Attachment-Informed EMDR: Framework and Illustrative Case Study

Christine Ramsey-Wade, Mark Brayne, Yesim Arikut-Treece and Abigail Mathews
First published in Counselling and Psychotherapy Research, 2026; 26:e70226. https://doi.org/10.1002/capr.70226
Open access under the Creative Commons Attribution License. © 2026 The Author(s). Published by John Wiley & Sons Ltd on behalf of the British Association for Counselling and Psychotherapy.

Keywords: attachment | attachment-informed eye movement desensitisation and reprocessing | childhood sexual abuse | complex post-traumatic stress disorder | EMDR | PTSD

1. An Introduction to Attachment-Informed EMDR

Eye movement desensitisation and reprocessing (EMDR) is a well-established integrative psychotherapy which aims to support clients to process adverse or traumatic life experiences, so that they can live life more fully, unencumbered by the past (Laliotis et al. 2021; Rydberg and Machado 2020; van der Kolk et al. 2007). Shapiro (2018) set out the eight-phase treatment model clearly in her original EMDR protocol, with the following treatment phases: (1) history-taking, (2) preparation, (3) assessment (including exploring cognitions, beliefs and schemas around the event), (4) desensitisation to the trauma, (5) installation of processing, (6) body scan, (7) closure and (8) re-assessment. Systematic reviews have consistently shown that EMDR is as effective as trauma-focused cognitive behavioural therapy (TF-CBT) for people experiencing post-traumatic stress (Seidler and Wagner 2006).

1.1 Online EMDR

While the delivery of psychotherapy online, via video-conferencing software, also often referred to as tele-health, pre-dates COVID-19 (Griffiths et al. 2006; Roesler 2017), this accelerated during and after the pandemic (Fisher 2021), such that this now feels like the unremarkable norm to many practitioners. Surveys of clinicians and clients demonstrate the acceptability of online EMDR (Bursnall et al. 2022; Mischler et al. 2021). Retrospective evaluations of clinical practice and some pilot clinical trials have also indicated the effectiveness of online EMDR (Farrell et al. 2022; McGowan et al. 2021; Perri et al. 2021; Rosser et al. 2023; Yurtsever et al. 2022). This echoes existing research on the ability to work remotely with even the most vulnerable members of society (Horrocks and Ireland 2020). Further prospective research is still needed, however, to confirm that online EMDR is not inferior to in-person treatment (Bursnall et al. 2022; Lenferink et al. 2020).

1.2 Trauma Complexity and Attachment

Complex post-traumatic stress is defined and measured by a disorganisation within the self, manifesting in overwhelming emotions that can feel out of control, negative beliefs about the self and challenges in forming and maintaining relationships, in addition to the flashbacks, avoidance and fear typical of post-traumatic stress (Cloitre et al. 2018). Complex post-traumatic stress can be experienced after early childhood interpersonal trauma (De Jongh et al. 2019) and/or after traumatic events in adulthood (Coventry et al. 2020). Several studies have indicated that EMDR could be an effective treatment for complex trauma (Coventry et al. 2020; De Jongh et al. 2019; Korn 2009). For many people, traumatic experiences are not one-off events; they can be frequent and consistent adverse experiences accumulated over a lifetime, whether this is a lack of parental attunement or poor attachment in childhood, bullying at school, divorce, bereavements, etc.

Adverse childhood experiences are often at the heart of complex trauma, such that early events may be key to the development of the client’s way of being in the world and their reactions to later difficult events. Several studies have indicated that EMDR can improve attachment security, and that this may be an important mechanism of change (Barazzone et al. 2023; Civilotti et al. 2019). This has led to the development of treatment protocols which centralise attachment, which therapists experience as acceptable and promising (Kaptan and Brayne 2022; Potter and Wesselmann 2022). However, it is important that any new complementary frameworks are clearly identified, with reference to their specific aims, and with evidence of fidelity (Laliotis et al. 2021).

1.3 Attachment-Informed EMDR

The EMDR Council of Scholars (Laliotis et al. 2021) and others (Rydberg and Machado 2020) have set out the case for EMDR to be understood and practised as an integrative psychotherapy, adjusted and adapted according to the needs of individual clients. For example, Farrell et al.’s (2020) paper on the Blind to Therapist framework (now known as Silent Memories) explores whether and how the Eight-Phase protocol could be adapted to clients who felt unable to verbally disclose their trauma, due to shame or perhaps fear of retribution. The aim of Farrell et al.’s (2020) study was to make EMDR more accessible to groups experiencing acute trauma due to war, sexual violations or genocide, who may not wish or be able to disclose the details of their traumatic experiences to their therapist.

In the Blind to Therapist study, verbalising cognitions about the event was bypassed to make EMDR more accessible to these under-served groups and to allow a greater focus on the emotional and physical aspects of the memory, while maintaining the client’s privacy. Therapists in Farrell et al.’s study focused on assessing the clients’ emotional and physical trauma symptoms, while those in the EMDR Standard Protocol arm assessed cognitions around the trauma as well. This small study found the Blind to Therapist framework to be as effective as the Standard Protocol and better tolerated by the target population (Farrell et al. 2020).

This begs the question of whether it is possible to adapt the original protocol for specific populations or clinical targets, while retaining its core components (Hase 2021; Rydberg and Machado 2020). Farrell et al. (2020) acknowledged that something is lost in the Blind to Therapist framework, as there is perhaps less clarity around the event or memory being processed. Nonetheless, this approach made EMDR more accessible for an under-served group, while retaining all the core elements of EMDR—activation of a memory of the event, dual attention bilateral stimulation and reprocessing of that memory—so that clients might recall experiences without having to re-live them. As shame can be a barrier to accessing trauma-focused psychotherapy (Cummings and Baumann 2021), it is important to continue to research trauma-focused therapies that rely less on verbal accounts of traumatic experiences and the cognitions around this to make services as accessible and effective as possible.

1.4 The Theory Behind Attachment-Informed EMDR

Ai-EMDR is not a new therapy or protocol. Shapiro’s eight-phase architecture is kept whole in this framework, reorganised around a single shift of emphasis, where attachment becomes the lens through which targets are identified and processed. Ai-EMDR sits inside EMDR’s own structure rather than departing from it. (The lowercase ‘ai’ aims both to avoid confusion with the capital AI of Artificial Intelligence, and to emphasise that this is a framework which complements and builds on the Standard Protocol of EMDR rather than claiming to be an entirely new protocol.)

What is novel is its understanding of targeting. Ai-EMDR uses the client’s presenting distress as a doorway into the root formative experiences that underlie it. The handling of the individual phases in standard EMDR is adapted rather than re-invented around this.

Attachment-informed EMDR (Kaptan and Brayne 2022), as in the Blind to Therapist framework, prioritises identifying the emotional and physical components of a client’s presenting distress over cognitions and numbers in the assessment phase. Explicit cognitive reframing of the event identified in this process emerges organically as the client’s maladaptive attachment experiences are processed. In EMDR’s preparation phase, ai-EMDR offers the client a comprehensive imaginal resourcing experience and then uses proactive bridging (‘floatback’ in Standard EMDR) in the assessment phase for target identification. In the desensitisation phase, a wide range of imaginal interweaves using these resources and a tight session structure are used to consolidate reprocessing of earlier life attachment dysfunction, with reference at the end of every session ‘back over the bridge’ to the client’s presenting issue in the here and now.

Clinical experience indicates that this simplified, relational and creative approach can enable a rapid and deep connection to, and revelation of, adverse attachment in childhood, seemingly allowing for the repair and ‘rewiring’ of root formative experiences which are key to how the client now operates in the world (Brayne 2022). The theoretical and clinical aim of ai-EMDR is therefore to update and integrate aspects of the self (i.e., parts or ego states) which emerged to survive difficult childhood experiences, and thus to process trauma passed down from parent to child over generations, with a specific focus on the absence of repair rather than external events—on what happens on the inside as a result of external experience (Brayne 2022; Mate 2023). A copy of the current ai-EMDR framework, detailing how it supplements aspects of the Standard EMDR Protocol to target attachment-informed complexity, can be found in Appendix 1. To date, some 2500 EMDR therapists, in the United Kingdom, United States, Australia/NZ and internationally, have been trained in this complementary framework in the past 10 years.

The following sections illustrate these components of ai-EMDR in detail, through an exemplar case study, delivered online prospectively under research conditions. The course of therapy described, therefore, provides a broad overview of ai-EMDR in action. Baseline data on resilience, complex post-traumatic stress, post-traumatic stress, anxiety and depression were collected prior to treatment (Cloitre et al. 2018; Smith et al. 2008), followed by session-by-session ratings of mood and post-traumatic stress (Connor and Davidson 2001; Kroenke et al. 2001).

The therapy was administered as part of a larger feasibility trial, where 10 sessions of therapy were allocated to each participant. The results of the feasibility trial were that the trial design was not feasible (Ramsey-Wade 2024). This case was the only completer before the trial was closed.

The EMDR Fidelity Rating Scale (Korn et al. 2018) was developed to provide consultants, researchers and clinicians with a system to ensure adherence to protocol for training and research purposes. The system consists of two stages. The trial therapist completes self-assessment forms and then submits these with video recordings of a sample of sessions to an independent assessor. The assessor reviews the self-rating forms and submitted recordings and then completes a scoring form to indicate level of compliance. This process was followed in full in the pilot feasibility trial. In addition, an adapted version of the EMDR Fidelity Rating Scale (Korn et al. 2018), with appropriate additional criteria relating to the ai-EMDR elements of the framework, was drafted by the first and second author and the independent assessor (see Data S1 in the published article’s Supporting Information). This was piloted in this study, as a simple and feasible manipulation check regarding fidelity to the ai-EMDR framework, and remains a work in progress.

Case studies can be important contributions to emerging areas of practice (Grey 2011; McLeod and Elliott 2011; Wesson and Gould 2009). Indeed, it has been suggested (Messer 2011) that published case studies can influence clinical practice more than randomised controlled trials. As ai-EMDR training is endorsed by both the EMDR Association UK and the Americas-based EMDR International Association (EMDRIA), we assert that it is important to articulate and publish this framework. The accompanying case study adds an example of the actual practice of ai-EMDR to the psychotherapy literature to illustrate the framework.

2. Case Study

This case study outlines the therapy provided to ‘Harriet’ (pseudonym), who came forward to take part in a pilot feasibility trial of ai-EMDR. The following sections will outline Harriet’s story, her presenting areas of difficulty, the approach taken within her therapy, and the progress that she made following the intervention.

2.1 Presenting Problems

Harriet is a woman in her late 40s who self-describes as of mixed Mediterranean/American descent. At the time she came for therapy, although she had many resources, such as exercise, a healthy diet, a regular meditation practice and a small group of good friends, her coping mechanisms were not working. Harriet was sleeping poorly, feeling depressed and anxious, and having suicidal thoughts. These issues were affecting important parts of her life, including her ability to work, her relationships and social life. Harriet believed her difficulties stemmed from sexual abuse which happened when she was 7 years old.

2.2 Client History

Harriet is the youngest of three sisters, and while growing up had a strong bond with the oldest of these siblings. She remembered her father as a strict disciplinarian who shouted a lot and was absent for much of the time. She described her mother as ‘a complicated person’ who had addiction problems with alcohol and other substances. Both parents came from large families, and each had many siblings. As a child, Harriet used to play or read on her own, as her sisters were much older than her. She remembers sleepwalking and even attempting to take her own life around the age of eight. Harriet believes that she suffered with chronic depression from her early 20s and had had previous therapy for around 7 years in duration.

2.3 Assessment

In the first EMDR session, Harriet’s history was taken, including her strengths and the challenges she has faced (Phase 1 of the EMDR protocol). A risk assessment was conducted, taking into consideration present suicidal thoughts and a past attempt at 7 or 8 years of age. Harriet did not have any plans or preparations, and she had strong protective factors—her two cats, her elder sister, her friends, her faith and her work. Presentation at the first session indicated low risk. The assessment of risk was re-visited at the beginning of each session during the evaluation phase. The second preparation session (Phase 2) was used for psychoeducation and to establish what in attachment-focused (Parnell et al. 2013) or attachment-informed EMDR is called a resource team of imaginal nurturer, protector and wise figures (see Appendix 1), together with the traditional calm/safe place of Standard Protocol EMDR.

The resource team is a central component of ai-EMDR. The resource team is not only available imaginally to support proactive repair work in the processing or desensitisation phase but also, as a diagnostic tool, can give the therapist a more focused understanding of likely gaps of nurture and protection in the client’s early development history. Harriet identified a diverse range of characters for her resource team, which included real people from her past and present, an animal, a fictional historic figure and a spiritual resource.

2.4 Case Conceptualisation

Case conceptualisation in ai-EMDR begins with the client’s present difficulties and builds from them a radical curiosity about how those difficulties might be grounded in the formative experiences of the early years (Mate 2023). The term ‘radical’ is used deliberately. Radical, from the Latin radix, root, captures a curiosity that reaches for the roots of present dysfunction in early relational history. It is at once collaborative and clinical: it is the open, non-judgemental wondering that Hughes (2007) places at the centre of attachment-focused work (see Appendix 1).

It also carries a second sense. Once the presenting difficulty has been identified and its roots traced, the same curiosity keeps the therapist open to wherever the client’s own processing needs the work to go, consistent with the adaptive information processing model that underpins EMDR more broadly (Shapiro 2001). Rather than imposing a fixed formulation, the therapist holds a working understanding of the roots lightly enough to follow the processing where it leads.

Harriet had experienced acute childhood trauma. However, through the course of her sessions, it became apparent that present negative appraisals of self (‘I’m not good enough’, ‘I’m not allowed to be me’, ‘I’m not important’), difficulties in relationships (‘I’m on my own’, ‘Nobody cares’, ‘I’m dismissed’, ‘My needs are not important’) and protection (‘I’m in danger’, ‘I’m not safe’) had their origins not only in the specific traumas of childhood sexual abuse but also from the lack of secure parental attachment within which, as a child, Harriet could seek protection and comfort and metabolise her experiences (Mate 2023).

2.5 Course of Treatment

Harriet received 10 weekly sessions of ai-EMDR, delivered online using the Bilateral Base platform by an EMDR therapist with some 20 years of experience. The trial therapist (third author) had trained in ai-EMDR with the framework originator (second author) approximately 2 years before this course of EMDR, ensuring adherence to the framework. As stated above, the first two sessions were used to take a full history, create a treatment plan and install resources specific to ai-EMDR.

The ai-EMDR framework builds on the standard eight-phase structure of EMDR (Shapiro 2001) and is centrally informed by EMDR’s core three-pronged protocol of past–present–future (Brayne 2022). The attachment-informed framework for Phases 3–8 was used for the remaining eight sessions. The client requested five more sessions after the 10 sessions provided by the research trial to, in her words, ‘develop a routine to make the most out of my healing process’ (i.e., of regular self-care activities). None of those later sessions were included in this case study.

2.5.1 Target Identification

The principal operational difference between ai-EMDR and the Standard Protocol lies in how targets are identified. Standard EMDR tends to locate targets as past events, sequenced by their level of disturbance. Ai-EMDR begins instead from the client’s presenting distress—the difficulty that brought them to therapy—and treats this as a doorway into the root formative experiences that underlie it. This is consistent with a more attachment-informed approach (Brayne 2022); theory predicts that lasting change depends on explicitly identifying and re-wiring these formative experiences, rather than on processing a presenting event alone. Therefore, as well as addressing the more familiar single-event traumas, ai-EMDR explicitly identifies and works with both a client’s presenting past (Shapiro 2018) and what in this model is termed their attachment-informed past (Mate 2023), being the actual autobiographical experiences in the formative past that continue to determine how a client’s nervous system reacts in the here-and-now.

These formative experiences can be theorised at four cumulative levels (Brayne 2022). The first is the rupture—the acute potentially traumatic event (PTE) with which a client presents. The second, and often the more significant level, shows in a nervous system’s response to experiences or events as laid down in patterns of early-life attachment, from which enduring beliefs about the self are laid down. The third level is the introjected and often emotionally compromised attachment figure, usually mother or father, taken in by the child to preserve a survival–critical bond and persisting into adulthood as an aspect of self. The fourth level, which can be explicitly targeted in the ai-EMDR model, is the collective, intergenerational root—the familial, cultural and historical inheritance within which the earlier levels sit.

Therefore, in sessions from the third meeting onwards, priority was given to identifying the client’s present-day experience of self, choosing in that context whether to continue work on the previous week’s focus (as per Standard EMDR’s Evaluation phase) or to bridge or re-bridge from distress that was live in Harriet’s current and immediate experience. In this case, Harriet bridged from present triggers and pervasive feelings both to experiences sitting at level one (the rupture of the childhood sexual abuse) and at level two—the absence of the secure parental attachment within which she needed validation and comfort.

2.5.2 Bridging in ai-EMDR

Targets are reached in ai-EMDR by proactive bridging from the client’s here and now, and from specific, sensory moments of present distress—a precise, split-second moment in space and time. This moment is activated using Parnell et al. (2013) modified Phase 3, running Image-Emotion-Body-Belief, rather than the standard EMDR sequence of Image-Negative Cognition-Validity of Cognition (VoC)-Emotion-Subjective Units of Distress (SUDs)-Body. Focusing on emotional and somatic activation over cognitive analysis, the discipline of tight language (see Appendix 1) allows the bridge to land cleanly in formative memory rather than in analytic narrative. The target on which the client’s nervous system lands (very often around the age of seven or so) is then activated using the same modified sequence that characterised the bridge from the present (Image, Emotion, Body, Belief), and processing commences.

Bridging points in the present might involve, for example, relational ruptures with friends, work colleagues or family members or other ‘triggers’ where a past maladaptive sense of self and safety disrupts a client’s capacity to be appropriately present to the now (Tolle 2020). To proceed, a freeze-frame/split-second image of a present moment of distress was identified with Harriet, and with that the associated emotion, body sensations and belief about self. With the current distress thus activated, Harriet was asked to ‘drop back in time’, to ‘go back as far as you can’ and note ‘the first place you land’.¹

As the sessions proceeded, Harriet landed on a range of childhood moments of feeling unprotected and unsafe, or where her parents were not there to see, hear, empathise, reassure or comfort her. Two of these early experiences were related to the memory of the sexual abuse. Others ranged from her beloved dog being put down to the childhood memory of finding her mother unconscious and being terrified that she was dead.

2.5.3 Processing in ai-EMDR

As in standard EMDR, the guiding principle in the desensitisation and reprocessing phase of ai-EMDR is to stay out of the way as far as possible, trusting the client’s own adaptive information processing to do the work (Shapiro 2018). The therapist’s more proactive moves are held in reserve and used only where they help. Processing in ai-EMDR can be understood as moving through two linked stages, captured in the three Rs: reveal and then repair/rewire.

In the reveal stage, the story from the formative past comes into awareness as the activated target is processed with EMDR’s standard dual attention stimulus (DAS). For much of this, the therapist witnesses and follows. With a target from early experience activated, Harriet and her therapist attuned to the distress she felt as a child, witnessing and processing this as it unfolded. As a session progresses, creative interweaves are encouraged to support the emergence of connections within the client’s own awareness.

In the repair/rewire stage, once the affect, the somatic impact and the narrative of her root formative experience (Brayne 2022) had come into conscious and shared awareness, Harriet used, where appropriate, her resource team and her own imagined adult presence to provide for her child self what was needed but was not available in the past. The reduction of subjective units of distress (see Appendix 1), followed by a positive self-belief emerging spontaneously and then being consolidated and installed, then signalled completion of this stage. When the body scan was clear, the session progressed to ‘coming back over the bridge’ to check the present distressing moment where that session’s work had begun. Every session, therefore, ended with identification, and where appropriate, the ‘tapping in’ of a now adaptive response to moments which pre-therapy would have triggered old, attachment-related maladaptive reaction.

3. Materials and Methods

3.1 Design

This illustrative case study had several data collection points. A single pre-treatment measurement was followed by an intervention phase, involving within-treatment sessional monitoring, followed by a single post-treatment measurement and a qualitative endpoint after the last session. Psychometric questionnaires measuring resilience, complex post-traumatic stress, post-traumatic stress, anxiety and depression were administered before and after the 10 sessions of ai-EMDR. Measures of post-traumatic stress, anxiety and depression were also taken at the beginning of each therapeutic session to track changes over time and to ensure an indicative data set in the event of missed sessions or an incomplete course of treatment. A short, mixed-methods survey was developed by the fourth author under the supervision of the first author to collect data on the participant experience (see Supporting Information in the published article). These data were gathered after the tenth session of ai-EMDR through an online questionnaire.

3.2 Ethics

An application for ethical approval for the pilot feasibility research trial was approved by the University of the West of England Faculty Research Ethics Committee (FREC reference number HAS.23.03.089). To use the data from the feasibility trial for this case study, an amendment to this application was submitted to the ethics committee and approved. Additional participant information sheets and consent forms were then created for the case study. After providing fully informed written consent to proceed, the participant was given a draft copy of this journal article, with the authority to remove any details which they felt would improve their anonymity.

3.3 Data Collection

Five psychometric instruments were used to assess Harriet’s progress during therapy, with two measures administered pre and post only, and three administered at each session to measure trends over time.

3.3.1 Pre/Post Measures

The International Trauma Questionnaire (ITQ) is an outcome measure that maps onto the World Health Organisation’s ICD-11 definition of complex trauma (Cloitre et al. 2018). It tracks both symptoms of post-traumatic stress and the disturbances in self-organisation which are the signature of more complex PTSD or C-PTSD. The ITQ was selected as the primary measure for this study due to its capacity to detect attachment-informed trauma within presentations arising from the absence of repair following difficult early experiences. The development and testing of the ITQ provided evidence of the factorial and discriminant validity of the constructs of C-PTSD (Hyland et al. 2017).

The Brief Resilience Scale (BRS-6) was also used at assessment and discharge, as an impaired ability to rebound from stress is a common feature of attachment-informed complexity (Smith et al. 2008). To take part in the pilot feasibility trial, interested client participants were screened using both the ITQ and the BRS-6. The inclusion criteria included meeting the minimum diagnostic criteria on both the Post-Traumatic Stress Disorder and Disturbances in Self-Organisation subscales of the International Trauma Questionnaire (Cloitre et al. 2018) and the maximum clinical cut-off score of 2.99 on the Brief Resilience Scale (BRS-6; Smith et al. 2008). (Scores below 3.0 on the BRS-6 indicate low resilience that may benefit from intervention; scores between 3.0 and 4.30 indicate normal resilience; and scores above 4.31 indicate high resilience.)

3.3.2 Sessional Measures

Trauma symptoms were also assessed at recruitment using the Short Post-traumatic Stress Disorder Rating Interview (SPRINT-8). The clinical cut-off score on the SPRINT-8 (minimum score of 14) was used as a further screen at recruitment (Connor and Davidson 2001). To reduce burden, the ITQ and BRS were not administered at every session, with the short SPRINT-8 questionnaire being preferred to monitor symptoms of post-traumatic stress over the course of therapy.

Symptoms of anxiety and low mood, as well as risk, were also tracked at recruitment, discharge and at each session through the administration of the Patient Health Questionnaire (PHQ-9) and Generalised Anxiety Disorder (GAD-7) questionnaires. These psychometric measures are brief and are widely used in UK health services on a sessional basis to track depression and anxiety, respectively, with strong internal consistency and good convergent validity with comparable measures (Kroenke et al. 2001; Spitzer et al. 2006). Both ask participants ‘Over the last two weeks, how often have you been bothered by any of the following problems?’ The nine PHQ items then include problems such as ‘little interest or pleasure in doing things’, while the seven GAD items include problems such as ‘feeling nervous, anxious or on edge’. Both are scored on a four-level Likert response scale, ranging from not at all (zero) to every day (three). A total score between zero and nine on the PHQ-9 indicates subclinical depression, and a score between zero and eight on the GAD-7 indicates subclinical anxiety (National Collaborating Centre for Mental Health 2019).

4. Results

Outcome measure data were recorded and displayed descriptively. Harriet’s pre- and post-treatment scores can be found in Table 1. Changes over time for the sessional outcome measures are displayed in Figures 1–3 of the published article. Post-traumatic stress, complex post-traumatic stress, low mood and anxiety all reduced over the course of treatment, while resilience increased (see Table 1). All measures moved from clinical ranges to non-clinical ranges, except for the PHQ-9, which dropped from 17 (moderately severe depression) to 10 (moderate depression/borderline) (Manea et al. 2012). The participant also completed a questionnaire at discharge with some qualitative and quantitative items; their comments are summarised below and in Figures 4 and 5 of the published article.

In response to the qualitative post-treatment survey questions, Harriet reported that she personally found this approach to be more effective than her previous therapy at getting at the root of her problems, and quicker to provide benefits. The sessions had in her words been ‘hard’, but, as she could see significant improvements on issues which had affected her since childhood, she was now feeling more content with herself and more optimistic about the future. She had no suggestions for improvement, saying ‘I wouldn’t change anything.’ To give Harriet the last word:

I felt I improved a lot in a few sessions, and having taken therapy before to deal with the same trauma, I am amazed by the recovery.

5. Discussion

Few studies have been published on the ai-EMDR framework. Those that have either have mixed results (Blake 2023) or report therapist perceptions of the framework (Kaptan and Brayne 2022). While such studies indicate that further research into ai-EMDR is warranted, this is hampered by the nascent state of the literature. In this paper, the basic principles of the ai-EMDR Framework have been described, with a copy of the full protocol included in the Appendices to support future research. A case study is also set out to illustrate ai-EMDR in action for complex trauma. This paper thus provides a foundation for future researchers to address the gap in the literature around this now widely used framework.

In the single case of Harriet, time-limited ai-EMDR appeared to be an impactful treatment for attachment-informed complex post-traumatic stress. Clinically significant reductions (i.e., a reduction of 5 points or more (Kroenke et al. 2001)) were observed across all variables after 10 sessions. Most variables moved into the non-clinical range by the end of treatment, including the GAD-7, as scores of ≥8 are required for caseness (National Collaborating Centre for Mental Health 2019, 2024). The one exception was the PHQ-9 score for depression, which reduced from 17 to 10. However, this is at the very bottom of the clinical range for this instrument, and some studies have questioned this cut-off (Manea et al. 2012). Given the strong reducing trend in PHQ-9 scores over the course of treatment, further sessions of ai-EMDR may have reduced symptoms of depression further, but this remains unknown. Importantly, feedback from the client on their treatment was positive. Altogether, these findings suggest that ai-EMDR is worthy of further research as a treatment for presentations involving attachment-informed complexity.

Existing research indicates that EMDR can be effective for post-traumatic stress (Seidler and Wagner 2006), for complex post-traumatic stress (De Jongh et al. 2019; Korn 2009) and when delivered online (Rosser et al. 2023; Yurtsever et al. 2022). Naturally, this single case study design does not allow the ai-EMDR-specific components to be isolated from the core components of standard protocol EMDR, or from non-specific therapeutic factors. It is, however, a useful demonstration of the impact of a relatively brief course of EMDR for long-standing issues based in attachment-informed complexity. Indeed, Harriet expressed her surprise at how quick and effective she had personally found this intervention, compared to her previous therapy.

These findings, therefore, while modest, indicate potential. Post-traumatic stress and complex post-traumatic stress present a severe burden to all populations, with increased rates of hospitalisation and alcohol abuse, and increased suicidality (Davidson 2000). More treatments are needed that can be delivered both briefly and flexibly, for example, either online or in person, even for those with more complex histories.

It is interesting that Harriet’s measures of distress increased from the first to the second session and started to reduce as compared to baseline only from session three for anxiety, and from session four for post-traumatic stress and depression. This detail illustrates the value of recording client data session by session rather than simply pre and post; the nuances of the client experience in therapy are more clearly visible with this design. Quantitative client feedback also indicated that it was not until the third session that she began to ‘feel better’ or experience her symptoms improving. Qualitative client feedback described the therapy as ‘hard’, but impactful. In total, these data are consistent with EMDR research and theory and reflect wider client reports of how EMDR and trauma-focused therapy, in general, can be experienced.

The rise in Harriet’s scores across the SPRINT-8, GAD-7 and PHQ-9 between sessions one and two reflects what is known of the early course of trauma-focused work. Within the adaptive information processing model that underpins EMDR, accessing a memory that has been stored in an incompletely processed form can transiently raise disturbance as the network is brought online, before that material links to more adaptive information and resolves; such between-session disturbance is anticipated in the model and managed clinically, rather than read as deterioration (Shapiro 2018). This pattern is not specific to EMDR. Across trauma-focused treatments, a temporary exacerbation of symptoms occurs in a minority of clients early in therapy, is generally not extreme and is unrelated either to dropout or to eventual outcome; clients who experience it nonetheless go on to achieve clinically significant improvement (Larsen et al. 2016). A short-lived increase in distress as a client stops avoiding troubling material and begins to engage with it may therefore be better understood as a sign of therapeutic work beginning than as a sign of harm. It is also a pattern worth naming for clients at the outset, so that an early rise in distress is met as an expected part of the process rather than as evidence that therapy is making things worse.

5.1 Limitations

While the findings of this single case study indicate what is possible, this study design does not allow causal inference; therefore, these results are not generalisable. Improvements may be due to multiple factors, such as the experience of the therapist, client factors such as motivation or psychological mindedness or other non-specific effects. Further research is needed to explore whether this is a typical result or an outlier. More prospective evidence for the efficacy and/or effectiveness of the ai-EMDR framework is needed.

Future research should also consider including the collection of follow-up data. In this design, refusing the client further sessions beyond the data collection period would have been unethical. Future designs could collect data to test whether such results endure. Further qualitative research is also needed. The client voice is often missing from the psychotherapeutic literature, on EMDR and in psychotherapy more widely (Butler and Ramsey-Wade 2024). Future researchers could ask clients how they experience these adjustments to the EMDR Standard Protocol.

The author of the ai-EMDR framework, which builds on the groundbreaking work of Laurel Parnell et al. (2013), is second author on this paper and was involved in both the design of this study and the piloted adapted ai-EMDR fidelity tool. The third author on this paper, the trial therapist, was trained in the framework by the second author. This means that fidelity to the framework was high throughout. Researchers designing and conducting ai-EMDR psychotherapy trials in the future should be mindful of this when interpreting the present and any future outcomes.

While taking measures at each therapeutic session is widely used in service evaluations and in clinical trials as it enables the recording of trends over time and guards against missing data, it can cause measurement reactivity. It is possible that the repeated use of questionnaires might make participants more aware of their behaviours or cause them to learn how to respond to the survey items, leading to practise effects or other biases due to desirability or fatigue. This is therefore a further limitation to note within this single case study design.

6. Conclusion

Ai-EMDR has had little empirical research to date. This paper explicitly articulates the ai-EMDR framework for the first time alongside an illustrative case study, providing the foundation for future studies. Ai-EMDR is worthy of investigation as an intervention for attachment-informed complexity. Further research is now needed to test or explore this framework using more generalisable or extensive research designs.

References

Appendix 1