VR in EMDR Phase 2: Preparing Patients for Processing

Why phase 2 deserves more time than we usually give it

The 8-phase EMDR protocol formalized by Francine Shapiro (2017) places preparation as the second step, after history-taking and before assessment of the target memory. In practice, many novice clinicians rush through this phase, assuming that the patient's motivation to process is enough to sustain the affective activation that follows. The usual clinical consequence is blocking in phase 4, overwhelming abreactions, or, worse, decompensation between sessions.

A well-executed phase 2 delivers three concrete things: the patient acquires a repertoire of self-regulation skills that can be activated inside and outside of session, the therapeutic alliance is built through work the patient perceives as useful from the very first moment, and the clinician gains diagnostic information about the patient's window of tolerance (Siegel, 1999) that will guide the pacing of processing.

The VRET clinical team proposes that virtual reality can accelerate the acquisition of these resources, especially for patients with imagery difficulties or marked interoceptive disconnection. What follows is a concrete workflow based on Shapiro's model, with VRET scenarios integrated at specific points. The EMDR protocol remains the responsibility of the certified clinician; virtual reality adds one more sensory channel to the preparation work.

What resources need to be installed in phase 2

The minimum package of resources in phase 2 includes, in standard EMDR clinical practice, the following elements: a safe or calm place (sometimes called a peaceful place), a container for storing activating material between sessions, a somatic anchor for rapid regulation (for example, the self-applied butterfly hug), and techniques for shifting affective state (diaphragmatic breathing, brief mindfulness). The classic EMDR literature (Shapiro, 2017; Hofmann, 2014) describes installing each of these resources with slow bilateral stimulation to strengthen them.

The safe place is traditionally built through guided imagery: the patient describes a scenario that evokes calm, the clinician adds sensory modality (what they hear, what they smell, what they feel on their skin), and it is installed with short series of slow bilateral stimulation. The relevant clinical question is: what do we do when the patient cannot evoke sufficiently vivid imagery? Patients with flat affect, alexithymia, or low-intensity residual dissociation find this task difficult.

This is where virtual reality contributes a complementary sensory channel. An environment such as the Mindfulness Forest scenario or the Enchanted Forest offers sensorially rich imagery that the patient can explore passively, without having to generate it internally. Once the virtual safe place is installed, the patient can be trained to evoke it without the headset, progressively transitioning from external immersion to internal representation.

Step-by-step protocol: sessions 1 through 4 of phase 2

The workflow that follows is a guideline, not a prescription. The licensed psychologist certified in EMDR adjusts the pace according to the patient, the reason for consultation, and the clinical formulation.

Session 1: introduction, psychoeducation, first contact with VR. After history-taking (phase 1), the AIP model is presented in accessible terms, the purpose of phase 2 is explained, and the headset is introduced in a brief session (10-15 minutes maximum). The goal is to assess VR tolerance before investing clinical time in the format. Any patient with intense cybersickness, postural vertigo, or persistent discomfort is redirected to phase 2 without the VR component.

Session 2: installing the virtual safe place. The patient enters a relaxing scenario (Mindfulness Forest, Enchanted Forest) and is invited to explore it without active tasks. After 8-12 minutes of immersion, the session is briefly interrupted and the patient is asked to identify three elements of the environment that evoke particular calm (a specific tree, the sound of water, the golden light). These elements become sensory anchors. Short series of slow bilateral stimulation are applied while the patient holds attention on each anchor, once outside the headset.

Session 3: installing the container and the keyword. An internal representation of a container (a safe, a chest, a locked room) is constructed, where the patient can deposit activating material between sessions. This work is essentially imaginal and does not require VR. A keyword is chosen that the patient will associate with the sense of calm acquired in session 2 (typically a concrete noun, not an adjective).

Session 4: integration and validation. The patient accesses the safe place without VR, evoking the internal imagery that was developed. If the internal representation is sufficiently vivid, phase 2 is closed. If it is still weak, an additional VR session is scheduled to reinforce the sensory anchors. The clinician documents the available resources before starting phase 3.

What clinical signs to watch for during phase 2 with VR

When virtual reality is incorporated into preparation work, direct clinical observation of the face is limited by the headset. The clinical team must rely on other indicators: audible breathing, body posture, patient verbalizations, latency between instruction and response. It is advisable to keep an open verbal channel throughout the immersion and to regularly ask about the patient's subjective experience.

Signs of good adjustment: the patient describes feelings of calm or curiosity, maintains a relaxed posture, responds fluently. Signs of poor adjustment: accelerated breathing, rigid posture, long non-spontaneous silences, comments about a sense of suffocation or unreality. At any sign of poor adjustment, the clinician interrupts the immersion, helps the patient remove the headset, and applies whichever regulation techniques have already been acquired (diaphragmatic breathing, somatic anchoring, orientation to the here and now).

A practical note: session closure is especially important when VR has been used. Before the patient leaves the office, the clinician verifies that they are oriented in time and space, that they have been able to return to their baseline affective state, and that they have at least one accessible resource for the week between sessions. A rushed session closure is one of the most common errors in EMDR, with or without VR.

Selection criteria: which patients benefit most?

The VRET clinical team observes that certain profiles seem to benefit particularly from VR integration in phase 2. Patients with imagery difficulties (including cases compatible with aphantasia or poor imagery) can access a vivid safe place without having to generate it internally. Patients with marked interoceptive disconnection (common in chronic PTSD, in some complex trauma presentations) regain contact with gentle bodily sensations within a controlled environment. Patients with high cognitive avoidance, who quickly abandon any imaginal exercise out of discomfort, tolerate passive exposure to the virtual environment better.

Specific contraindications for incorporating VR into phase 2: persistent cybersickness after the session 1 assessment, severe dissociation with risk of decompensation, active psychotic episodes, acute postural vertigo, photosensitive epilepsy. Virtual reality is not indispensable for a well-executed phase 2; when a contraindication is present, classic imaginal work retains its effectiveness.

A special case: patients with complex trauma or significant dissociation (for example, profiles compatible with DID or DESNOS — Disorder of Extreme Stress Not Otherwise Specified). Here the clinical rule is conservative. Any intervention that activates intense affective states without a safety net can produce fragmentation. Preparation work takes longer, requires specialized supervision, and the introduction of VR must be assessed with more restrictive criteria. The clinical reference remains Herman's (1992) three-phase model and the work of van der Hart, Nijenhuis, and Steele on structural dissociation.

Documentation, framing, and informed consent

Every EMDR intervention with a VR component must be documented in the patient's clinical record with the same level of detail as conventional sessions. It is advisable to record: the VR scenario used, duration of immersion, resources installed, relevant clinical observations, regulation techniques trained. The Mindfulness Forest scenario's clinical fact sheet offers reference information on indications, standard duration, and specific contraindications.

The framing given to the patient at the start of phase 2 should include: an accessible explanation of the AIP model, a description of the resources to be installed, the purpose of the VR component (when it will be used), explicit acknowledgment that cybersickness may occur and that the intervention can be interrupted at any time at the patient's request. It is advisable to draw on the informed-consent models from the official psychology licensing boards (COP in Spain), adapted to the VR context.

This article is for informational purposes for psychology professionals. It is not clinical advice for any individual case and does not replace the judgment of the licensed psychologist in charge. VRET is professional clinical-support software, not a CE-marked medical device.