clinically significant threshold (≥2) to fulfil the diagnostic criteria. For the present case, a formal PTSD diagnosis was established not only based on the total CAPS-5 score but also by confirming that the DSM-5 criteria were met across all symptom clusters, with each cluster containing sufficient clinically significant symptoms.

3.2.2. Young Schema Questionnaire

The Young Schema Questionnaire-Long Form 3 (YSQ-L3; Young & Brown, 2003) is a 232-item self-report measure used to assess early maladaptive schemas (EMS) across 18 schemas, grouped into five broad domains. The items are rated on a 6-point Likert scale ranging from 1 (completely untrue) to 6 (describes me perfectly). The YSQ-L3 has demonstrated high internal consistency (α = .96; with subscales ranging from α = .85 to .95) and good factorial validity (Young et al., 2003). Items with scores exceeding 3, particularly those rated 5 or 6, are considered significant elevated. Research also shows that the YSQ-L3 is significantly correlated with post-traumatic symptoms (Dutra et al., 2008). Although most schemas show strong reliability, the Enmeshment schema has a lower internal consistency coefficient of .57 (Yalcin et al., 2023).

3.2.3. Schema Mode Inventory

The Schema Mode Inventory (SMI; Young et al., 2007) is a 118-item self-report measure used to assess the intensity of schema modes, which represent distinct personality states. The items are rated on a 6-point Likert scale ranging from 1 (completely untrue) to 6 (describes me perfectly). The SMI evaluates 14 different schema modes, capturing shifting emotional and cognitive states. The SMI demonstrates strong internal consistency (α = .87 with subscales ranging from α = .76 to α = .96), indicating reliable psychometric properties (Lobbestael et al., 2010). The construct validity of the SMI was supported by its significant correlations with other well-established measures of emotional regulation and personality traits, such as the Young Schema Questionnaire (YSQ) and the Beck Depression Inventory (BDI) (Young et al., 2007).

3.3. Clinical process measure

3.3.1. Working alliance inventory

The Working Alliance Inventory (WAI; Dutch version: Stinckens et al., 2009) is used to assess the therapeutic alliance between the therapist and client. The WAI consists of 12 items rated on a 5-point Likert scale (1 = strongly disagree to 5 = strongly agree) to evaluate the quality of the therapeutic relationship. The instrument assesses three key dimensions: bond, task, and goal agreement, which are essential components of the therapeutic alliance. The WAI has demonstrated high internal consistency (with subscales ranging from α = .82−.85) across different clinical settings, suggesting reliable psychometric properties. It also has strong predictive validity for treatment outcomes, indicating that a stronger therapeutic alliance is associated with better treatment results (Stinckens et al., 2009). The reliability of the WAI in measuring the therapeutic alliance is well-supported. In this study, the WAI was administered after each session to monitor the ongoing development of the therapist-client relationship.

We stopped assessing the WAI after session 23 because by this point, a ‘good enough’ therapeutic alliance had already been established, which is crucial for therapy success (Horvath et al., 2011). The early phases of therapy had focused on adjusting methods to fit the client’s specific needs, expectations, and capacities, fostering a collaborative environment. This allowed for the introduction of new ways to address the client’s concerns, making further WAI assessments less necessary as the alliance was solidified and no longer required frequent evaluation.

3.4. Course of treatment and assessment of progress

3.4.1. Sessions 1–10 – therapeutic relationship building, case conceptualization, and initiation of schema therapy

The first five sessions focused on psychoeducation about PTSD and introducing EMDR, which Marie declined as finding it too overwhelming. Given her trust issues and uncertainty around trauma-focused therapy, these sessions aimed to strengthen the therapeutic alliance, develop a case conceptualization, and boost her motivation for treatment.

After five sessions, we decided to begin schema therapy to process childhood emotional deprivation and neglect, aiming to build trust in the therapeutic relationship and eventually prepare Marie for trauma-focused treatment.

Sessions 5–10 focused on integrating the schema mode model and using experiential techniques like chair dialogues and diagnostic imagery. Key components included:

  • Validating Marie’s feelings, adapting to her needs, and building the therapeutic relationship.

  • Psychoeducation on trauma, schema therapy principles, and the impact of childhood experiences on maladaptive schemas.

  • Developing a case conceptualization by exploring early maladaptive schemas and identifying triggers and behavioural patterns, such as through mode diaries.

  • Defining treatment goals and discussing Marie’s expectations, with a focus on reducing the punishing parent mode and strengthening the healthy adult mode.

  • Using experiential techniques, such as chair dialogues, to explore and understand modes and set boundaries, with small behavioural assignments to help Marie reduce protective modes.

3.4.2. Sessions 11–20 – reducing protector modes and implementing experiential treatment

After session 10, Marie reported feeling validated and more aware of her emotions and behaviour, prompting the continuation of Schema Therapy with a shift toward processing past trauma. She identified emotional neglect and deprivation as key distress sources, and together we decided to apply ImRs over multiple sessions. The therapist took a directive, supportive stance to help Marie express emotions and assert herself.

ImRs was conducted in three phases: Re-experiencing the trauma with pauses to maintain control; reshaping the memory with adult empowerment; revisiting the revised memory from the child’s perspective to meet unmet needs. This helped Marie reduce emotional intensity and reframe her past. On days when protective modes interfered, chair dialogues were used instead to address internal conflicts and support trauma processing.

Key components of sessions 11–20 included:

  • ImRs helped Marie reprocess childhood neglect, offering relief and a more adaptive perspective.

  • Chair dialogues addressed emotional modes and reduced protective coping strategies that blocked trauma work.

3.4.3. Sessions 21–40 – Trauma-Focused Therapy

After session 20, Marie reported feeling better, but CAPS scores revealed heightened PTSD symptoms, likely due to reduced protective modes and increased access to her vulnerable child mode. She initially asked to slow down therapy but later requested more frequent sessions, feeling ready to disclose painful experiences, including sexual abuse by her stepfather.

As trust deepened, Marie became open to trauma-focused treatment. Given her distress, EMDR was proposed for its potential rapid symptom relief. After psychoeducation and trauma mapping in session 29, EMDR began in session 30. Marie processed multiple incidents of sexual and physical abuse. By session 40, she reported substantial symptom reduction, including fewer nightmares and flashbacks.

Key components of sessions 21–40:

  • Sessions were less frequent initially, but there was not a therapy break. Rather, the adjusted session schedule allowed for more time between appointments to process the work done up to that point.

  • Marie’s self-disclosure increased, including revelations of sexual abuse.

  • EMDR helped reprocess traumatic memories, significantly reducing PTSD symptoms.

3.4.4. Sessions 41–50 – relapse prevention and follow-up

Sessions 41–47 focused on relapse prevention, helping Marie manage child modes, regulate emotions, and strengthen her healthy adult mode. Strategies were also aimed at expanding her social network. To support a gradual detachment and increase her confidence, sessions were held biweekly. The final three sessions were monthly follow-ups, offering support during the transition and reinforcing closure, shifting Marie’s experience from abandonment to empowerment.

4. Results

4.1. SCID-5-CV

Based on the SCID-5-CV assessment, Marie met the criteria for posttraumatic stress disorder (PTSD) at intake, exhibiting symptoms of re-experiencing, avoidance and heightened irritability. No panic disorder was diagnosed, as she lacked avoidance or anticipatory anxiety.

4.2. ECR-R adult attachment questionnaire

Marie scored within the normal range for anxious attachment (3/7), but scored 5.5/7 for avoidant attachment, indicating clinical significance. This suggests that the client tends to be emotionally distant in relationships, has difficulty relying on others for support, and may suppress emotional needs as a coping mechanism. These attachment patterns were considered in the case conceptualization, as her avoidant attachment style likely contributed to difficulties in forming close connections and trusting others, including within the therapeutic relationship. Furthermore, individuals with this attachment style may also tend to avoid their own internal experiences, which can pose additional challenges in trauma-focused treatment.

4.3. CAPS

At the start of treatment, Marie’s initial CAPS-5 score was 54. This score, in combination with assessment of DSM-5 symptom cluster criteria, indicated a diagnosis of PTSD. By session 20, her score had increased to 76. Higher CAPS-5 scores correspond to greater symptom severity, with scores above 75 generally indicating a extreme/severe presentation of PTSD. From sessions 20 to 40, the focus shifted to trauma-focused therapy, adding EMDR to ImRs to specifically target her PTSD symptoms. By session 40, her score had dropped to 30, approaching the clinical cut-off for PTSD. At this point, Marie no longer met the diagnostic criteria for PTSD, as she no longer exhibited sufficient symptoms across all required clusters. By the end of treatment, her score had further decreased to 12, indicating full remission of PTSD symptoms (Figure 2).

Figure 2.

Figure 2.

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CAPS-5 scores over time at baseline, session 20, session 40, and session 50, with key therapeutic interventions indicated.

4.4. YSQ

The greatest reduction was seen in Unrelenting Standards/Hypercriticism, which dropped by 2.94 points (RCI = 4.63, p < .05). Significant decreases were also found in Self-Sacrifice (−1.76, RCI = 2.20, p < .05) and Dependence/Incompetence (−0.93, RCI = 3.65, p < .05). Enmeshment/Undeveloped Self decreased by 1.18 points, though this change was not statistically significant. By session 40, all schema scores were below 3.0. Notably, at intake, only Self-Sacrifice (3.76) and Unrelenting Standards/Hypercriticism (4.50) exceeded this threshold. These relatively low initial scores may reflect Marie’s emotional suppression and hesitancy to open up early in treatment (Figure 3).

Figure 3.

Figure 3.

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Mean scores on the Young Schema Questionnaire–Long Form 3 (YSQ-L3; Young et al., 2003) at intake and at sessions 20, 40, and 50.

4.5. SMI

The most significant reductions were found in the Detached Self-Soother (−2.75, RCI = 2.91, p < .05) and Demanding/Hypercritical Parent modes (−2.86, RCI = 2.79, p < .05). The Vulnerable Child mode also decreased significantly (−1.4, RCI = 3.17, p < .05). Surprisingly, the Healthy Adult mode declined slightly from 5.2 to 4.6 (RCI = 2.65, p < .05), which may reflect an initially inflated score due to limited insight, defensiveness, or mistrust early in treatment. Despite relatively low baseline scores, the data indicate meaningful reductions in dysfunctional modes, which is notable in the context of complex PTSD (Figure 4).

Figure 4.

Figure 4.

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Mean scores on the Schema Mode Inventory (SMI; Young et al., 2007) at intake and at sessions 20, 40, and 50.

4.6. WAI

Therapist scores ranged from 35 (58%) to 49 (82%), averaging 42 (70%). A peak appeared during sessions 14–17, coinciding with imagery rescripting. Marie’s scores ranged from 41 (60%) to 54 (88%), with a notable dip in session 5, likely due to a three-week therapy break. From session 11 to 23, her scores remained consistently high (average 49), with notable peaks in sessions 12 and 15, suggesting a strong and stable therapeutic alliance during this phase.

5. Discussion

This case study examined the effectiveness of combining ST and EMDR in treating CPTSD. Marie’s trajectory highlights both the promise and complexity of this approach. Although her CAPS-5 score initially rose to 76 by session 20, reflecting a severe intensification of symptoms, this increase was interpreted as a temporary, expected response to engaging more fully with traumatic material rather than treatment failure. Early sessions focused on reducing maladaptive coping and building trust. As avoidance diminished, Marie became more emotionally vulnerable, which led to heightened distress. The therapist actively monitored risk, validated Marie’s experiences, and employed stabilization techniques to maintain engagement and minimize the risk of dropout. This emotional engagement marked a key therapeutic turning point: Marie became more open, disclosed deeper trauma, and embraced trauma-focused interventions. Over time, these strategies facilitated substantial clinical improvement, with final CAPS-5 scores falling below the PTSD threshold, indicating full symptom remission.

While Marie demonstrated improvements in maladaptive schemas such as Unrelenting Standards and Self-Sacrifice, notable discrepancies emerged between her self-report scores and clinical observations. Her initially low scores likely reflected avoidant attachment patterns, coping through emotional suppression, and an internalized demanding parent mode, all of which contributed to underreporting distress. Although Marie appeared resilient, deeper therapeutic work revealed significant emotional turmoil. This underscores a key challenge in treating CPTSD: clients often downplay symptoms due to avoidance, mistrust, or high self-expectations. Standardized measures may fail to capture this complexity, highlighting the value of case studies in providing a more accurate and nuanced understanding of symptom severity in this population (Beutler et al., 2020).

Marie’s case contributes to the growing body of evidence supporting ST and ImRs as promising stand-alone or adjunctive treatments for CPTSD (Arntz et al., 2007; Boterhoven de Haan et al., 2020; Jung & Steil, 2013; Peeters et al., 2022; Raabe et al., 2022). While prior studies have primarily applied ImRs to directly target traumatic memories, in this case, it was used both alongside EMDR to process high-impact traumatic experiences and independently to address early experiences of emotional neglect. These findings also align with Cloitre’s (2015) emphasis on tailoring trauma treatment to individual profiles, considering factors such as trauma history, attachment patterns, current life context, and treatment readiness. However, as a single case study, these results are not generalizable. The observed effects may be influenced by individual factors, including Marie’s specific trauma history, therapeutic relationship, and treatment context. Future research should aim to replicate these findings in larger, more diverse samples, ideally using single-case and group experimental designs, to determine the broader efficacy of combining ST, ImRs, and EMDR for CPTSD. Additionally, longitudinal studies could clarify the durability of treatment effects and identify patient characteristics that predict optimal outcomes. Such research would help refine personalized approaches and provide stronger empirical guidance for clinical practice.

Considering the inherent limitations of case studies, one notable drawback of this particular case is the limited number of assessment points. In hindsight, a more consistent approach, with assessments conducted every ten sessions, might have provided a clearer understanding of the CAPS-5 scores over time. This would have been especially beneficial during the trauma-focused treatment phase, as an additional assessment could have helped to better evaluate the effects of ImRs and EMDR. Furthermore, this case study highlights the complexities of real-world clinical practice, where treatments do not always follow a straightforward path and the timing and application of different techniques can be unclear. In Marie’s case, for instance, she began to withdraw from therapy as her symptoms worsened, telling the therapist she was feeling better when, in reality, her symptoms had increased. Between sessions 20 and 27, Marie attended therapy less frequently and reported improvements, despite her symptoms not fully reflecting this. Notably, it was only in session 28, after disclosing her most invalidating traumas, that a relatively short, protocol-driven EMDR sequence was introduced. However, this case study does not suggest that the small number of EMDR sessions alone were sufficient for such significant progress. Rather, it highlights that the earlier phases of treatment were crucial in preparing Marie to engage with and benefit from the trauma-focused interventions that she had previously been reluctant to pursue.

In conclusion, this case study illustrates the value of tailoring trauma treatment to the individual’s readiness, coping capacity, and therapeutic needs. Marie’s trajectory highlights the importance of integrating experiential techniques within a phased model of care, particularly for patients with complex trauma. Future research should investigate which individuals benefit most from integrative approaches, and under what conditions and timing these interventions are most effective.

Appendix.

Table A1.

Mean schema scores (YSQ-L3; Young et al., 2003) at intake, session 20, session 40, and session 50, with change scores, corrected test-retest coefficients (rC), standard deviations (SD), and Reliable Change Index (RCI).

Modes Intake Session 20 Session 40 Session 50 Change rt SD2 RCI
Vulnerable child 2.5 2.7 1.8 1.1 1.4 0.89 0.94 3.17*
Angry child 2.4 2.3 2.4 1.8 0.6 0.14 0.90 0.51
Enraged child 1.1 1.33 1.22 1 0.1 0.59 0.67 0.17
Impulsive child 2.25 2.13 2.38 2.25 0 0.13 0.72 0.00
Undisciplined child 1.8 2 2 1.6 0.2 0.67 0.85 0.29
Happy child 4.4 4.6 4.7 5.4 1 0.12 0.87 0.87
Compliant Surrenderer 2 2.43 2.43 1.57 0.43 0.34 0.88 0.43
Detached Protector 2.11 2.22 1.78 1.56 0.55 0.63 0.94 0.68
Detached Self-Soother 4 3.25 2.25 1.25 2.75 0.46 0.91 2.91*
Self-Aggrandizer 3.4 3 2 1.6 1.8 0.20 0.76 1.87
Bullying/Attacking 1.78 1.56 1.33 1 0.78 0.52 0.68 1.17
Puntitive Parent 2 2 1.4 1.1 0.9 0.77 0.90 1.47
Demanding/Hypercritical Parent 4 3.14 2.29 1.14 2.86 0.27 0.85 2.79*
Healthy Adult 5.2 5.1 5 4.6 0.6 0.96 0.80 2.65*
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1. rt = ICC(3.1). used as a test-retest coefficient between different tests over time. as described in Lobbestael et al. (2010).

2. SD as described in Lobbestael et al. (2010). from the clinical sample (Axis I).

* Changes with a Reliable Change Index (RCI) greater than 1.96 are considered statistically significant at the p < .05 level.

Table A2.

Mean schema mode scores (SMI; Lobbestael et al., 2010) at intake, session 20, session 40, and session 50, with change scores, corrected test-retest coefficients (rC), standard deviations (SD), and Reliable Change Index (RCI).

Schemas Intake Session 20 Session 40 Session 50 Change rC1 SD2 RCI
Emotional Deprivation 1.89 2.11 2.67 1.67 0.22 0.95 1.28 −0.54
Abandonment/Instability 1.94 2.17 1.89 1.17 0.77 0.83 1.05 1.26
Mistrust/abuse 2.53 2.06 2.18 1.71 0.82 0.83 1.05 1.34
Social isolation/Alienation 2.4 2.4 2.1 1.6 0.80 0.87 1.29 1.22
Defectiveness/Shame 1.93 2 1.53 1.07 0.86 0.91 1.25 1.62
Dependence/Incompetence 2.13 2.07 1.6 1.2 0.93 0.97 1.04 3.65*
Failure 2 2.11 1.89 1.22 0.78 0.89 1.20 1.39
Vulnerability to Harm or Illness 1.86 1.71 1.5 1 0.86 0.65 1.05 0.98
Enmeshment/Undeveloped Self 2.73 3.09 2.73 1.91 0.82 0.82 1.02 1.34
Entitlement/Grandiosity 2.27 2.36 1.73 1.64 0.63 0.87 0.79 1.56
Insufficient Self-Control/Self-Discipline 1.93 1.87 1.8 1.53 0.40 0.83 0.99 0.69
Subjugation 1.7 1.7 1.2 1.1 0.60 0.79 1.15 0.81
Self-Sacrifice 3.76 3 2.65 2 1.76 0.63 0.93 2.20*
Emotional Inhibition 1.89 1.78 1.78 1.22 0.67 0.92 1.19 1.41
Unrelenting Standards/Hypercriticalness 4.5 3.13 2.25 1.56 2.94 0.85 1.16 4.63*
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1. rC = corrected test-retest coefficient as described in Rijkeboer et al. (2005). 2. As described in Rijkeboer et al. (2005), from the clinical sample. * Changes with a Reliable Change Index (RCI) greater than 1.96 are considered statistically significant at the p < .05 level.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Ethics approval and consent to participate

Client signed informed consent and gave permission for publication. All identifiable details have been altered.

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