A Qualitative Study on Clinicians’ Perceptions of Attachment-Focused Eye Movement Desensitisation and Reprocessing Therapy

Safa Kemal Kaptan (University of Manchester; ORCID 0000-0002-4709-6543) and Mark Brayne (EMDR Focus, Norfolk, UK)
First published in Counselling and Psychotherapy Research, 2022; 22(3): 594–605. https://doi.org/10.1002/capr.12479
Received 28 April 2021; revised 1 October 2021; accepted 2 October 2021.
© 2021 British Association for Counselling and Psychotherapy. Reproduced with permission.

Keywords: AI-EMDR | Attachment-Focused EMDR | developmental trauma | eye movement desensitisation and reprocessing | modified protocol

1. Introduction

Eye movement desensitisation and reprocessing (EMDR) therapy is an individual psychotherapeutic technique developed to treat experience-based trauma (Shapiro, 1989, 2007). EMDR therapy aims to address trauma-informed memories as they relate to the past, the present and the future, using the principles of what its founder Francine Shapiro termed the Adaptive Information Processing system (AIP; Shapiro, 2007). This posits that the human nervous system and brain, like the body, have a natural tendency towards healing which will naturally unfold once the traumatic imprint of past negative events (cognitions, emotions and somatic memories) has been addressed. EMDR Therapy’s Standard Protocol (SP), or what are also known as its Standard Procedural Steps (Shapiro & Laliotis, 2011), consists of eight phases, starting with history taking/formulation and then Phase Two, preparation of the client for therapy. Work proceeds through Phase Three, assessment of symptoms and target memory, into the central Phase Four, desensitisation of stressful memories/experiences. In Phase Five, a positive cognition is ‘installed’ (or ‘tapped in’), with Phase Six inviting the client to scan their Body for any residual disturbance, followed by Phase Seven, closure of the individual session, and then Phase Eight, re-evaluation as the therapy moves through past, present and future targets. EMDR’s Phase Three represents a particularly important point in this approach, the point at which therapist and client together identify core trauma-informed memories, which continue to drive experiential dysfunction in the present. The traumatic past re-presents itself (APA, 2013) in classic PTSD in the four domains of Intrusion (e.g., flashbacks or nightmares), Avoidance (behavioural or emotional), Negative Alterations in Cognitions and Mood, and Hyperarousal (e.g., exaggerated startle response or sleep difficulties).

According to the AIP, the human brain and nervous system are programmed by evolution with the innate capacity to process emotions, cognitions and bodily sensations that arise in response to potentially traumatic events and experiences. However, where the trauma overwhelms that capacity, unprocessed memories (with their images, sounds, cognitions, etc.) are stored in a dysfunctional format in the brain, rendering these experiences susceptible to triggering in the form of continued past-related distress in the client’s present life. EMDR therapy, therefore, invites participants to focus on specific stressful memories, while the therapist administers eye movements or other forms of bilateral sensory stimulation to facilitate adaptive processing (Shapiro & Laliotis, 2011). There is still debate (van den Hout & Engelhard, 2012; Jeffries & Davis, 2013; Leer et al., 2014; van Veen et al., 2019) about how precisely this works, but research and practice confirm that EMDR therapy can be effective in processing those dysfunctional memories and reducing their vividness and impact on a client’s current life (Christman et al., 2003; Lee & Cuijpers, 2013; Maxfield et al., 2008).

As set out by Shapiro, EMDR’s Standard Protocol is built on the identification first of a traumatic event or experience, assessed in Phase Three in the specific order of Image (representing the worst part of that experience), Negative Cognition (NC), the preferred Positive Cognition (PC), the client’s felt Validity of that Cognition (VoC) on a scale of 1–7, the nature of the Emotion being felt when the memory is activated, measured on a 0–10 scale of Subjective Units of Distress/Disturbance (SUDs), then finally, before active processing begins with Bilateral Sensory Stimulation (eye movements, alternating left-right sounds or tactile buzzers, self-tapping or taps on the knees), identifying where that emotion is experienced in the Body.

EMDR therapy is now attracting increasing attention for its beneficial impact on a range of psychological presentations including, but not limited to, PTSD (Bisson et al., 2007; Khan et al., 2018), depression (Gauhar, 2016; Wood & Ricketts, 2013), anxiety (Yunitri et al., 2020), obsessive–compulsive disorder (Keenan et al., 2014) and chronic pain (Tesarz et al., 2014). Several studies (Wesselmann et al., 2012) have also considered the beneficial effect EMDR therapy can have on attachment status and relational trauma. EMDR has also shown promising results for various sample groups such as refugees (Acarturk et al., 2016), cancer patients (Portigliatti Pomeri et al., 2021), children (Rodenburg et al., 2009) and combat veterans (Albright & Thyer, 2010). Reflecting extensive research confirming the effectiveness of EMDR therapy, organisations including the World Health Organisation (World Health Organisation, 2013), the American Psychiatric Association (American Psychological Association, 2017; Ursano et al., 2004), the International Society for Traumatic Stress (Bisson et al., 2019; ISTSS, 2018) and the UK’s National Institute for Clinical Excellence (NICE; NICE, 2018) recommend EMDR as a treatment for PTSD.

Since its inception in the late 1980s, EMDR therapy for individuals has been based on the standardised eight-phase protocol. However, despite a sharing of core principles, EMDR therapy is not a monolithic model. To accommodate mental health needs in global settings with limited availability of psychologically-trained workers, or a high number of individuals in need, EMDR group therapies have been developed (Kaptan et al., 2021). Group protocols aimed at a scaling up of EMDR have opened up new fields of application (Jarero et al., 2008; Korkmazlar et al., 2020; Shapiro, 2013). Moreover, in recent years, EMDR has increasingly accommodated attachment theory and the treatment of relational trauma. One application of EMDR in this way has become known as Attachment-Focused EMDR (Brown, 2007; Parnell, 2013), emphasising a more explicit use of attachment-based resources and understandings in the application of EMDR Therapy’s Standard Procedural Steps.

The fundamental principles of AF-EMDR were first set out by Dr Laurel Parnell in her book A Therapist’s Guide to EMDR: Techniques for Successful Treatment (Parnell, 2007), elaborated six years later in Attachment-Focused EMDR: Healing Relational Trauma (Parnell, 2013). Parnell initially put forward the case for adapting the Standard EMDR protocol with: (a) richer and more imaginal resourcing in Phase 2 (with the routine installation of a ‘team’ of nurturing, protector and wise figures as well as the peaceful place); (b) more proactive use of what she termed simply ‘bridging’ (also known as floatback or affect bridge in standard EMDR terminology) to use the client’s presenting issues to trace dysfunctions back to their earlier developmental roots; (c) modifications to Phase 3 of the Standard Protocol when working with client complexity, to reorder questions into the simpler and more right-brain focused sequence of Image-Emotion-Body-Belief, without asking at this stage for a Positive Cognition or a VoC and using a SUDs rating only if useful at this point; (d) more creative use of a wider range of proactive interweaves when working with earlier childhood stories and trauma-informed complexity; (e) a tighter session structure with return to the client’s presenting target by the end of this piece of work, even where the SUDs on the past issue are not necessarily down to a zero.

In her later book (2013) developing the specific concept of ‘Attachment-Focused EMDR’ (a term suggested to her by one of neuropsychiatry’s leading global figures, Dr Dan Siegel), Parnell further refined these ideas around the five basic principles of: client safety; the importance of the therapeutic relationship; working in a client-centred way; the development of reparative neuro-networks using Resource Tapping; and the use of what she termed Modified EMDR (EMDR-M, specifically relating to Phase 3). However, AF-EMDR has been the focus of some controversy in the field of EMDR, felt at times to be deviating from the Standard Protocol and threatening the integrity of EMDR’s core approach validated by RCTs and national healthcare institutions. See Table 1 for an overview of the two approaches.

As stated above, the effectiveness of EMDR has been demonstrated since the late 1980s in a range of published research papers, both qualitative and quantitative, and including RCTs, case studies and systematic reviews (Cuijpers et al., 2020; Jowett et al., 2016; Sepehry et al., 2021; Yunitri et al., 2020). Outside the many books written by EMDR practitioners about ideas developed in the course of client-based practice (Hensley, 2016; Knipe, 2018; Luber, 2015; Parnell, 2007, 2013), there have been fewer qualitative research-focused explorations of EMDR therapy (Marich et al., 2020; Whitehouse, 2021). Although these studies provide useful insight into how and why EMDR works, to the best of our knowledge this is to be the first published study that aims to explore the perception and experiences of EMDR clinicians in the UK and Ireland with a special emphasis on Attachment-Focused EMDR.

2. Methods

The Consolidated Criteria for Reporting Qualitative Research (COREQ; Tong et al., 2007) and the Thematic Analysis Checklist for Publication (Braun & Clarke, 2020) have been used in reporting this work.

2.1 Study Design

This study employed a qualitative design, with data collected from one-to-one semi-structured interviews with eight EMDR Europe-Accredited Consultants, recruited through a purposive sampling method. A purposive sampling method was considered the best approach for recruiting a homogeneous participant group (Marshall & Rossman, 1999). Ethical approval was obtained from the University of Worcester.^*

2.2 Data Collection

One-to-one semi-structured interviews were performed by the second author in 2018 using the online video conferencing platform Zoom. Inclusion criteria were as follows: (a) being an EMDR Europe-accredited EMDR therapist; (b) being trained in and actively using AF-EMDR; (c) agreement to be audio-recorded; and (d) for the interview to be conducted in English. Participants were identified and invited to take part from the second author’s database of accredited Consultant colleagues trained by either himself or by Dr Parnell in the Attachment-Focused approach to EMDR. The eight professionals participating in the study had an average of 15 years of experience in EMDR Therapy (Table 2). The interviews were conducted in a concentrated period from 2018 and were all structured around a shared set of questions identified at the outset of the research project, with supplementary questions asked for clarification where necessary. The study did not try to reach data saturation as it was not a supported concept for reflexive thematic analysis (Braun & Clarke, 2019). Before the interview, the researcher explained verbally and in writing the aims of the study and his personal role. All participants provided written consent, and interviews ranged in length from 33 to 68 min (mean = 45 min). Interviews were audio-recorded and transcribed verbatim by the second author. The semi-structured interview guide covered a range of questions including therapists’ experiences of using EMDR, and their perceptions of AF-EMDR in particular. Semi-structured questions allowed adaptation of questions in service to more comprehensive and focused answers. As the interviews proceeded, the interview guide (listed in Table 3) was updated. Transcriptions were checked against the audio recordings.

2.3 Data Analysis

As the aim of the study was to explore ‘the shared meanings’ among interviewees of EMDR with a special focus on AF-EMDR, data were analysed using reflexive thematic analysis (Braun & Clarke, 2006; Clarke & Braun, 2017). Thematic analysis consists of six steps, starting with data familiarisation in step one and then generating initial codes in step two. Analyses proceed through the third and fourth steps of identifying shared meaning and organising them into themes. In step five, themes are finalised, named and checked for accuracy to be written in step six. The research team read and re-read the transcripts to ensure full familiarity with their content. Then, the first author used NVivo software to identify initial codes with an inductive (data-driven) approach. Codes were continuously updated and grouped into themes by the research team through discussion as the analysis progressed.

2.4 Reflexivity / Researcher Positionality

The authors acknowledge their personal experiences and the possible consequent impact on data collection and analysis, defined as reflexivity (Mosselson, 2010). The study was conducted by two authors who have experience of using EMDR in their own practice and can be considered advocates of psychological therapies for developmental trauma. The first author is a PhD candidate in the Clinical Psychology programme at the University of Manchester. The second author, who conceived and implemented the data collection for this study, is an accredited EMDR Consultant and transpersonally trained psychotherapist with a personal interest in the implementation and training of AF-EMDR, which was also known to the interviewees. The authors appreciate that this might influence expectations around the interview process. For instance, the second author’s personal interest in attachment theory may have led to increased focus on the relational aspect of AF-EMDR. In order to keep a more balanced tone and enhance trustworthiness, the first author with no clinical experience of AF-EMDR ran and reviewed analysis continually. Furthermore, regular meetings offered the research team a chance to reflect on their assumptions and motivations to reveal any personal biases and keep analyses data-driven. However, given the controversy still prevalent at the time about the use of AF-EMDR in established EMDR, and noting the absence of published research, the authors viewed the benefits of proceeding with this pioneering, if still limited, research as outweighing the qualities of compromise in its design. The second author designed the study in consultation with external supervisors.

3. Results

Three key themes and several sub-themes were developed through data analysis. Themes are outlined in Figure 1 and discussed further below with quotes from interviews.

Figure 1. Thematic map.

3.1 Perceptions of AF-EMDR

This theme encompasses the portrayal of AF-EMDR as experienced by the interviewees, with a focus on their motivations to use AF-EMDR and its techniques.

3.1.1 Making the connection

Several interviewees reported the usefulness of the Standard EMDR protocol and its success in treating a range of mental health difficulties. However, they also highlighted several caveats which encouraged them to use AF-EMDR. This was specifically evident when working with more complex clients. The mentioned factors can be categorised as manual-focused factors, therapist-focused factors and client-focused factors. On the most basic level, AF-EMDR offers them wider information and techniques.

Interviewee 1: ‘When working with more complex clients, EMDR often goes in too quickly. So, for many people, it is too abrupt and too fast and too quick, and they get dysregulated, and even just doing the safe place is not enough for many clients. And so, she (Parnell) introduced the whole concept of doing extra resourcing, and the whole, you know, thoughts about really pacing it for the client and staying very attuned to the client definitely struck a chord’.

Attachment-informed client preparation in Phase Two of EMDR’s Standard Procedural Steps, with the installation/tapping in of imaginal figures with the qualities of nurture, protection and wisdom, was valued by several interviewees, setting the stage for smoother adaptive processing in Phase Four of the EMDR eight-phase protocol.

Interviewee 3: ‘With more complex clients, and I felt it needed another element to it. So, I felt it needed, I needed something more relational’.

Several interviewees reported that despite some initial scepticism they found AF-EMDR warmer, more alive and more facilitative of the therapeutic alliance.

Interviewee 4: ‘AF-EMDR is so spiritual. I liked it because the standard protocol is exciting too but as I said very dry. But AF-EMDR brought it alive’.

Interviewee 1: ‘I find that generally speaking the Modified Protocol is just so much smoother and more elegant and helpful’.

Several interviewees identified obstacles with using the wordings and structure of the Standard EMDR Protocol with more complex clients, and highlighted solutions offered by AF-EMDR in omitting/delaying the identification of an explicit pre-processing Positive Cognition and the numerically defined Validity of Cognition (VoC, on a scale of 1–7) in Phase Three.

Interviewee 4: ‘When people have got such chronically devastating core beliefs about themselves, and they wouldn’t be able to conceive themselves with having a positive belief about themselves or about that situation. It has got to come later if you want the therapeutic relationship to stay strong. So, when that modified protocol came out, I was very excited about it’.

Interviewee 3: ‘I felt, like, all the things over the years which I’d found annoying is, potentially obstacles causing such as the VoC, and people getting hung up on the VoC, and feeling like they couldn’t get an answer properly, and letting me down sometimes that the PC wasn’t right. I just felt like those bits created problems within my therapy, and when I did the Modified Protocol, it removed those obstacles and made it easier, it made it simpler’.

3.1.2 The value of attachment-based resources

Attachment-based resources in the form of imaginal Nurturing, Protector and Wise figures (Parnell, 2013) installed (or ‘tapped in’) in Phase Two of the Standard EMDR eight-phase protocol were reported to be powerful in improving processing and increasing feelings of control and safety in subsequent Phase Four work. Several interviewees found that these resources were able to serve as key processing support for what the Standard Protocol calls ‘cognitive interweaves’ with clients presenting with trauma-informed attachment narratives from earlier life.

Interviewee 6: ‘It just enhances the work. It helps the client to process it. So that when processing is stalled, what would your wise figure say, what you need in that situation, it makes a very bland, flat process much richer’.

Interviewee 2: ‘So by tapping in the attachment resources prior to then going onto the desensitisation, I think you’re helping the client to have more easy access to that adaptive information. I think for me it really speeds up the processing’.

Two interviewees also found this form of resourcing with a range of imaginal figures to provide a stronger sense of safety and control in later processing than the ‘safe place’ of Shapiro’s original protocol.

Interviewee 5: ‘When you do this type of resourcing with the figures, it brings in complete magic control. It is far more powerful because they are choosing somebody or something that is the extreme of, probably, what they cannot feel. So that they can feel it in the stronger way because they are on their own. They have got more attachment’.

Interviewee 3: ‘I knew that standard protocol had a safe place, but I felt like there was a bit missing. And that was where this stuff came in, and it was more around the complex end of the patients that needed the attachment resources really’.

The interviewees also engaged in discussion of the originality of resources, supporting a routine installation of such resources in preparing clients for trauma reprocessing.

Interviewee 1: ‘You have to build your clients up first, right. You can argue that the Standard Protocol says that is all part of Phase 1, Phase 2. But there [are] no specific instructions about what that means. AF-EMDR is giving a very clear things to do that. It just, kind of, fills out what Phase 1 and Phase 2 are’.

In line with previous points, several interviewees also emphasised a perceived shortcoming of the safe place as in effect inviting clients to dissociate from a focus on the trauma narratives requiring reprocessing. In line with previous sub-themes, interviewees found imaginal figures more grounded and safer, reflecting as they do resources previously untapped in the client’s inner world.

Interviewee 7: ‘Yeah, just kind of doing just peaceful or safe place and off we go. And people got incredibly dissociated, they were not stabilised enough’.

3.1.3 AF-EMDR empowers autonomy

Several interviewees reported the positive role of AF-EMDR in improving the autonomy of clients.

Interviewee 3: ‘They bring their own resources in, often sometimes we haven’t even thought of, you know, they will bring their own in, and that’s where the power of the empowerment comes for them in their own healing. And I feel like that fits lovely within, with natural healing, with the adaptive information process’.

Interviewee 2: ‘I think for me it complies with the AIP model very well, I think particularly in terms of the resources. Because in tapping in the resources for the client, the client comes up with their existing resources. So, you are not giving something kind of new from yourself. So, you are literally tapping into what the clients already have access to, but when the person is overwhelmed by the traumatic memory, they lose that connection’.

3.1.4 Bridging to be found more targeted

Several interviewees noted the grounding of what Parnell terms the ‘bridging’ technique in the floatback and affect bridge of standard EMDR training, appreciating the originality of its targeted nature.

Interviewee 6: ‘For me it is about being connected. It is giving the person the idea that there is a connection to link back to, to bridge back to, rather than just aimlessly wandering off and floating back. We are not directing them to look for anything that way’.

3.1.5 Previous experiences

Interviewees discussed how their theoretical orientations complemented their use of AF-EMDR and how AF-EMDR fits with their previous experiences, a familiarity which appeared to influence their appraisal of AF-EMDR in practice.

Interviewee 7: ‘I guess I came from a sensorimotor background, I felt like a fairly solid understanding of trauma that clicked for me. So, AF-EMDR fits very nicely into that in terms of the mind and body way of processing traumatic memory’.

Interviewee 5: ‘…… part of my old training was in psychotherapy and ego state work. It just fits, so I do use them, and they work, including the imaginary parents, imagining the perfect parents’.

Interviewee 1: ‘Well I’d read her (Parnell’s) books on transpersonal EMDR, because my training was in transpersonal. I was drawn to her and her books that way, and very drawn to working with complex, kind of, complex clients, and drawn to attachment’.

3.1.6 AF-EMDR meets expectations

Interviewees were uncomfortable with how they felt Phase Three of the Standard Protocol can be experienced by clients as moving from left brain to right brain and back again in the activation of trauma-informed processing targets (for an exploration of brain laterality, see McGilchrist, 2012), describing relief on encountering the modifications of AF-EMDR.

Interviewee 4: ‘When she (Parnell) came along, it was like, great, somebody else is validating the way that I’m working. And I think every time I went on one of her trainings, it was a validation of, Oh, so I am doing it ok. (laughs.) You know, doing it like that is OK. You know, there’s somebody else out there that’s also, yeah…’

Interviewee 8: ‘I’m very attachment-based anyhow, and reading the book, it was all very gentle. Anyhow, I thought I wanted that three-day training just to consolidate my reading and to think this is kind of, fits in very nicely with what I think should be done’.

Another interviewee also reported how they felt relief to see their approach being taught in, and integrated into, EMDR.

Interviewee 2: ‘I use my systemic thinking I guess at all times. So even when I am offering very direct EMDR, I still wear my systemic hat and that is certainly informs. So, as a systemic psychotherapist where much of my focus is on relationships, whether that is the therapeutic relationship or relationships between the client and the system around them, AF-EMDR felt a bit like coming home I guess, really’.

3.2 It is not ‘versus’, it is ‘with’

3.2.1 Learning and knowing EMDR’s Standard Protocol remains essential to effective practice of EMDR

Despite their support for modifications, interviewees in this research project did not experience AF-EMDR and its modifications as a replacement or substitute for the Standard EMDR Protocol. Even when using modifications, all interviewees emphasised the importance of adherence to EMDR’s Standard Eight-phase model.

Interviewee 4: ‘You need the Standard Protocol in training as the bedrock’.

Interviewee 5: ‘I do like using all the phases. I do like getting results at the end and knowing what the numbers are. And I do get a sense of using that for research and I still do it. I use the whole eight phases with every time’.

Some interviewees reported reassurance in how the Standard Protocol can be experienced as creating a safety net for the supervision of best-practice EMDR. They also felt, at times, discouraged from engaging with these modifications, at least until reaching accredited Practitioner status.

Interviewee 2: ‘We need to know the Standard Protocol, and it’s my responsibility when putting them (supervisees) forward for accreditation to be able to say that they know how to use it, and they’re familiar with it and do use it, and that if they make adaptations from it, they can give me an explanation as to why they’re doing that within the EMDR, the AIP model. And that seems to satisfy people, that seems OK’.

3.2.2 It fits with, and is complementary to, the EMDR Standard Protocol

Interviewees were unanimous in experiencing AF-EMDR as consistent with the core principles of Standard Protocol EMDR. The two approaches were seen as having the same theoretical background, prioritising the position of Dual Attention Stimulus/Bilateral Stimulation for working through clients’ narratives of trauma.

Interviewee 3: ‘I believe that they’re the same process. It is EMDR. What else could it be? You start off with a trauma memory. It is distressing. It is high impact. It is body-located. It is just done in a different way. So, I see it as one and the same thing, but one is more structured around dealing with trauma in a kind of targeted, sequential way, and the other one is slightly more innovative’.

Interviewee 6: ‘I see them as being almost synonymous with each other, because the resources that we use, and the skills and strengths of the client are integral to actually helping them to overcome the trauma. Because the clients I work with have very few resources. So, they have not got the resources to say, well, what would you. They need a lot of interweaves to help them through’.

The interviewees welcomed changes and adaptations to the Standard Protocol, supporting the development of EMDR since it was introduced by Shapiro in 1989. Interviewees noted how EMDR did not start off the way it is now when it was just EMD, without Shapiro’s subsequent emphasis on the deeper and more meaningful reprocessing of trauma memories. Many participants saw the AF-EMDR approach as an enhancement to their practice.

Interviewee 1: ‘I do not think what she (Parnell) is saying is new. I think that fits into the Standard Protocol. She is just expanded it to have a much more proactive approach….’

Interviewee 2: ‘There are lots of other uses or adaptations or integrations that are used within EMDR, and people do not seem to have such a problem with them. So CIPOS (Constant Installation of Present Orientation and Safety) or Flash technique. So, there are lots of adaptations or integrations, I think, and my understanding is that, as an EMDR community, we are encouraged to explore those and use those where appropriate’.

Several interviewees noted that they did not see EMDR as being either the one or the other, viewing AF-EMDR as an adjunct to their practice.

Interviewee 1: ‘I think like any good theory has to evolve and change to adapt. So, the relational psychoanalytical thought now is so far from what Freud did. Just, like Attachment-Focused EMDR is considered by some as far from the Standard Protocol. But it does not have to be either/or, it could just be an evolution. So, I think, you know, the more options we have the better. The Standard Protocol works, great. The Modified Protocol works, great. The Flash technique works, great’.

3.3 The spirit of EMDR is innovation

This theme encapsulates participant perceptions of EMDR under three sub-themes.

3.3.1 EMDR therapists value creativity

Many interviewees talked about why they value EMDR and welcome different approaches.

Interviewee 3: ‘When you hear people arguing over what works better and what does not, that is not the spirit of EMDR. The spirit of EMDR is innovation. It is being creative. It is finding a way through difficulty and diversity. And if we cannot do that, the therapists, what chance have our patients got. It is about sharing good practice, being open, and for me, all the political stuff just got in the way of that’.

Despite several interviewees acknowledging the effectiveness of the Standard Protocol, some questioned the need for rigidity. Interviewees were uncomfortable with the idea that EMDR is not instrumental unless it is done in a very specific order.

Interviewee 7: ‘When you hang on so tightly to your model of working, then I think, you know, we have a responsibility to ask, why, why do we hang on so tightly?’.

3.3.2 Need for authentic approaches

Interviewees also recognised the need for awareness of individual differences with clients, adapting EMDR to the person they are working with and how they process traumatic experiences.

Interviewee 7: ‘EMDR can be done in different ways and has to be adjusted according to the person you’re working with. Some people need much more stabilisation and resource tapping in, they need much more creative type of work’.

The analysis highlighted how these interviewees were motivated to find the most effective approach for clients rather than implementing the Standard Protocol exactly as trained. Interviewees found what might be termed a ‘one-size-fits-all’ approach to be unproductive.

Interviewee 1: ‘To try to squeeze a client into a theory and model is actually bad practice. So, here is the theory, here is what we should be doing, but when it does not work, it is our duty to find a way to work with the person with us in a way that is going to be helpful to them. And so, then we can explore other ways of working’.

3.3.3 EMDR is not a mechanic process, but should be warm and alive

Interviewees rejected hard-structured approaches as cold and unproductive, rather expecting EMDR to offer a warmer relationship between therapist and client. Several discussions emphasised the importance of the therapeutic alliance for successful therapy.

Interviewee 3: ‘There is something about the attunement. I just feel like, the more papers you have got, the more didactic you are, I mean the more structured you are, the less attuned you are. And that is just, from an attachment trauma perspective that is not what is needed’.

Interviewee 8: ‘I have had referrals from psychiatrists before that said, can you see this person, and he is ready for EMDR. And then I have seen them for one session and thought, not at all is this person ready. But because of their training they thought, right, I have done this, I have done that, let us get in there’.

Many interviewees emphasised the value of AF-EMDR in helping them to be more autonomous and client-focused in their work.

Interviewee 3: ‘The Standard Protocol is structured, and it feels like you’re following a script, and it pulls from attunement that, and I think what Laurel Parnell’s work (AF-EMDR) it frees you up to be able to actually connect with the patient and stop worrying’.

4. Discussion

4.1 Findings

Attachment theory acknowledges, as does Shapiro’s AIP model, the profound influence of early life on an individual’s later functioning. In particular, attachment theory suggests that views of self and others are influenced by children’s early experiences of primary caregivers (Ahn & Jun, 2007; Albert & Bowlby, 1982; Bowlby, 1973, 2005). The overlap between the two theories creates a new avenue for EMDR and underpins the subsequent development of AF-EMDR. Despite the overlap, AF-EMDR has been criticised in recent years as lacking research-based evidence in its modifications of the core Standard Protocol, and, therefore, as threatening the integrity of EMDR as validated by RCTs and national healthcare institutions.

This research was therefore undertaken to explore the understanding and perception of therapists who actively use AF-EMDR in their practice. Analysis of data using reflexive thematic analysis generated three broad themes and 11 sub-themes. Figure 1 illustrates the overlap of these themes and the relationship between them. Overall, throughout the dataset, the sense of approval and positive experience was the main perception and experience of AF-EMDR, with several personal and professional factors contributing to the use of AF-EMDR in practice.

All interviewees endorsed the particular value of AF-EMDR’s emphasis on identifying and tapping in attachment-based resources in Phase Two (Preparation) as a key factor in their choice to use the AF-EMDR approach and the modifications to Phase Three (Assessment). It is possible that this choice might be moderated by the previous theoretical orientation of the interviewees, as several interviewees emphasised how they incorporated previous experiences into their practice of AF-EMDR.

Interviewees also reported that resources installed in Phase Two enabled patients to experience a sense of control, which is an essential part of any trauma therapy, and particularly so with developmental trauma (Herman, 2015). In line with this, Phase Two resources were also identified as an important factor in the management of client dissociation. It is noteworthy that interviewees found the therapeutic attunement stronger in AF-EMDR than Standard Protocol EMDR. This might be attributed to the attachment-related focus of AF-EMDR, reflecting the findings of an earlier study into Standard EMDR, suggesting that clients associated success less with their relationship with the therapist than with their perception of EMDR as procedural (Edmond et al., 2004).

Omitting the Positive Cognition in Phase Three, and reordering the sequence of NC/PV/VoC/Emotions/SUDs/Body to Emotions/Body/Belief was particularly approved by participants in this research, appearing to help therapists and clients avoid the previously common experience of becoming stuck when identifying Cognitions before processing begins. The therapeutic process appeared to be thereby enhanced, as challenges to the verbalisation of traumatic experiences and related emotions were avoided (Ehlers & Clark, 2000; Van der Kolk, 2000). Despite the perceived advantages of AF-EMDR and its modifications, participants also confirmed their adherence to all eight phases of the Standard Protocol as ensuring a sense of control and safety, which is essential for successful EMDR (Whitehouse, 2021). This was explored by interviewees in the context of AF-EMDR’s standing at the time the interviews were conducted (2018) in the EMDR UK community. An awareness of negative perceptions of AF-EMDR was evident throughout the interviews, experienced by the participants as reflecting prejudice in the field as well as a previous lack of research evidence. As well as seeing the Standard Protocol as essential for accreditation, participants in this survey looked forward to future basic training in EMDR routinely incorporating AF-EMDR principles, helping with the regulation of therapist anxiety and supporting cultural flexibility in the EMDR community regarding new approaches.

4.2 Limitations

While this is, to our knowledge, the first study of therapists’ perceptions of AF-EMDR, several important limitations need to be considered. The study used a purposive sampling method, and the authors acknowledge that there might be attendant bias in the responses. Furthermore, the sample size is small, representing only therapists for whom AF-EMDR is central to their work. Therapists trained in EMDR but not actively using an Attachment-Focused approach therefore were not surveyed. Further research is needed to explore the interplay between therapists’ own experiences and enthusiasms and their efficacy, perceptions and experiences of Attachment-Focused EMDR, as their views on AF-EMDR might colour their perceptions and experiences. Also, AF-EMDR has become very personally associated with Dr Laurel Parnell, who at the time of writing up this research is in the process of setting up her own autonomous EMDR trainings, independent of the accreditation and quality monitoring processes of the EMDR International Association (EMDRIA) in North America. Given the challenges of personality and politics that inevitably arise in such circumstances, future research may wish to redefine this approach more broadly as attachment-informed, rather than Attachment-Focused, EMDR.

5. Conclusion

This study aims to begin to fill the gap in EMDR literature regarding the use of an explicit attachment focus in the clinical practice of EMDR. Although the interviewees here found AF-EMDR beneficial in their own experience of treating developmental trauma, further studies are now essential to explore the effectiveness of this approach and protocol at depth. In the recent years since the interviews that underpin this study were conducted, EMDR’s mainstream training and management culture has begun to pay more active attention to the importance of attachment narratives in case conceptualisation, history taking and treatment planning. It is hoped that this article will help stimulate further productive debate in the EMDR community and pave the way for highly needed future studies into attachment-informed EMDR regarding its applicability, acceptability and effectiveness.

References