# Brief Intensive EMDR Therapy for PTSD in Adults with Mild Intellectual Disability or Borderline Intellectual Functioning and Behavioural Problems: A Multiple Baseline Design Study

- URL: https://alisanburak.com/en/hafif-duzeyde-zihinsel-yetersizligi-veya-sinirda-zihinsel-islevselligi-ve-davranissal-sorunlari-olan-yetiskinlerde-tssb-icin-kisa-sureli-yogunlastirilmis-emdr-terapisi-coklu-baslangic-duzeyi-desenli
- Language: en
- Last updated: 2026-08-15
- Page title: Brief Intensive EMDR Therapy for PTSD in Adults with Mild Intellectual Disability or Borderline Intellectual Functioning and Behavioural Problems: A Multiple Baseline Design Study | Assoc. Prof. Dr. Alişan Burak Yaşar

> Brief Intensive EMDR Therapy for PTSD in Adults with Mild Intellectual Disability or Borderline Intellectual Functioning and Behavioural Problems: A Multip

This page was translated automatically from Turkish. [Read the original](https://alisanburak.com/hafif-duzeyde-zihinsel-yetersizligi-veya-sinirda-zihinsel-islevselligi-ve-davranissal-sorunlari-olan-yetiskinlerde-tssb-icin-kisa-sureli-yogunlastirilmis-emdr-terapisi-coklu-baslangic-duzeyi-desenli)

[← Back to blog](https://alisanburak.com/en/blog)

# Brief Intensive EMDR Therapy for PTSD in Adults with Mild Intellectual Disability or Borderline Intellectual Functioning and Behavioural Problems: A Multiple Baseline Design Study

October 15, 2025General

**Brief Intensive EMDR Therapy for PTSD in Adults with Mild Intellectual Disability or Borderline Intellectual Functioning and Behavioural Problems: A Multiple Baseline Design Study*****(Brief intensive EMDR therapy for PTSD in adults with mild intellectual disability or borderline intellectual functioning and behavioural problems: a multiple baseline design study)***

**Authors:**Anne Versluis a,b, Ad de Jongh c,d,e,f, Liesbeth Mevissen g, Carlo Schuengel h, Lianne Bakkum h and Robert Didden b,i
a Advisium, ‘s Heeren Loo, Amersfoort, The Netherlands;
b Behavioural Science Institute, Radboud University, Nijmegen, The Netherlands;
c Institute of Health and Society, University of Worcester, Worcester, UK;
d Research Department PSYTREC, Bilthoven, The Netherlands;
e School of Health Sciences, Salford University, Manchester, UK;
f School of Psychology, Queen’s University, Belfast, UK;
g PsychotraumaPractice, Rha, The Netherlands;
h Faculty of Behavioural and Movement Sciences, Section Clinical Child and Family Studies, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands;
i Research & Development, Trajectum, Zwolle, The Netherlands

**Translated by:** Specialist Psychologist Elena Gizem Pozam

**ABSTRACT**

Background: Individuals with mild intellectual disability (MID; IQ 50-70) or borderline intellectual functioning (BIF; IQ 70-85) are at increased risk of post-traumatic stress disorder (PTSD), and PTSD symptoms are likely associated with behavioural problems. It is important to test the effectiveness of trauma-focused treatments, such as eye movement desensitisation and reprocessing (EMDR) therapy, for adults with MID-BIF, PTSD and severe behavioural problems.

Objective: To determine the safety and effectiveness of brief intensive EMDR therapy delivered by a rotating team of therapists in adults with MID-BIF, PTSD and severe behavioural problems.

Methods: Using a randomised non-concurrent multiple baseline design across participants, 11 adults with MID-BIF, PTSD and severe behavioural problems received up to 16 intensive EMDR sessions, twice daily for no more than two weeks, from six different EMDR therapists. Primary outcome measures included PTSD symptom severity, PTSD diagnostic status and adverse events. Secondary outcome measures included the frequency and severity of behavioural problems, the presence of adaptive behaviour and the use of involuntary care. Outcome measures were assessed during baseline, intervention and post-intervention phases, and at follow-up, and subjected to randomisation tests for statistical significance.

Results: Intensive EMDR therapy delivered by a rotating team of therapists resulted in significant reductions in PTSD symptoms (Mdifference​ = 15.84, p < .001), and nine of the 11 participants no longer met the diagnostic criteria for PTSD immediately after treatment and at the 9-week follow-up. Randomisation tests revealed no significant changes in adaptive behaviour or in the frequency and severity of behavioural problems. Additionally, no reduction in the use of involuntary care measures was observed. One participant dropped out; no adverse events were observed.

Conclusions: Brief intensive EMDR therapy delivered by a rotating team of therapists for individuals with MID-BIF and severe behavioural problems can be provided safely and effectively to reduce PTSD symptoms.

**HIGHLIGHTS**

- Intensive EMDR therapy with rotating therapists effectively reduces PTSD symptoms in adults with mild intellectual disability and severe behavioural problems.
- Nine of the 11 participants no longer met the criteria for PTSD after treatment.
- Treatment was found to be safe, with no adverse events.

1. Introduction

Individuals with mild intellectual disability or borderline intellectual functioning (MID-BIF; IQ 50-85) may be at increased risk of developing post-traumatic stress disorder (PTSD) compared with the general population (Mason-Roberts et al., 2018; Mevissen et al., 2020). This increased risk may be attributed to frequent exposure to traumatic events (McDonnell et al., 2019; Nieuwenhuis et al., 2019) and difficulties processing these events due to deficits in adaptive and cognitive functioning (Skelly, 2020). The prevalence of PTSD in this group ranges from 10% to ≥40%, with higher rates observed among individuals living in supported housing (Mevissen et al., 2020; Versluis et al., 2025).

PTSD symptoms in individuals with MID-BIF are similar to those in individuals without intellectual disability (Hoogstad et al., 2023; Mevissen et al., 2020). These symptoms also overlap with behavioural problems such as verbal or physical aggression (Kildahl & Helverschou, 2024; Rittmannsberger et al., 2020). Rittmannsberger and colleagues (2020) found that the relationship between trauma exposure and challenging behaviour in individuals with MID-BIF was mediated by the severity and frequency of PTSD symptoms. Partly because of these behavioural problems, PTSD in individuals with MID-BIF often remains undiagnosed (Kildahl et al., 2020) and untreated (Keesler, 2020). Diagnosing PTSD requires more than observing overt behaviour; it requires knowledge of the types of events a person may have been exposed to and how these relate to their current symptoms (American Psychiatric Association, 2022). Without such a nuanced approach, individuals with MID-BIF may be referred for behaviour-based interventions. Such interventions may not treat the underlying problems, and when PTSD symptoms persist, restrictive measures (e.g. restraint and locked doors) are sometimes used as a last resort, which may lead to further PTSD symptoms. Despite ongoing concerns about the effectiveness and quality of involuntary care for individuals with intellectual disability (Heyvaert et al., 2014, 2015), these practices remain widespread (Bakkum et al., 2023; Fitton & Jones, 2020), particularly among individuals with severe behavioural problems (Hastings et al., 2013). For example, Schippers and colleagues (2018a, 2018b) found that certain coercive measures were frequently used for residents of supported living facilities for people with intellectual disability: 43.6% (audio monitoring), 41.6% (restricted access to rooms/areas) and 33% (locking external doors).

Trauma-focused therapeutic approaches such as eye movement desensitisation and reprocessing (EMDR) therapy have shown promising results for individuals in the general population (De Jongh et al., 2024). However, conventional PTSD treatments in the general population have been associated with high dropout rates, possibly due to symptom exacerbation, which can be difficult to distinguish from the temporary distress inherent in trauma-focused therapy (e.g. Bongaerts et al., 2022; Lewis et al., 2020; Van Woudenberg et al., 2018). Between a quarter and a third of participants receiving trauma treatment dropped out, with some studies showing even higher dropout rates (e.g. Niles et al., 2018). To address this problem, intensive trauma treatments have been developed that involve multiple therapy sessions per week or even multiple sessions per day, often with different therapists rotating between sessions to maintain treatment intensity. Intensive trauma treatments have been associated with better therapeutic outcomes in the general population (Hoppen et al., 2023), and these intensive treatments have resulted in low dropout rates. For example, Van Woudenberg and colleagues (2018) reported a dropout rate of less than 3%, whereas Bongaerts and colleagues (2022) reported no dropouts.

Although intensive trauma treatments have been shown to be effective in children and adolescents with MID-BIF (Ooms-Evers et al., 2021), the effectiveness of intensive EMDR therapy in adults with MID-BIF and severe behavioural problems has not been investigated. There is an urgent need to test appropriate treatment options, such as intensive EMDR therapy, for this vulnerable population. The aim of this study is to determine the safety and effectiveness of intensive EMDR therapy with a rotating team of therapists in adults with MID-BIF and PTSD. We hypothesise that PTSD symptoms and behavioural problems will decrease significantly after treatment, that participants' adaptive behaviour (i.e. behaviour in daily life related to PTSD symptoms, such as talking to strangers again; see Methods) will improve, and that these changes will be maintained at the 6-week, 9-week and 4-month follow-ups. Additionally, we expect that most participants who met the diagnostic criteria for PTSD before treatment will no longer meet them after treatment, and that the intervention will reduce the use of involuntary care in adults with MID-BIF. We also expect that EMDR therapy will not be associated with adverse events.

1. **Methods**

2.1. Design

A non-concurrent multiple baseline design across participants (Coon & Rapp, 2018) was used to investigate the effectiveness of intensive EMDR therapy with rotating therapists on PTSD symptom severity, PTSD diagnostic status, adaptive behaviour, the frequency and severity of behavioural problems, and the use of involuntary care measures in 11 adults with MID-BIF and behavioural problems. The design included 11 AB experiments (A = baseline phase; B = post-intervention phase and follow-up measurements), with participants randomly assigned to baseline periods of five, six or seven weeks. The person performing the randomisation was blinded to participants' identities. The intervention phase consisted of a maximum of two weeks, during which EMDR therapy was delivered eight times per week, from Monday to Thursday. Completion of EMDR therapy was followed by a three-week post-intervention phase and then three follow-up measurements (six weeks, nine weeks and four months after the intervention).

2.2. Participants and Setting

Adults with MID-BIF (IQ 50-85) living in supported housing provided by an intellectual disability care service ('s Heeren Loo) in the Netherlands and on a waiting list for EMDR therapy were informed about the study by the first author. The inclusion criteria were: a diagnosis of MID or BIF, age of at least 18 years, meeting the DSM-5-TR diagnostic criteria for PTSD, severe behavioural problems (classified as Care Intensity Level 7 (Dutch: Zorg Zwaarte Pakket; ZZP), representing eligibility for the highest level of care intensity according to the Dutch healthcare authority and indicating a need for intensive support due to severe behavioural problems, as recorded in client files), and sufficient Dutch language skills. Each participant had at least one regular professional caregiver throughout the study period. Exclusion criteria were a high suicide risk and excessive alcohol/substance use that would make it difficult for the participant to attend therapy sober.

Participation in this study was voluntary. The study protocol was approved by the Medical Research Ethics Committee of Eastern Netherlands (reference number: 2020-6967- NL75909.091.20). All clients interested in participating in the study received an information letter. Nine participants provided written informed consent to participate in this study. For three participants, consent was provided by their legal representatives because they lacked the capacity to provide written consent. However, these three participants still provided verbal consent. This resulted in an initial sample of 12 participants. One participant dropped out on the second day of EMDR therapy because they felt overwhelmed by emotional stress and refused to continue with the study. Six women and five men aged 21-65 participated in this study. Table 1 presents the participants' characteristics.

2.3. Measures

Primary and secondary outcome measures were assessed in this study. The assessment frequencies used for these measures are listed in Table 2. Descriptive statistics for the outcome measures are listed in Table 3.

**2.3.1. Primary outcome measures**

2.3.2. PTSD symptoms

The symptom section of the Trauma Screener–Intellectual Disability (TS-ID; Versluis et al., 2025), a self-report measure, was used to assess PTSD symptoms. This section consists of 20 questions rated on a 4-point Likert scale (0 = never, 1 = sometimes, 2 = often, 3 = almost always). The total symptom frequency score (range 0-60) was obtained by summing the scores for the 20 questions; questions 9, 10 and 15 were divided into several subquestions. For these latter questions, only the highest score was included in the final score. Higher scores indicate higher levels of PTSD symptoms. The TS-ID has good psychometric properties, including high internal consistency and excellent validity in identifying PTSD in adults with MID-BIF based on DITS-ID results (Versluis et al., 2024). Participants completed the TS-ID symptom questions with the DITS-ID timeline (see DITS-ID) placed alongside them, providing a clear visual cue for the (traumatic and stressful) events. A professional caregiver was available to explain TS-ID items if necessary.

2.3.3. DSM-5-TR PTSD diagnostic status

PTSD diagnostic status was assessed using the Diagnostic Interview Trauma and Stressors–Intellectual Disability–Adult Version (DITS-ID; Mevissen et al., 2018). This clinical interview takes approximately 45-60 minutes to complete and is used for DSM-5-TR PTSD classification. The first section consists of 31 questions (yes/no/other) about Type A events and stressful life events (events that do not meet Criterion A but are experienced negatively by the person). The symptom section includes 39 PTSD symptom questions (PTSD criteria B, C, D and E) and four questions (yes/no/other) about potential atypical trauma symptoms. A thermometer card is then used to help the person indicate impairment in daily life on a scale from 0 (none at all) to 8 (very much). If the impairment score is four or higher (Criterion G), the participant is asked when the symptoms began to confirm whether they have persisted for more than one month (Criterion F). Finally, the interviewer checks whether the symptoms are attributable to medication, substance use, medical conditions or somatic disorders (Criterion H). Several versions of the DITS-ID are available. This study used the adult version and follow-up assessments, which take approximately 15 minutes. First, participants are asked whether they have experienced a traumatic or stressful event since the previous DITS-ID administration, followed by the symptom questions and the thermometer card. The adult version of the DITS-ID has good psychometric properties, with high internal consistency, good-to-excellent inter-rater reliability and good construct validity (Mevissen et al., 2020; Versluis et al., 2024). All DITS-ID interviews were conducted by trained master's students and an independent psychologist.

2.3.4. Participant safety

Participant safety was defined as the absence of adverse events, including increased suicidal ideation or placement in a crisis intervention facility. All recorded adverse events were extracted from participants' electronic client records.

**2.3.5. Secondary outcome measures**

2.3.5.1. Adaptive behaviour

Goal Attainment Scaling (GAS) was used to monitor adaptive behaviour on a 6-point scale (-3 = deterioration, –2 = baseline, –1 = less than the goal, 0 = goal, +1 = more than the goal, +2 = much more than the goal). Adaptive behaviour was defined in agreement with the participant, professional caregiver and their psychologists, and focused on behaviour observable (to the professional caregiver) that the participant would be expected to display in the absence of PTSD. Adaptive behaviour was defined for each participant before EMDR therapy, and professional caregivers rated the GAS scale daily (twice a day, in the morning and afternoon).

2.3.5.2. Behavioural problems

The Behavior Problems Inventory (BPI; Rojahn et al., 2001) indexes the frequency and severity of problem behaviour. Both frequency and severity scores can be derived from the total BPI score. The frequency score for problem behaviour (51 items) was measured on a 5-point Likert scale (0 = never, 1 = monthly, 2 = weekly, 3 = daily and 4 = hourly). The severity score for problem behaviour (51 items) was measured on a 3-point Likert scale (1 = mild problem, 2 = moderate problem, 3 = severe problem). Total scores were calculated for both frequency and severity, with higher scores indicating more frequent/severe problem behaviour. In our study, we used the Dutch version of the BPI, which has adequate-to-good psychometric properties, including good inter-rater and intra-rater reliability, internal consistency and convergent validity (Dumont et al., 2014). A professional caregiver who had regular contact with the participants completed the BPI.

2.3.5.3. Involuntary care

Involuntary care measures are defined as: 'Any care opposed by a client or a client's representative' (Staatsblad, 2018), and were recorded by participants' professional caregivers in the 'Involuntary Care Reporting System' in clients' electronic records. Documentation was maintained in this system for each participant, recording both predetermined (agreed upon by a multidisciplinary team) involuntary care (e.g. 'locking the bedroom door at night') and involuntary care incidents (e.g. 'restraint by professional caregivers'). A study by Schippers and colleagues (2018a, 2018b) on the 'Involuntary Care Reporting System' at 's Heeren Loo showed that involuntary care could be reliably recorded using this system. All recorded involuntary care was extracted from participants' electronic client records.

2.4. Intensive EMDR therapy and procedure

Participants received EMDR therapy twice daily for a maximum of two weeks from six therapists. Three of the therapists were certified 'EMDR Europe practitioners', while the other three had completed basic and advanced EMDR courses accredited by the Dutch EMDR Association. All therapists had treated at least 20 clients with MID-BIF and PTSD before the start of the study. The authors did not serve as therapists in this study. Treatment integrity was monitored by the first author and an accredited supervisor from the Dutch EMDR Association (the third author) through three supervision sessions during the baseline phase and three during the intervention phase. These sessions involved reviewing video recordings and discussing cases to ensure adherence to the treatment protocol.

One week before therapy (baseline), professional caregivers and, where possible, a relative of the client received psychoeducation about PTSD and EMDR therapy. Therapy sessions took place twice daily (morning and afternoon), Monday to Thursday, over a two-week period. In the first therapy session (60 minutes), a case conceptualisation was developed based on the DITS-ID timeline. For this case conceptualisation, all traumatic (meeting Criterion A) and stressful (not meeting Criterion A) events on the timeline were rated for distress using the Subjective Units of Disturbance (SUD) scale, ranging from 0 = no distress to 10 = extreme distress, and ranked from highest to lowest SUD. This resulted in a list of traumatic and stressful events that could be treated (case conceptualisation). The first therapy session included psychoeducation for participants about PTSD and EMDR therapy. Participants were not trained in coping skills or the use of emotion regulation techniques before treatment (De Jongh et al., 2016). After the first session, all subsequent sessions consisted of 60 minutes of EMDR therapy. We used the EMDR therapy protocol for children and adolescents up to the age of 18 (De Roos et al., 2021). This protocol includes the same eight phases as the standard protocol developed by Shapiro (2018), but is adapted for individuals with lower language abilities, such as those with MID-BIF. Where necessary, cognitive interweaves were used as described by Shapiro (2018). In accordance with working memory theory (for a review, see De Jongh et al., 2024), working memory was taxed during EMDR therapy using various tasks, particularly eye movements (following fingers or a light bar), combined with vibrating devices. If the participant was unable to perform eye movements, an additional distracting task, such as tapping, counting or a simple calculation task, was added. These tasks were also added when the SUD score remained high (Matthijssen et al., 2021). When a memory had been successfully processed, it was marked on the case conceptualisation together with the participant, and therapy moved on to the next traumatic event. Therapy was completed once all memories in the case conceptualisation had been processed. Treatment duration varied depending on the number of traumatic events and the time required to process the traumatic memories.

2.5. Statistical analyses

All analyses were performed in R (R Core Team, 2023, version 4.3.2) and RStudio (Posit, 2024, version 2024.09.0). To determine the required sample size, we calculated the number of permutations for this non-concurrent multiple baseline design across participants. For a robust randomisation test, the number of possible starting points (k) should exceed 20, yielding 1/k (p < .05) (Bulté & Onghena, 2009). With 11 participants and three starting points, our study generated 177 randomisation possibilities, resulting in 1/177 (p < .001) and ensuring sufficient statistical power. To assess test–retest reliability during the baseline phase, the Intraclass Correlation Coefficient (ICC; Koo & Li, 2016) was calculated using a one-way random-effects model to measure consistency for the BPI, TS-ID and GAS.

To calculate nonoverlap of all pairs (NAP) for the TS-ID, GAS and BPI for each participant, the *SingleCaseES* package (Pustejovsky et al., 2024) was used. For the TS-ID and BPI, symptom improvement was indicated by a decrease in scores, whereas for GAS, improvement was indicated by an increase. Baseline (phase A) was compared with the post-intervention and follow-up phases (phase B). Missing values were excluded from the analysis. Effect size was assessed according to the guidelines of Parker and Vannest (2009).

To compare baseline (phase A) with the post-intervention and follow-up phases (phase B), group-level randomisation tests were conducted for TS-ID, GAS and BPI (total and subscale) scores using a t-statistic to measure phase differences, with the *scan* package (Wilbert & Luke, 2023). Randomisation tests were performed using data distributions based on random samples of = 177 possible permutations. Missing values were imputed by interpolation before analysis.

PTSD symptom frequency scores (TS-ID) were plotted for visual analysis using the *scplot* package (Wilbert, 2023). PTSD diagnostic status (DITS-ID) was analysed visually using a table. The use of involuntary care was documented and described in the results section.

1. **Results**

Eleven participants attended an average of 13 therapy sessions (range = 9-16). At the start of the study, participants had experienced an average of 12 traumatic and stressful events, and by the end of the study, ten participants had processed all their traumatic and stressful events (SUD = 0). Table 1 provides an overview of the stressful and traumatic events treated during therapy, as well as the number of therapy sessions attended by each participant. The ICC was .97 for baseline TS-ID total frequency scores, .94 for BPI total frequency scores, .95 for BPI total severity scores and .92 for GAS scores, all indicating high reliability of the measures (p < .01).

**3.1. Primary outcome measures**

3.1.1. PTSD symptoms

Figure 1 shows the visual analysis of PTSD symptom frequency scores (TS-ID) throughout the study. NAP values for individual participants' TS-ID scores indicated moderate differences between phases A and B in four participants and large differences in seven participants (see Table 4). The randomisation test showed a statistically significant group-level effect (observed Mdifference​ = 15.84, p < .01).

3.1.2. DSM-5-TR PTSD diagnostic status

Table 5 presents participants' DSM-5-TR PTSD diagnostic status at different phases. Nine of the 11 participants no longer met the diagnostic criteria for PTSD one week after the start of treatment. Participant 8 was classified as having PTSD again at the first follow-up assessment, but this classification was no longer present at the second follow-up. Participants 2 and 5 retained their PTSD classification throughout the study.

3.1.3. Participant safety

One participant stayed in a crisis shelter during the baseline and intervention phases but actively participated in therapy. They returned home after the intervention. Placement in the crisis shelter was considered unrelated to the intervention, as confirmed by both the participant and the professional caregiver. No other adverse events were reported in participants' electronic records.

**3.2. Secondary outcome measures**

3.2.1. Adaptive behaviour

NAP values for GAS scores indicated that differences between A and B ranged from weak to moderate effects and one large effect (Table 6). The randomisation test was not statistically significant (observed Mdifference​ = 8.81, p = .712). Participant 1 was excluded from both analyses due to excessive missing values (87%).

3.2.2. Behavioural problems

NAP values for BPI total frequency and severity scores indicate that differences between A and B ranged from predominantly weak effects to moderate and (one) large effects (see Table 6). Randomisation tests were not statistically significant for the total frequency (observed Mdifference​ = 0.80, p = .407) or total severity of behavioural problems (observed Mdifference​ = 0.73, p = .367).

3.2.3. Involuntary care

For one participant, one additional instance of predetermined (multidisciplinary) involuntary care (off-label psychotropic medication) was recorded by professional caregivers during the intervention phase compared with baseline. Another participant experienced an involuntary care incident during the follow-up phase, recorded by the professional caregiver. No other changes in recorded involuntary care measures or involuntary care incidents were recorded.

1. **Discussion**

The findings showed a significant reduction in PTSD symptoms, and nine of the 11 participants no longer met the diagnostic criteria for PTSD after the intervention. These improvements were maintained at both the 9-week and 4-month follow-ups, demonstrating the sustained effectiveness of intensive EMDR therapy in this population. These findings are consistent with previous research on intensive trauma therapy in children and adolescents with MID-BIF and PTSD (Ooms-Evers et al., 2021). Importantly, the intervention did not lead to any adverse events, highlighting its safety.

Only one participant dropped out of therapy. This is consistent with the low dropout rates consistently reported in intensive trauma-focused treatment programmes in the general population (e.g. Bongaerts et al., 2022; Voorendonk et al., 2023). An intensive format with frequently scheduled sessions has been found to reduce avoidance behaviour and encourage greater engagement (Hendriks et al., 2018; Szafranski et al., 2017).

While the results for adaptive behaviour showed improvements in some participants, others exhibited less noticeable changes. Significant changes in adaptive behaviour may require direct, targeted interventions aimed at learning new skills and adapting the environment. For example, adaptive behaviour such as 'the participant walking home from work independently' may be facilitated by a reduction in PTSD symptoms, but the ongoing involvement of professional caregivers may result in caregivers continuing to walk with the individual, preventing a genuine improvement in the participant's adaptive behaviour.

Some participants showed minimal changes in behavioural problems, whereas others showed slight improvement. Additionally, no changes (i.e. neither increases nor decreases) in involuntary care measures were observed, which may be attributable to the continued presence of behavioural problems. Although brief trauma-focused treatment programmes have generally been found to reduce PTSD symptom severity (Hoppen et al., 2023; Voorendonk et al., 2023), this may not always translate into changes in behavioural problems (Cuijpers et al., 2020). Because EMDR therapy focuses on reducing PTSD symptoms by processing participants' traumatic memories rather than targeting behavioural problems, its ability to address these problems directly may be limited. There is currently limited research on the relationship between behavioural problems and PTSD symptoms in individuals with MID-BIF. The present findings suggest that intensive trauma treatment is feasible and effective despite severe behavioural problems. Further research is needed to assess whether intensive trauma treatment enhances the effectiveness of interventions aimed at reducing behavioural problems, or vice versa. Alternatively, trauma treatment and behavioural interventions may achieve their effects independently of one another and may also independently improve quality of life.

4.1. Study Limitations

First, although the randomised non-concurrent multiple baseline design provides robust insights, it does not provide information about which subgroups within the MID-BIF population benefit more or less from the intervention. Second, PTSD classification was not repeatedly measured within the different study phases, preventing us from measuring a statistically significant loss of PTSD diagnostic status. A third limitation is potential selection bias due to loss to follow-up. The design used in the present study does not account for this bias, as not all participants were included in the analyses, which may have affected the validity and generalisability of the results. Fourth, we investigated a specific sample of adults with MID-BIF living in supported housing provided by a single ID care service in the Netherlands. Further research is needed to determine whether the observed effects can be replicated in more diverse or larger samples, which would enhance the applicability of these treatment approaches across various clinical contexts.

1. **Conclusion**

In conclusion, the findings of this study support the effectiveness and safety of intensive EMDR therapy delivered by a rotating team of therapists in reducing PTSD symptoms among adults with MID-BIF and behavioural problems. Although treatment showed significant improvements in PTSD symptoms, its effects on adaptive behaviour and behavioural problems were more variable, suggesting a need for further research to explore complementary approaches. Despite the small sample size, our results provide valuable insights and clinical implications for offering accessible trauma therapy to this population, and suggest that severe behavioural problems may not necessarily be a contraindication to intensive trauma treatment for individuals with MID-BIF.

Disclosure Statement

No potential conflict of interest was reported by the authors.

Data Availability Statement

The data supporting the findings of this study are available from the corresponding author upon request. The data are not publicly available due to privacy or ethical restrictions.

**Additional Information**

Funding

This study was supported by ZonMw, the Netherlands Organisation for Health Research and Development, and the 's Heeren Loo Scientific Research Foundation.

**References**

1. American Psychiatric Association. (2022). *Diagnostic and statistical manual of mental disorders: DSM-5-TR* (5th ed., text rev.). [https://doi.org/10.1176/appi.books.9780890425787](https://doi.org/10.1176/appi.books.9780890425787)
2. Bakkum, L., Bisschops, E. H., Lagerweij, S., & Schuengel, C. (2023). Impact of the care and coercion act on recorded involuntary care in intellectual disability care: A time-series analysis. *Journal of Intellectual Disability Research*, *67*(12), 1216–1226. [https://doi.org/10.1111/jir.12991](https://doi.org/10.1111/jir.12991)
3. Bongaerts, H., Voorendonk, E. M., Van Minnen, A., Rozendaal, L., Telkamp, B. S. D., & de Jongh, A. (2022). Fully remote intensive trauma-focused treatment for PTSD and complex PTSD. *European Journal of Psychotraumatology*, *13*(2), 2103287. [https://doi.org/10.1080/20008066.2022.2103287](https://doi.org/10.1080/20008066.2022.2103287)
4. Bulté, I., & Onghena, P. (2009). Randomization tests for multiple-baseline designs: An extension of the SCRT-R package. *Behavior Research Methods*, *41*(2), 477–485. [https://doi.org/10.3758/BRM.41.2.477](https://doi.org/10.3758/BRM.41.2.477)
5. Coon, J. C., & Rapp, J. T. (2018). Application of multiple baseline designs in behavior analytic research: Evidence for the influence of new guidelines. *Behavioral Interventions*, *33*(2), 160–172. https://doi.org/10.1002/bin.1510
6. Cuijpers, P., Veen, S. C. V., Sijbrandij, M., Yoder, W., & Cristea, I. A. (2020). Eye movement desensitization and reprocessing for mental health problems: A systematic review and meta-analysis. *Cognitive Behaviour Therapy*, *49*(3), 165–180. [https://doi.org/10.1080/16506073.2019.1703801](https://doi.org/10.1080/16506073.2019.1703801)
7. De Jongh, A., de Roos, C., & El-Leithy, S. (2024). State of the science: Eye movement desensitization and reprocessing (EMDR) therapy. *Journal of Traumatic Stress*, *37*(2), 205–216. [https://doi.org/10.1002/jts.23012](https://doi.org/10.1002/jts.23012)
8. De Jongh, A., Eland, J., Bongaerts, H., & van der Hart, O. (2016). EMDR therapy for trauma-related disorders: An overview of the evidence. In F. W. van der Hart, D. J. A. K. van der Kolk, & D. A. K. K. W. L. J. van der Hart (Eds.), *The handbook of EMDR and family therapy processes* (pp. 177–196). Wiley.
9. Dumont, E., Kroes, D., Korzilius, H., Didden, R., & Rojahn, J. (2014). Psychometric properties of a Dutch version of the behavior problems inventory-01 (BPI-01). *Research in Developmental Disabilities*, *35*(3), 603–610. [https://doi.org/10.1016/j.ridd.2014.01.003](https://doi.org/10.1016/j.ridd.2014.01.003)
10. Fitton, L., & Jones, D. R. (2020). Restraint of adults with intellectual disabilities: A critical review of the prevalence and characteristics associated with its use. *Journal of Intellectual Disabilities*, *24*(2), 268–283. [https://doi.org/10.1177/1744629518778695](https://doi.org/10.1177/1744629518778695)
11. Hastings, R. P., Allen, D., Baker, P., Gore, N. J., Hughes, J. C., McGill, P., Noone, S. J., & Toogood, S. (2013). A conceptual framework for understanding why challenging behaviours occur in people with developmental disabilities. *International Journal of Positive Behavioural Support*, *3*(2), 5–13. [https://www.ingentaconnect.com/content/bild/ijpbs/2013/00000003/00000002/art00002F](https://www.ingentaconnect.com/content/bild/ijpbs/2013/00000003/00000002/art00002F)
12. Hendriks, L., de Kleine, R. A., Broekman, T. G., Hendriks, G. J., & van Minnen, A. (2018). Intensive prolonged exposure therapy for chronic PTSD patients following multiple trauma and multiple treatment attempts. *European Journal of Psychotraumatology*, *9*(1), 1425574. [https://doi.org/10.1080/20008198.2018.1425574](https://doi.org/10.1080/20008198.2018.1425574)
13. Heyvaert, M., Saenen, L., Maes, B., & Onghena, P. (2014). Systematic review of restraint interventions for challenging behaviour among persons with intellectual disabilities: Focus on effectiveness in single-case experiments. *Journal of Applied Research in Intellectual Disabilities*, *27*(6), 493–510. [https://doi.org/10.1111/jar.12094](https://doi.org/10.1111/jar.12094)
14. Heyvaert, M., Saenen, L., Maes, B., & Onghena, P. (2015). Systematic review of restraint interventions for challenging behaviour among persons with intellectual disabilities: Focus on experiences. *Journal of Applied Research in Intellectual Disabilities*, *28*(2), 61–80. [https://doi.org/10.1111/jar.12095](https://doi.org/10.1111/jar.12095)
15. Hoogstad, A., Mevissen, L., Kraaij, M., & Didden, R. (2023). Assessment of posttraumatic stress disorder in adults with severe or moderate intellectual disability: A pilot study using the diagnostic interview trauma and stressors – severe intellectual disability. *Journal of Mental Health Research in Intellectual Disabilities*, 17(4), 297–317. [https://doi.org/10.1080/19315864.2023.2223522](https://doi.org/10.1080/19315864.2023.2223522)
16. Hoppen, T. H., Kip, A., & Morina, N. (2023). Are psychological interventions for adult PTSD more efficacious and acceptable when treatment is delivered in higher frequency? A meta-analysis of randomized controlled trials. *Journal of Anxiety Disorders*, *95*, 1–12. [https://doi.org/10.1016/j.janxdis.2023.102684](https://doi.org/10.1016/j.janxdis.2023.102684)
17. Keesler, J. M. (2020). Trauma-specific treatment for individuals with intellectual and developmental disabilities: A review of the literature from 2008 to 2018. *Journal of Policy and Practice in Intellectual Disabilities*, *17*(4), 332–345. [https://doi.org/10.1111/jppi.12347](https://doi.org/10.1111/jppi.12347)
18. Kildahl, A. N., & Helverschou, S. B. (2024). Post-traumatic stress disorder and experiences involving violence or sexual abuse in a clinical sample of autistic adults with intellectual disabilities: Prevalence and clinical correlates. *Autism*, *28*(5), 1075–1089. [https://doi.org/10.1177/13623613231190948](https://doi.org/10.1177/13623613231190948)
19. Kildahl, A. N., Oddli, H. W., & Helverschou, S. B. (2020). Potentially traumatic experiences and behavioural symptoms in adults with autism and intellectual disability referred for psychiatric assessment. *Research in Developmental Disabilities*, *107*, 103788. [https://doi.org/10.1016/j.ridd.2020.103788](https://doi.org/10.1016/j.ridd.2020.103788)
20. Koo, T. K., & Li, M. Y. (2016). A guideline of selecting and reporting intraclass correlation coefficients for reliability research. *Journal of Chiropractic Medicine*, *15*(2), 155–163. [https://doi.org/10.1016/j.jcm.2016.02.012](https://doi.org/10.1016/j.jcm.2016.02.012)
21. Lewis, C., Roberts, N. P., Gibson, S., & Bisson, J. I. (2020). Dropout from psychological therapies for post-traumatic stress disorder (PTSD) in adults: Systematic review and meta-analysis. *European Journal of Psychotraumatology*, *11*(1), 1709709. [https://doi.org/10.1080/20008198.2019.1709709](https://doi.org/10.1080/20008198.2019.1709709)
22. Mason-Roberts, S., Bradley, A., Karatzias, T., Brown, M., Paterson, D., Walley, R., Truesdale, M., Taggart, L., & Sirisena, C. (2018). Multiple traumatisation and subsequent psychopathology in people with intellectual disabilities and DSM-5 PTSD: A preliminary study. *Journal of Intellectual Disability Research*, *62*(8), 730–736.
23. Matthijssen, S. J. M. A., Brouwers, T. C., van Roozendaal, C., Vuister, T. C. M., & De Jongh, A. (2021). The effect of EMDR versus EMDR 2.0 on emotionality and vividness of aversive memories in a non-clinical sample. *European Journal of Psychotraumatology*, *12*(1), 1956793. [https://doi.org/10.1080/20008198.2021.1956793](https://doi.org/10.1080/20008198.2021.1956793)
24. McDonnell, C. G., Boan, A. D., Bradley, C. C., Seay, K. D., Charles, J. M., & Carpenter, L. A. (2019). Child maltreatment in autism spectrum disorder and intellectual disability: Results from a population-based sample. *Journal of Child Psychology and Psychiatry*, *60*(5), 576–584. [https://doi.org/10.1111/jcpp.12993](https://doi.org/10.1111/jcpp.12993)
25. Mevissen, L., Didden, R., & De Jongh, A. (2018). *Handleiding diagnostisch interview trauma en stressoren – licht verstandelijke beperking* . Accare.
26. Mevissen, L., Didden, R., De Jongh, A., & Korzilius, H. (2020). Assessing posttraumatic stress disorder in adults with mild intellectual disabilities or borderline intellectual functioning. *Journal of Mental Health Research in Intellectual Disabilities*, *13*(2), 110–126. [https://doi.org/10.1080/19315864.2020.1753267](https://doi.org/10.1080/19315864.2020.1753267)
27. Nieuwenhuis, J. G., Smits, H. J. H., Noorthoorn, E. O., Mulder, C. L., Penterman, E. J., & Nijman, H. L. (2019). Not recognized enough: The effects and associations of trauma and intellectual disability in severely mentally ill outpatients. *European Psychiatry*, *58*, 63–69. [https://doi.org/10.1016/j.eurpsy.2019.02.002](https://doi.org/10.1016/j.eurpsy.2019.02.002)
28. Niles, B. L., Polizzi, C. P., Voelkel, E., Weinstein, E. S., Smidt, K., & Fisher, L. M. (2018). Initiation, dropout, and outcome from evidence-based psychotherapies in a VA PTSD outpatient clinic. *Psychological Services*, *15*(4), 496–502. [https://doi.org/10.1037/ser0000175](https://doi.org/10.1037/ser0000175)
29. Ooms-Evers, M., van der Graaf-Loman, S., van Duijvenbode, N., Mevissen, L., & Didden, R. (2021). Intensive clinical trauma treatment for children and adolescents with mild intellectual disability or borderline intellectual functioning: A pilot study. *Research in Developmental Disabilities*, *117*, 104030. [https://doi.org/10.1016/j.ridd.2021.104030](https://doi.org/10.1016/j.ridd.2021.104030)
30. Parker, R. I., & Vannest, K. (2009). An improved effect size for single-case research: Nonoverlap of All pairs. *Behavior Therapy*, *40*(4), 357–367. [https://doi.org/10.1016/j.beth.2008.10.006](https://doi.org/10.1016/j.beth.2008.10.006)
31. Posit. (2024). RStudio (Version 2024.09.0) . Posit Software, PBC. [https://posit.co/](https://posit.co/)
32. Pustejovsky, J. E., Chen, M., & Swan, D. M. (2024). SingleCaseES: A calculator for single-case effect sizes (Version 0.7.3) . Comprehensive R Archive Network (CRAN). [https://CRAN.R-project.org/package=SingleCaseES](https://cran.r-project.org/package=SingleCaseES)
33. R Core Team. (2023). R: A language and environment for statistical computing (Version 4.3.2) . R Foundation for Statistical Computing. [https://www.r-project.org/](https://www.r-project.org/)
34. Rittmannsberger, D., Yanagida, T., Weber, G., & Lueger-Schuster, B. (2020). The association between challenging behaviour and symptoms of post-traumatic stress disorder in people with intellectual disabilities: A Bayesian mediation analysis approach. *Journal of Intellectual Disability Research*, *64*(7), 538–550. [https://doi.org/10.1111/jir.12733](https://doi.org/10.1111/jir.12733)
35. Rojahn, J., Matson, J. L., Lott, D., Esbensen, A. J., & Smalls, Y. (2001). The behavior problems inventory: An instrument for the assessment of self-injury, stereotyped behavior, and aggression/destruction in individuals with developmental disabilities. *Journal of Autism and Developmental Disorders*, *31*(6), 577–588. [https://doi.org/10.1023/A:1013299028321](https://doi.org/10.1023/A:1013299028321)
36. Schippers, B., Frederiks, B. J. M., Van Nieuwenhuijzen, M., & Schuengel, C. (2018a). Feasibility and reliability of full registration of restraints in care for people with intellectual disabilities. A study on reliability and implementation. *Journal of Policy and Practice in Intellectual Disabilities*, *15*, 202–213. [https://doi.org/10.1111/jppi.12252](https://doi.org/10.1111/jppi.12252)
37. Schippers, B., Frederiks, B. J. M., Van Nieuwenhuijzen, M., & Schuengel, C. (2018b). Reliability and feasibility of systematic registration of coercive measures in care for people with intellectual disabilities. *Journal of Policy and Practice in Intellectual Disabilities*, *15*(3), 202–213. [https://doi.org/10.1111/jppi.12252](https://doi.org/10.1111/jppi.12252)
38. Shapiro, F. (2018). *Eye movement desensitization and reprocessing (EMDR) therapy: Basic principles protocols, and procedures*. Guilford Press.
39. Skelly, A. (2020). Trauma exposure and the importance of attachment in people with intellectual disabilities. *FPID Bulletin: The Bulletin of the Faculty for People with Intellectual Disabilities*, *18*(1), 15–19. [https://doi.org/10.53841/bpsfpid.2020.18.1.15](https://doi.org/10.53841/bpsfpid.2020.18.1.15)
40. Staatsblad. (2018). Houdende regels ten aanzien van zorg en dwang voor personen met een psychogeriatrische aandoening of een verstandelijke handicap (Wet Zorg en Dwang psychogeriatrische en verstandelijke gehandicapte cliënten). [http://www.dwangindezorg.nl](http://www.dwangindezorg.nl/)
41. Szafranski, D. D., Smith, B. N., Gros, D. F., & Resick, P. A. (2017). High rates of PTSD treatment dropout: A possible red herring? *Journal of Anxiety Disorders*, *47*, 91–98. [https://doi.org/10.1016/j.janxdis.2017.01.002](https://doi.org/10.1016/j.janxdis.2017.01.002)
42. Van Woudenberg, C., Voorendonk, E. M., Bongaerts, H., Zoet, H. A., Verhagen, M., Lee, C. W., van Minnen, A., & De Jongh, A. (2018). Effectiveness of an intensive treatment programme combining prolonged exposure and eye movement desensitization and reprocessing for severe post-traumatic stress disorder. *European Journal of Psychotraumatology*, *9*(1), 1487225. [https://doi.org/10.1080/20008198.2018.1487225](https://doi.org/10.1080/20008198.2018.1487225)
43. Versluis, A., Mevissen, L., de Jongh, A., Schuengel, C., & Didden, R. (2024). Reliability and validity of the diagnostic interview trauma and stressors- intellectual disability in adults with mild intellectual disabilities or borderline intellectual functioning. *Journal of Mental Health Research in Intellectual Disabilities*, *18*(2), 204–220. [https://doi.org/10.1080/19315864.2024.2416694](https://doi.org/10.1080/19315864.2024.2416694)
44. Versluis, A., Schuengel, C., Mevissen, L., de Jongh, A., & Didden, R. (2025). Development and evaluation of the trauma screener-intellectual disability: A post-traumatic stress disorder screening tool for adults with mild intellectual disability or borderline intellectual functioning. *Journal of Intellectual Disability Research*, *69*(2), 127–136. [https://doi.org/10.1111/jir.13198](https://doi.org/10.1111/jir.13198)
45. Voorendonk, E. M., Sanches, S. A., Tollenaar, M. S., Hoogendoorn, E. A., de Jongh, A., & van Minnen, A. (2023). Adding physical activity to intensive trauma-focused treatment for post-traumatic stress disorder: Results of a randomized controlled trial. *Frontiers in Psychology*, *14*, 1215250. [https://doi.org/10.3389/fpsyg.2023.1215250](https://doi.org/10.3389/fpsyg.2023.1215250)
46. Wilbert, J. (2023). Scplot – Single-Case Data Plots . GitHub. [https://github.com/jazznbass/scplot](https://github.com/jazznbass/scplot)
47. Wilbert, J., & Lüke, T. (2023). Scan: Single-case data analyses for single and multiple baseline designs. (Version 0.60) . CRAN. [https://cran.r-project.org/web/packages/scan/scan.pdf](https://cran.r-project.org/web/packages/scan/scan.pdf)

[← Previous EMDR Ruh Sağlığı Tedavisinin Sanal Gerçeklikte Otomatikleştirilmesi (Automating EMDR Mental Health Treatment in Virtual Reality)](https://alisanburak.com/en/emdr-ruh-sagligi-tedavisinin-sanal-gerceklikte-otomatiklestirilmesi-automating-emdr-mental-health-treatment-in-virtual-reality)[Next → Is EMDR Therapy Effective in Older Adults?](https://alisanburak.com/en/emdr-terepisi-yasli-bireylerde-etkili-mi)

---

Kaynak / Source: https://alisanburak.com/en/hafif-duzeyde-zihinsel-yetersizligi-veya-sinirda-zihinsel-islevselligi-ve-davranissal-sorunlari-olan-yetiskinlerde-tssb-icin-kisa-sureli-yogunlastirilmis-emdr-terapisi-coklu-baslangic-duzeyi-desenli

İletişim / Contact: Bağdat Caddesi, Veli Güneysu Apt. No:453 K:4 D:9, Suadiye / Kadıköy, İstanbul · +90 532 642 95 25 · info@alisanburak.com · https://alisanburak.com/bagdat-caddesi-psikoterapi-iletisim