Stages of Change and EMDR Protocol Selection in Addiction Treatment

EMDR protocol selection in addiction treatment can become complicated when a client’s readiness for change does not match the intervention a clinician initially has in mind. A client who does not view substance use as a problem may be ready to work on trauma, anxiety, sleep, or emotional regulation while having little interest in directly addressing alcohol or drug use. Another client may be actively pursuing recovery and asking for help with cravings, relapse memories, or high-risk situations.

The Stages of Change model offers one way to organize these differences. Pre-Contemplation, Contemplation, Preparation, Action, and Maintenance describe different relationships to behavior change, and each stage can suggest different treatment priorities. Clients may also move forward, return to an earlier stage, or shift between stages as treatment and recovery progress.

For EMDR clinicians, the client’s current stage of change adds useful information to treatment planning. It can help clarify what the client is currently willing to address, which treatment targets are available, and whether the work may focus on stabilization, ambivalence, recovery planning, cravings and triggers, trauma memories, or longer-term recovery concerns.

Which EMDR Interventions Fit the Client’s Current Stage of Change?

When considering EMDR protocol selection in addiction treatment, begin with the client’s current relationship to change:

• The client does not identify substance use or the problematic behavior as something they want to change → Consider Pre-Contemplation and begin with the concerns the client identifies.

• The client recognizes concerns but remains uncertain about changing → Consider Contemplation and focus on ambivalence, discrepancies, recovery fears, and the perceived benefits of the substance or behavior.

• The client wants to make a change and is beginning to plan for it → Consider Preparation and strengthen recovery planning, coping capacities, trigger identification, and readiness for Action.

• The client is actively reducing or stopping substance use or changing a problematic behavior → Consider Action and assess cravings, triggers, relapse memories, trauma targets, and current relapse risk.

• The client is sustaining changes over time → Consider Maintenance and continue addressing residual triggers, recovery identity, future risk, unresolved memories, and major life transitions.

• The client’s motivation or behavior has changed since the previous assessment → Reassess the current stage before assuming the existing treatment sequence still fits.

Clients may move between stages as treatment progresses, and their stage of change may differ across substances or problematic behaviors. A client may be in Action around alcohol use while remaining in Contemplation about gambling, or may return to Contemplation after a relapse despite previously functioning in Action. Ongoing reassessment helps clinicians adjust treatment priorities and EMDR interventions as the client’s readiness changes.

Stages of Change Can Inform EMDR Treatment Planning

The Stages of Change model describes change as a process that develops over time. In addiction treatment, this is especially useful because recognizing a problem, deciding to change, preparing for change, actively changing behavior, and sustaining those changes involve different clinical tasks.

EMDR treatment planning can reflect those differences. A client who has no interest in stopping cannabis use but wants treatment for childhood trauma presents a different clinical decision from a client who has stopped using cannabis and is experiencing intense cravings every evening. The substance may be the same, but the client’s goals and available treatment targets are different.

Stage-based planning also helps clinicians avoid assuming that addiction-focused EMDR work always needs to begin with cravings or substance-related memories. Sometimes the appropriate EMDR work is the treatment the client actually came seeking. At other points, substance use, urges, relapse experiences, idealized memories, or fears about recovery become increasingly available for direct assessment.

Foundations of EMDR and Substance Use Treatment Planning can provide additional context for clinicians considering how readiness, stability, substance use patterns, trauma history, and recovery supports fit into the broader treatment plan.

Pre-Contemplation: Begin With the Client’s Treatment Goals

Clients in Pre-Contemplation generally do not identify their substance use or problematic behavior as something they want to change. They may be attending treatment because of pressure from a partner, employer, court, physician, or family member, or they may have entered therapy for a concern they see as unrelated to their substance use.

A client might say, “My wife thinks I drink too much, but I’m here because I can’t sleep.” Another may acknowledge consequences associated with gambling while maintaining that the behavior is manageable. Trying to organize treatment around recovery before the client has identified recovery as a goal can create tension that is unnecessary for EMDR treatment to proceed.

The clinician can begin with the concerns the client identifies. If the client wants help with anxiety, trauma symptoms, depression, relationship difficulties, or sleep, those concerns can guide assessment and treatment planning. Resource development and stabilization may also be appropriate when the client needs additional capacities for affect regulation or coping.

Trauma reprocessing is not automatically excluded because a client is in Pre-Contemplation about substance use. When the client is sufficiently stable and identifies trauma material they want to address, Standard Protocol work may remain appropriate. The clinician can continue assessing how trauma symptoms, coping patterns, and substance use interact without requiring the client to adopt a recovery goal they have not chosen.

Some clients begin identifying discrepancies during this work. They may notice that drinking helps them sleep initially but contributes to waking during the night, or that gambling provides temporary escape while worsening financial stress. When the client begins expressing those discrepancies, the treatment conversation may gradually shift toward Contemplation.

Contemplation: Work With Ambivalence

Clients in Contemplation recognize some concerns about their substance use or problematic behavior but remain uncertain about changing it. They may understand the consequences and simultaneously remember the relief, connection, confidence, pleasure, or escape the behavior has provided.

EMDR treatment planning during this stage can focus on understanding that ambivalence. The Two-Hand Interweave may be considered when the client is expressing competing positions about change, while Flashforward work may become relevant when fears about recovery are maintaining uncertainty. Idealized memories may also need assessment when positive experiences associated with substance use or the behavior continue to exert a strong pull.

For example, a client may say that they want to stop drinking because their relationship is deteriorating, then describe sobriety as lonely and boring. Another client may want to stop gambling while continuing to think about the excitement, confidence, and sense of possibility associated with previous wins. These statements provide information about the experiences that may need attention before the client can make a decision that feels like their own.

Working With Ambivalence About Recovery in EMDR explores this stage in greater depth. When positive memories of use are contributing to uncertainty, Idealized Memories of Substance Use in EMDR provides additional discussion of how those experiences can be incorporated into case conceptualization.

Standard trauma processing may also continue during Contemplation when the client is sufficiently stable and the identified memories fit their treatment goals. A client does not have to resolve every question about recovery before addressing trauma material they have chosen to work on.

Preparation: Build the Recovery Plan Before Action

Clients in Preparation are beginning to move from considering change toward planning it. They may be setting a quit date, discussing treatment options, reducing access to a substance or behavior, identifying support people, or deciding whether abstinence or harm reduction fits their goals.

This stage gives clinicians an opportunity to identify the conditions that could make Action difficult. External triggers, internal states, cravings, idealized memories, fears about recovery, previous treatment experiences, and available supports can all become part of treatment planning. The clinician can also assess whether additional stabilization or coordination with medical, psychiatric, or substance use providers is needed.

Relapse-prevention or harm-reduction planning belongs prominently here. The client can identify known triggers, coping responses, recovery supports, high-risk situations, and steps to take if urges increase. For some clients, medication treatment, medical stabilization, psychiatric care, structured substance use treatment, or community recovery support will also be part of the plan.

Preparation can include EMDR work when appropriate. Resource installation may support regulation, while work with idealized memories or recovery fears may address material that continues to interfere with the client’s plan. Trauma or decision-linked memories can also be considered when the client is stable and those experiences are directly connected with readiness for change.

Clients sometimes move back toward Contemplation during Preparation. A person who seemed ready to stop drinking may become uncertain as the quit date approaches, or someone preparing to change a compulsive sexual behavior may become increasingly aware of what they fear losing. That shift gives the clinician information about the next treatment task.

Action: Address Cravings, Triggers, and Relapse Memories

Clients in Action are actively changing their substance use or problematic behavior. They may have stopped using, substantially reduced use, entered a treatment program, restricted access to a behavior, or begun establishing new routines and recovery supports.

The treatment targets available during this stage are often more directly connected with the addictive cycle. External triggers may become apparent as clients encounter people, places, objects, websites, social situations, or other cues associated with previous behavior. Internal states may emerge when clients discover that loneliness, confidence, excitement, relief, sexual desirability, power, or emotional numbing had become strongly connected with the substance or behavior.

Different addiction-focused EMDR approaches address different parts of this clinical picture. DeTUR is designed around urges associated with external triggers, Feeling State Addiction Protocol addresses positive feeling states linked with addictive or dysfunctional behaviors, and CravEx includes addiction memories such as craving and relapse experiences. Standard Protocol work may continue to address trauma memories associated with the addictive cycle when the client has sufficient stability for reprocessing.

Protocol selection should follow assessment of the target. A client who experiences an urge every time they drive past a particular bar presents a different treatment problem from someone whose strongest urges occur when they feel rejected or inadequate. A third client may be relatively stable around current triggers but remain highly activated by a recent relapse that reinforced the belief, “I’ll never be able to stop.”

EMDR for Cravings: External Triggers, Internal States, and Relapse Memories examines those distinctions in greater detail. When a return to use or a problematic behavior has already occurred, Lapse, Relapse, and Shame: Revising the EMDR Treatment Plan After Use addresses how the episode itself can provide information for subsequent target selection.

Maintenance: Continue Treatment Beyond Initial Behavior Change

Clients in Maintenance are sustaining changes and developing ways to protect those changes over time. The immediate demands associated with stopping or reducing the behavior may have decreased, but new stressors, triggers, relationships, and life transitions can continue to expose areas that need attention.

Residual addiction-related targets may still be present. External triggers, positive feeling states, relapse memories, trauma experiences, shame, or fears about future relapse can remain appropriate areas for EMDR assessment. A client may also encounter new ambivalence when considering medication changes, leaving structured treatment, changing relationships, or making other decisions connected with recovery.

Identity can become increasingly prominent during this stage. Clients may be deciding how recovery fits into their understanding of themselves, how much of their history they want to disclose, or what life looks like after the behavior no longer organizes as much of their time and attention. Future-oriented work may also address anticipated high-risk situations, major transitions, and the client’s ability to respond differently when old cues reappear.

Maintenance does not mean the treatment sequence is complete. A previously unidentified trauma memory may emerge after the client has developed greater stability, or a major loss may reactivate urges that had been quiet for months. Continued assessment allows the treatment plan to change as the client’s recovery develops.

A Client’s Stage Can Change During EMDR Treatment

Stages of change are fluid. Clients may progress, return to an earlier stage, or cycle through stages repeatedly, including after periods of sustained recovery. Consider a client who has stopped using alcohol and has been actively addressing triggers. After several months, they return to use and begin questioning whether abstinence is realistic or even desirable. The clinician now has both a relapse memory to assess and new information suggesting that the client’s relationship to change has shifted.

The previous treatment sequence may need revision. Craving or trigger work may still be relevant, but renewed ambivalence, shame, fears about recovery, or changes in the client’s goals may need attention first. Reassessing stage of change helps clinicians respond to the current presentation instead of continuing a sequence developed for an earlier point in treatment.

Organizing EMDR Protocol Selection by Stage of Change

With several possible EMDR approaches available for substance use and problematic behaviors, protocol selection can become increasingly complex as treatment progresses. The clinician may be considering work with ambivalence, recovery fears, idealized memories, external triggers, internal feeling states, relapse memories, or trauma experiences, while also assessing whether the client is ready to engage with that material. This can leave clinicians asking two related questions: What is the client ready to work on at this point in the change process, and which intervention fits the treatment target that is currently available?

The Applying EMDR to Addiction & Problematic Behaviors: Protocol Sequencing by Stage of Change guide organizes treatment-planning considerations across Pre-Contemplation, Contemplation, Preparation, Action, and Maintenance. It is designed for EMDR clinicians who are already familiar with the protocols and interventions referenced in the guide, with the focus placed on deciding when different approaches may fit the client’s current readiness, treatment goals, and available targets. The guide does not teach the individual protocols or replace protocol-specific training, supervision, or consultation.

→ Applying EMDR to Addiction & Problematic Behaviors: Protocol Sequencing by Stage of Change

Using Stage of Change Alongside Target Assessment

Knowing that a client is in Action still does not tell the clinician whether the next target should involve an external trigger, a positive feeling state, a relapse memory, an earlier trauma experience, or something else. Stage of change helps organize treatment priorities, while target assessment identifies the material the clinician and client are actually working with.

This distinction becomes especially useful when several addiction-focused approaches appear relevant. DeTUR, CravEx, Feeling State Addiction Protocol, Flashforward, the Idealization Protocol, the Two-Hand Interweave, and Standard Protocol work address different clinical material. The presence of an addiction or problematic behavior alone is not enough to choose among them.

A client in Action could have a highly specific environmental trigger, a recurring internal feeling state associated with use, an emotionally charged relapse memory, and unresolved developmental trauma at the same time. Stage tells us something about the client’s current relationship to change. Assessment helps determine which of those experiences belongs next in the treatment sequence.

Comparing Addiction-Focused EMDR Approaches

Once the clinician has identified the client’s current stage and the treatment material requiring attention, comparing the purpose of individual approaches becomes useful. The goal is to match the intervention to the identified target while maintaining individualized case conceptualization.

The Addiction & Problematic Behavior Protocols in EMDR guide provides a concise clinical reference for commonly used approaches, including CravEx, DeTUR, Feeling State Addiction Protocol, Flashforward, the Idealization Protocol, and the Two-Hand Interweave. It summarizes their purpose, treatment targets, and clinical considerations so clinicians can compare approaches after identifying the clinical problem they are trying to address.

→ Addiction & Problematic Behavior Protocols in EMDR

The guide is intended for licensed mental health professionals trained in EMDR and assumes appropriate professional training and clinical judgment. It is an educational and organizational reference and does not replace formal protocol training, supervision, or consultation.

Protocol Selection Remains Individualized

Stage-based sequencing can organize clinical thinking, but clients rarely fit neatly into one category. A person may be in Maintenance with alcohol while remaining in Contemplation about gambling, or may be committed to stopping substance use while having no interest in changing another behavior that the clinician sees as concerning.

The client’s identified goals remain central to treatment planning. Stage of change can help the clinician understand the client’s current relationship to a specific change, while ongoing assessment provides information about stability, readiness for reprocessing, trauma history, cravings, relapse risk, medical and psychiatric concerns, recovery supports, and the targets currently available for EMDR work.

Protocol selection can therefore change without indicating that the previous treatment plan was incorrect. New targets emerge, motivation shifts, recovery experiences provide additional information, and previously inaccessible material may become available as treatment progresses. Returning to the client’s current presentation keeps EMDR treatment planning responsive to those changes.

Continue Your Learning

Stage of change is one component of EMDR treatment planning for substance use disorders. Applying stage-based reasoning in practice also requires clinicians to assess readiness and stability, identify treatment targets, understand addiction-focused EMDR approaches, coordinate care when needed, and revise the treatment sequence as recovery progresses.

The Applying EMDR to Substance Use Disorder Treatment continuing education course examines these areas in greater depth, including assessment, stabilization, stages of change, addiction-focused EMDR approaches, target selection, relapse prevention, and individualized treatment planning. The course offers EMDRIA Credits and is provided by Cannon Psychology, an APA-approved sponsor of continuing education for psychologists.

→ Applying EMDR to Substance Use Disorder Treatment CE

Continue Exploring EMDR and Addiction Treatment

Protocol selection intersects with many other clinical decisions in addiction treatment. Clinicians may also need to assess readiness for trauma processing, work with ambivalence, understand cravings, address relapse memories and recovery fears, strengthen relapse-prevention planning, and reconsider treatment priorities as the client’s recovery changes.

The Addiction Treatment & Recovery Hub brings these topics together with clinician-focused articles, practical tools, and educational resources for integrating EMDR into treatment for substance use disorders and other addictive or problematic behaviors.

→ Addiction Treatment & Recovery Hub

Conclusion

Stages of change give clinicians a useful way to consider what a client is currently ready to address in EMDR treatment. Pre-Contemplation may call for beginning with the client’s identified concerns, Contemplation may bring ambivalence into treatment, Preparation may emphasize recovery planning and developing capacities, Action may make cravings, triggers, relapse memories, and addiction-related targets increasingly available, and Maintenance may expand the work into residual targets, identity, future situations, and longer-term recovery concerns.

Those priorities can change throughout treatment. A client may become more interested in recovery after trauma symptoms decrease, return to Contemplation following a relapse, or identify new treatment targets after months of stability. Reassessing stage of change alongside current targets, stability, and treatment goals allows protocol selection to develop with the client instead of remaining tied to an earlier treatment plan.

References

1. Hase, M. (2009). CravEx: An EMDR approach to treat substance abuse and addiction. In M. Luber (Ed.), EMDR scripted protocols: Special populations (pp. 467–488). Springer Publishing Company.

2. Hase, M., Schallmayer, S., & Sack, M. (2008). EMDR reprocessing of the addiction memory: Pretreatment, posttreatment, and 1-month follow-up. Journal of EMDR Practice and Research, 2(3), 170–179. https://doi.org/10.1891/1933-3196.2.3.170

3. Knipe, J. (2018). Targeting idealization defenses. In EMDR toolbox: Theory and treatment of complex PTSD and dissociation (2nd ed., pp. 77–100). Springer Publishing Company.

4. Logie, R. D. J., & de Jongh, A. (2014). The “Flashforward Procedure”: Confronting the catastrophe. Journal of EMDR Practice and Research, 8(1), 25–32. https://doi.org/10.1891/1933-3196.8.1.25

5. Prochaska, J. O., & DiClemente, C. C. (1983). Stages and processes of self-change of smoking: Toward an integrative model of change. Journal of Consulting and Clinical Psychology, 51(3), 390–395.

6. Shapiro, F. (2018). Eye movement desensitization and reprocessing (EMDR) therapy: Basic principles, protocols, and procedures (3rd ed.). Guilford Press.

7. Shapiro, R. (2005). The two-hand interweave. In R. Shapiro (Ed.), EMDR solutions: Pathways to healing (pp. 160–166). W. W. Norton & Company.