How is EMDR best conducted and adapted for trauma-focused work within bipolar disorder? A Delphi study

Background: Individuals with bipolar disorder are at increased risk of exposure to traumatic events and associated psychological distress, including affective, cognitive, physiological, and mood-related difficulties. Eye movement desensitisation and reprocessing (EMDR) targets unprocessed trauma memory networks underlying these difficulties; however, guidance on adapting EMDR for this population is limited. This study aimed to establish practitioner consensus on adaptations to enhance the accessibility and effectiveness of EMDR for trauma in individuals with bipolar disorder.Methods: A three-round Delphi study was conducted with an international sample of EMDR practitioners (34 in Round 1, 22 in Round 2, 20 in Round 3). Round 1 responses were thematically analysed to generate 131 statements for Round 2. Statements with ≥80% agreement as 'essential' or 'important' achieved consensus, while those with 60-79% agreement were re-rated in Round 3 to clarify areas of uncertainty.Results: Practitioners identified key barriers to EMDR, including client-related factors (e.g. mood variability, inconsistent attendance), safety concerns (e.g. risk of triggering mood shifts), systemic issues (e.g. service inflexibility), and limited guidance. Consensus was reached on 71 EMDR adaptations, spanning general strategies (e.g. mood monitoring, safety planning, pacing, coping skills) and phase-specific modifications (particularly in preparation, assessment, and desensitisation). Fifteen supervision elements were also endorsed, emphasising the importance of support for clinical decision-making.Conclusions: Trauma-focused EMDR for individuals with bipolar disorder can be delivered using the standard eight-phase protocol with phase-specific, formulation-driven adaptations. Key recommendations include structured preparation, ongoing mood monitoring, flexible pacing, and attention to safety. These findings provide practical guidance for clinicians and highlight the need for further training and research.