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TIRCIA · Psychotraumatology

Do we really need to “stabilise” before treating trauma?

What the science says in 2026

Reference: van Vliet N.I., Huntjens R.J.C., van Dijk M.K., Bachrach N., Meewisse M.-L. & de Jongh A. (2021). Phase-based treatment versus immediate trauma-focused treatment for post-traumatic stress disorder due to childhood abuse: randomised clinical trial. BJPsych Open, 7(6), e211. https://doi.org/10.1192/bjo.2021.1057

Marie-Agnès Thulliez

By Marie-Agnès Thulliez · Author · Publishing Director13-minute read

A calming therapy room: two armchairs facing each other by a window, in soft light

If you work with traumatised people, you are probably familiar with this rule: stabilise first, then treat the trauma. Before approaching painful memories, the patient learns to regulate emotions, to ground themselves, to install resources or to visualise a “safe place”.

This rule seems prudent and intuitive. But does it rest on evidence? Over the past fifteen years, research has provided some surprising answers. Here is where we stand.

In brief

  • The “stabilise first, treat later” rule rests on expert consensus; comparative trials came later.
  • Randomised trials show that, for most adults traumatised in childhood, trauma-focused therapy can begin early, with no increased risk.
  • Stabilisation remains valuable for certain goals, such as emotion regulation, and for certain patients.
  • For highly dissociative patients and dissociative identity disorder, the question remains open.

1. Where does the stabilisation rule come from?

The three-phase model was popularised by Judith Herman in 1992:

  1. safety and stabilisation;
  2. processing of traumatic memories;
  3. reintegration into relational, working and social life.

In 2012, the international learned society ISTSS made it its recommendation for complex PTSD. It drew on a survey in which 84% of 50 expert clinicians supported the phase-based approach (Cloitre et al., 2011).

The key point is that this was expert opinion, rather than the result of comparative trials.

2. The challenge

In 2016, a group of leading researchers published a strong critique. They included Patricia Resick, who created cognitive processing therapy, and Edna Foa, who created prolonged exposure (De Jongh et al., 2016).

Their conclusion: the studies supporting mandatory stabilisation are methodologically limited. Nor was there any evidence that trauma-focused therapies are dangerous for complex patients. In their view, imposing lengthy stabilisation mainly risked delaying access to effective treatments.

This remained to be tested. Several randomised trials set out to do just that.

3. What the trials show

Dutch trial, 2021, with EMDR (Van Vliet et al., BJPsych Open)

  • 121 adults with PTSD following childhood abuse.
  • One group received 8 sessions of STAIR, a training in emotional and interpersonal regulation, followed by 16 sessions of EMDR.
  • The other group went straight to 16 sessions of EMDR.
  • No difference in symptoms, complex PTSD or dropout.
  • The EMDR-only group even improved faster at the start.

IMPACT trial, 2021, with prolonged exposure (Oprel et al., Eur J Psychotraumatol)

  • 149 patients, three variants of prolonged exposure, one of which was preceded by STAIR.
  • Substantial improvement in all three groups, with no difference between them.
  • Stabilisation brought no additional gain, even on emotion regulation or self-esteem.
  • Adverse events were rare.

Key point

For most adults traumatised in childhood, the stabilisation phase is useful, and optional. Trauma-focused therapy can begin early, safely.

Guidelines have followed suit. The UK’s NICE (NG116) does not require a stabilisation phase. Instead, it recommends:

  • more sessions, or longer ones;
  • attention to the safety of the person’s living situation;
  • help to overcome obstacles such as dissociation or emotional dysregulation.

4. “Useful, and optional”: the nuance that matters

Does stabilisation still have a place? Yes, for certain goals.

A 2026 meta-analysis (Lee et al., Eur J Psychotraumatol) finds no difference between phase-based and non-phase-based approaches on most outcomes. It does, however, show an advantage for approaches with prior stabilisation on emotion regulation difficulties.

Multi-phase interventions also showed a stronger effect on PTSD symptoms, in a small number of trials. In other words, when the main target is managing emotions, a skills module makes perfect sense.

Tools with proven value

STAIR (Cloitre). This is the best-studied stabilisation programme, delivered in 8 to 12 individual sessions. The first sessions focus on emotion regulation; the second part on interpersonal skills, assertiveness and flexibility in relationships. STAIR can precede work focused on traumatic memories, or be used on its own (Cloitre, ISTSS).

A word of caution: in one randomised trial, the STAIR phase alone changed dissociation and emotion regulation only slightly. Most of the progress came from the trauma-focused phase (Wigard et al., 2024).

DBT-PTSD, dialectical behaviour therapy adapted for trauma. It is intended for highly dysregulated patients, often with borderline traits or self-harm.

  • A trial in 193 women compared it with cognitive processing therapy (Bohus et al., 2020, JAMA Psychiatry). DBT-PTSD did slightly better on PTSD, with more remissions and fewer early dropouts.
  • An earlier inpatient trial had already shown its effectiveness, with no worsening of risk behaviours (Bohus et al., 2013).
  • An important point: DBT-PTSD includes trauma work. It goes beyond stabilisation.

5. The “safe place” and resource installation: what do the studies say?

This point often surprises EMDR practitioners.

RDI (Resource Development and Installation) is taught everywhere. Yet its founding article rests on two case studies (Korn & Leeds, 2002).

An experiment then tested whether eye movements really strengthen resource memories. The authors’ conclusion: their effect is “questionable” (Hornsveld et al., 2011).

These exercises keep their value: evoking resources can support the therapeutic alliance and give a sense of mastery. They are best seen as low-cost additions, rather than as techniques of demonstrated effectiveness.

6. What about dissociation? The real area of uncertainty

This is where the debate remains lively.

First argument: dissociation does not hinder treatment. A meta-analysis of 21 trials and 1,714 patients found no link between the level of dissociation and the effectiveness of therapy (Hoeboer et al., 2020).

Second argument: in highly dissociative patients, it does. In a trial of 193 women who had experienced childhood abuse, high dissociation at baseline predicted poorer outcomes. An early reduction in dissociation, by contrast, predicted greater success (Kleindienst et al., 2025). Critics also point out that the patients in the meta-analysis were, on average, only mildly dissociative.

For dissociative identity disorder (DID), the learned society ISSTD still recommends phase-oriented treatment. It warns that memory work undertaken too early can lead to decompensation (ISSTD guidelines). However, a 2025 review points out that this model has never been evaluated in a controlled trial (Griffiths et al., 2025).

Practical resource

The TOP DD programme. It consists of online videos and exercises for the patient and their therapist. The programme is accompanied by reductions in dissociation, PTSD and self-harm, even in very severe patients (Brand et al., 2019). The study had no control group.

7. In practice: a guide for the therapist

  1. Assess before deciding. Use the International Trauma Questionnaire for complex PTSD and the DES or a structured interview for dissociation. A heavy trauma history alone does not justify months of stabilisation.
  2. For most patients, offer trauma-focused therapy early: EMDR, prolonged exposure, cognitive processing therapy or trauma-focused CBT. Add skills as you go.
  3. If emotion regulation is the central problem, use STAIR.
  4. In cases of self-harm, severe dysregulation or borderline traits, consider DBT-PTSD.
  5. In cases of marked dissociation or DID, work in phases, and measure: is dissociation decreasing early on? The PITQ questionnaires (Schielke et al., 2017) help assess the patient’s readiness, rather than relying on a fixed duration.
  6. Safe place and RDI: use them freely, while keeping a realistic view of what they can do.

Clinical vignette

Fictional case, built from common clinical situations.

Nathalie, 41, experienced repeated abuse in childhood. She seeks help for nightmares, flashbacks and pervasive shame. For two years she has been in a stabilisation-focused therapy: safe place, breathing exercises, resource work. She is somewhat better day to day, but the nightmares have not changed, and she is beginning to think she is “too damaged” to be helped.

Her new therapist starts with an assessment. The complex PTSD questionnaire confirms the diagnosis; dissociation is present, but moderate. There is no current danger and no self-harm. After two sessions of psychoeducation and learning a few regulation tools, EMDR work on the memories begins from the fourth session. The first weeks are demanding, and the therapist adds emotion regulation exercises as the sessions go on. Then the nightmares become less frequent, and the shame gradually gives way to another understanding: “it wasn’t my fault”.

Had the assessment revealed severe dissociation or dissociative identity disorder, the therapist would have worked in phases, measuring at each step whether the patient was becoming ready for memory work.

What is established, and what is not

  • Established: for most adults with PTSD related to childhood abuse, starting trauma-focused therapy straight away is as effective and as safe as preceding it with a stabilisation phase (van Vliet et al., 2021; Oprel et al., 2021).
  • Well supported: a skills module can bring additional benefit on emotion regulation (Lee et al., 2026). DBT-PTSD is effective in highly dysregulated female patients (Bohus et al., 2020).
  • Debated: the role of dissociation. On average, it does not reduce the effectiveness of therapy (Hoeboer et al., 2020), but high dissociation could slow it down (Kleindienst et al., 2025).
  • Weakly supported: the specific effectiveness of the safe place and resource installation (Korn and Leeds, 2002; Hornsveld et al., 2011).
  • Not evaluated in a controlled trial: phase-oriented treatment of dissociative identity disorder (Griffiths et al., 2025).

What we do not yet know

A good scientific article should also say where knowledge ends.

  • “Parts” approaches (IFS, ego state therapy) and somatic or polyvagal approaches have, to my knowledge, yet to be tested in controlled trials in these populations. Their evaluation is still to come.
  • There is no randomised trial on DID.
  • Most trials involve women who experienced childhood abuse. The results are less certain for men, refugees and adolescents.
  • Studies still to be completed. Several leading researchers also designed or teach the methods they study, such as Marylène Cloitre for STAIR or Ad de Jongh for EMDR. This is what makes their expertise so rich. New studies by other teams will add to these findings.
  • The ISTSS has announced new guidelines. They could change this picture.

Frequently asked questions

Should the preparation phase in EMDR be dropped?

No. Preparation keeps its full place: explaining the method, building the alliance, making sure the patient has a few ways to regulate. What research calls into question is a long, mandatory stabilisation before any work on memories.

Does early trauma work risk making the patient worse?

In the trials cited, patients treated directly did not drop out more often, and adverse events were rare. Memory work can be demanding in the moment: it helps to prepare for this with the patient.

How long should stabilisation last?

There is no fixed duration. Stabilisation is adjusted to the patient’s needs, and their readiness for memory work is assessed regularly, rather than relying on a number of sessions.

And if the patient is still in danger?

Safety comes first: ongoing violence, acute suicide risk or self-endangerment call for action on the situation first. This is a prerequisite for any care, distinct from a stabilisation phase in the technical sense.

In one sentence

Stabilisation has become a tool to be adjusted to each patient, rather than a mandatory step.

For most patients, trauma treatment can begin early. For the most dissociative, caution remains advisable, even though science has yet to settle the question.

References

  1. Bohus, M., Dyer, A. S., Priebe, K., et al. (2013). Dialectical behaviour therapy for post-traumatic stress disorder after childhood sexual abuse in patients with and without borderline personality disorder: A randomised controlled trial. Psychotherapy and Psychosomatics, 82(4), 221-233. Link
  2. Bohus, M., Kleindienst, N., Hahn, C., et al. (2020). Dialectical behavior therapy for posttraumatic stress disorder (DBT-PTSD) compared with cognitive processing therapy (CPT) in complex presentations of PTSD in women survivors of childhood abuse: A randomized clinical trial. JAMA Psychiatry, 77(12), 1235-1245. Link
  3. Brand, B. L., Schielke, H. J., Putnam, K. T., et al. (2019). An online educational program for individuals with dissociative disorders and their clinicians: 1-year and 2-year follow-up. Journal of Traumatic Stress, 32(1), 156-166. Link
  4. Cloitre, M. (n.d.). Skills Training in Affective and Interpersonal Regulation (STAIR). International Society for Traumatic Stress Studies, Clinician’s Corner. Link
  5. Cloitre, M., Courtois, C. A., Charuvastra, A., et al. (2011). Treatment of complex PTSD: Results of the ISTSS expert clinician survey on best practices. Journal of Traumatic Stress, 24(6), 615-627. Link
  6. De Jongh, A., Resick, P. A., Zoellner, L. A., et al. (2016). Critical analysis of the current treatment guidelines for complex PTSD in adults. Depression and Anxiety, 33(5), 359-369. Link
  7. Griffiths, T. A., Dimitrova, L. I., Linington, M., et al. (2025). Effectiveness of phase-oriented treatment for trauma-related dissociative disorders: A systematic review. European Journal of Psychotraumatology, 16(1), 2545734. Link
  8. Herman, J. L. (1992). Trauma and Recovery. New York: Basic Books.
  9. Hoeboer, C. M., De Kleine, R. A., Molendijk, M. L., et al. (2020). Impact of dissociation on the effectiveness of psychotherapy for post-traumatic stress disorder: Meta-analysis. BJPsych Open, 6(3), e53. Link
  10. Hornsveld, H. K., Houtveen, J. H., Vroomen, M., et al. (2011). Evaluating the effect of eye movements on positive memories such as those used in resource development and installation. Journal of EMDR Practice and Research, 5(4), 146-155. Link
  11. International Society for the Study of Trauma and Dissociation (2011). Guidelines for treating dissociative identity disorder in adults, third revision. Journal of Trauma & Dissociation, 12(2), 115-187. Link
  12. Kleindienst, N., Steil, R., Priebe, K., et al. (2025). Is dissociation predicting the efficacy of psychological therapies for PTSD? Results from a randomized controlled trial comparing DBT-PTSD and CPT. Psychological Medicine, 55, e59. Link
  13. Korn, D. L., & Leeds, A. M. (2002). Preliminary evidence of efficacy for EMDR resource development and installation in the stabilization phase of treatment of complex posttraumatic stress disorder. Journal of Clinical Psychology, 58(12), 1465-1487. Link
  14. Lee, Y., Park, S., & Cho, Y. E. (2026). Phase-based versus non-phase-based psychological interventions for complex PTSD: A systematic review and meta-analysis. European Journal of Psychotraumatology, 17(1), 2644112. Link
  15. National Institute for Health and Care Excellence (2018). Post-traumatic stress disorder (NG116). Link
  16. Oprel, D. A. C., Hoeboer, C. M., Schoorl, M., et al. (2021). Effect of prolonged exposure, intensified prolonged exposure and STAIR+prolonged exposure in patients with PTSD related to childhood abuse: A randomized controlled trial. European Journal of Psychotraumatology, 12(1), 1851511. Link
  17. Schielke, H. J., Brand, B. L., & Marsic, A. (2017). Assessing therapeutic change in patients with severe dissociative disorders: The progress in treatment questionnaire, therapist and patient measures. European Journal of Psychotraumatology, 8(1), 1380471. Link
  18. van Vliet, N. I., Huntjens, R. J. C., van Dijk, M. K., et al. (2021). Phase-based treatment versus immediate trauma-focused treatment for post-traumatic stress disorder due to childhood abuse: Randomised clinical trial. BJPsych Open, 7(6), e211. Link
  19. Wigard, I., Meyerbröker, K., Ehring, T., et al. (2024). Skills training followed by either EMDR or narrative therapy for posttraumatic stress disorder in adult survivors of childhood abuse: A randomized controlled trial. European Journal of Psychotraumatology, 15(1), 2332104. Link

This article summarises the scientific evidence available at the date of publication. It is no substitute for clinical training, supervision, or the advice of a health professional.

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