# Translated Article: Klinisyenler’in Bağlanma-Odaklı EMDR Terapisine Dair Algıları: Kalitatif bir Çalışma (Clinicians’ Perceptions of Attachment-Focused EMDR Therapy: A Qualitative Study)

- URL: https://alisanburak.com/en/ceviri-makalesi-klinisyenlerin-baglanma-odakli-emdr-terapisine-dair-algilari-kalitatif-bir-calisma
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- Page title: Translated Article: Klinisyenler’in Bağlanma-Odaklı EMDR Terapisine Dair Algıları: Kalitatif bir Çalışma (Clinicians’ Perceptions of Attachment-Focused EMDR Therapy: A Qualitative Study) | Assoc. Prof. Dr. Alişan Burak Yaşar

> Klinisyenler’in Bağlanma-Odaklı EMDR Terapisine Dair Algıları: Kalitatif bir Çalışma (Clinicians’ Perceptions of Attachment-Focused EMDR Therapy: A Qualita

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# Translated Article: Klinisyenler’in Bağlanma-Odaklı EMDR Terapisine Dair Algıları: Kalitatif bir Çalışma (Clinicians’ Perceptions of Attachment-Focused EMDR Therapy: A Qualitative Study)

December 20, 2021Writings and Talks

[Görsel: Translated Article: Klinisyenler’in Bağlanma-Odaklı EMDR Terapisine Dair Algıları: Kalitatif bir Çalışma (Clinicians’ Perceptions of Attachment-Focused EMDR Therapy: A Qualitative Study)]

**Klinisyenler’in Bağlanma-Odaklı EMDR Terapisine Dair Algıları: Kalitatif bir Çalışma (Clinicians’ Perceptions of Attachment-Focused EMDR Therapy: A Qualitative Study)**

**Abstract:** First described and codified in the late 1980s by Dr Francine Shapiro, Eye Movement Desensitization and Reprocessing (EMDR) therapy is increasingly recommended as a first-line treatment for post-traumatic stress disorder (PTSD). As PTSD itself has come to be understood as a consequence not only of potentially traumatic events (PTEs), but also of dysfunctional attachment experiences with primary caregivers in early childhood, EMDR therapy has begun to embrace attachment theory and the need to raise awareness. The development of the Standard EMDR Protocol built on this understanding has become known as Attachment-Focused EMDR (AF-EMDR). Although increasingly used by EMDR therapists, to date there has been no published research into how AF-EMDR is experienced in practice by qualified and accredited therapists trained in AF-EMDR. This article aims to fill that gap.

**Methods:** A qualitative approach was used to analyze semi-structured online interviews with 8 experienced British therapists trained in AF-EMDR and accredited at Consultant level by the EMDR Europe Association. Data were analyzed using reflexive thematic analysis.

**Findings:** Three broad themes were generated through thematic analysis: perceptions of AF-EMDR; together, rather than opposed; and EMDR itself being viewed as an innovative approach.

**Conclusion**: The study found that AF-EMDR was highly regarded by therapists trained and experienced in this approach. Considering the nature of developmental trauma, the authors suggest that basic training and supervision in EMDR should allow more room for an explicit focus on clients’ early childhood attachment histories, in both case conceptualization and treatment.

[Görsel: Phases of EMDR Therapy - Psychiatrist - Psychotherapist]

**INTRODUCTION**

Eye Movement Desensitization and Reprocessing (EMDR) Therapy is an individual psychotherapeutic technique developed to treat experience-based trauma (Shapiro, 1989, 2007). EMDR therapy aims to address trauma-related memories as they relate to the past, present, and future, using the principles its founder, Francine Shapiro, called the Adaptive Information Processing system (AIP; Shapiro, 2007). This assumes that the human nervous system and brain, like the body, have an inherent tendency toward healing, which will emerge naturally when the traumatic traces of past adverse events—cognitions, emotions, and somatic memories—are addressed. The Standard Protocol (SP) of EMDR Therapy, also known as the Standard Procedural Steps (Shapiro & Laliotis, 2011), consists of eight phases, beginning with history-taking/formulation and followed by the second phase, which prepares the patient for therapy. The work progresses from the third phase, assessment of symptoms and the target memory, to the fourth phase, desensitization of distressing memories/experiences.

In the fifth phase, a positive cognition is ‘installed’ (or ‘tapped in’), while the sixth phase invites the client to scan their body for any residual disturbance. This is followed by closure of the individual session in phase seven, and then reevaluation in phase eight as therapy progresses across past, present, and future targets. The third phase of EMDR represents a particularly important point in this approach, at which therapist and client jointly identify the core trauma-related memories that continue to maintain experiential dysfunction in the present. In classic PTSD, the traumatic past re-presents itself across four domains: Intrusion (e.g., flashbacks or nightmares), Avoidance (behavioral or emotional), Negative Alterations in Cognitions and Mood, and Hyperarousal (e.g., an exaggerated startle response) (APA, 2013). According to AIP, the human brain and nervous system have been programmed by evolution with an innate capacity to process the emotions, cognitions, and bodily sensations that arise in response to potentially traumatic events and experiences. However, when trauma overwhelms this capacity, unprocessed memories—with their associated images, sounds, cognitions, and so on—are stored in the brain in a dysfunctional form, leaving these experiences susceptible to triggering as ongoing distress relating to the past.

EMDR therapy therefore invites participants to focus on specific distressing 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 about exactly how well this works (van den Hout & Engelhard, 2012; Jeffries & Davis, 2013; Leer et al., 2014; van Veen et al., 2019), but research and practice confirm the potential of EMDR therapy. In other words, EMDR is effective in processing dysfunctional memories and reducing their vividness and impact on the client’s present life (Christman et al., 2003; Lee & Cuijpers, 2013; Maxfield et al., 2008). As outlined by Shapiro, the Standard Protocol of EMDR is built on the initial identification of a traumatic event or experience, assessed in Phase Three in the following sequence: a specific image representing the worst part of that experience; a Negative Cognition (NC); a preferred Positive Cognition (PC); the participant’s perceived Validity of Cognition (VoC), rated on a scale of 1–7; and the nature of the emotion felt when the memory is activated, measured on a 0–10 Subjective Units of Disturbance scale.

EMDR therapy is now attracting increasing interest because of its beneficial effects on a range of psychological conditions, 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 effects EMDR therapy may have on attachment status and relational trauma. EMDR has also shown promising results in various populations, such as refugees (Acarturk et al., 2016), cancer patients (Portigliatti Pomeri et al., 2021), children (Rodenburg et al., 2009), and war veterans (Albright & Thyer) (2010). Reflecting the extensive research confirming the effectiveness of EMDR therapy, the World Health Organization (World Health Organization, 2013), the American Psychiatric Association (American Psychological Association, 2017; Ursano et al., 2004), the International Society for Traumatic Stress Studies ( Bisson et al., 2019; ISTSS, 2018), and the UK National Institute for Clinical Excellence (NICE; NICE, 2018) recommend EMDR as a treatment for PTSD.

Since its inception in the late 1980s, individual EMDR therapy has been based on a standardized eight-phase protocol. However, despite its shared core principles, EMDR therapy is not a monolithic model. EMDR group therapies have been developed to meet mental health needs in settings around the world where psychologically trained workers are in short supply or large numbers of individuals require help (Kaptan et al., 2021). Group protocols aimed at scaling up EMDR have opened up new areas of practice (Jarero et al., 2008; Korkmazlar et al., 2020; Shapiro, 2013). In addition, in recent years EMDR has increasingly accommodated attachment theory and the treatment of relational trauma. One such application has become known as Attachment-Focused EMDR (Brown, 2007; Parnell, 2013), emphasizing the more explicit use of attachment-based resources and understandings in applying the Standard Procedural Steps of EMDR Therapy. The core principles of AF-EMDR were first set out by Dr Laurel Parnell in her book A Therapist's Guide to EMDR: Techniques for Success Treatment (Parnell, 2007), followed six years later by Bağlanma Odaklı EMDR: Healing Relational Trauma (Parnell, 2013). Parnell initially made the case for adapting the Standard EMDR Protocol through: (a) richer and more imaginative resourcing in Phase 2, with the routine installation of a peaceful place as well as a “team” of nurturing, protective, and wise figures; (b) more proactive use of what she simply called “bridging,” also known as floatback or the affect bridge in standard EMDR terminology, to trace the patient’s presenting problems back to earlier developmental roots of their difficulties; (c) when working with complex clients, using a Positive Cognition or a VoC at this stage, and a SUD rating only if useful at that point; (d) more creative use of a broader range of proactive interweaves when working with earlier childhood histories and trauma-related complexity; (e) a more tightly structured session, returning to the client’s presenting target at the end of this work, even where SUD ratings for the past issue have not necessarily fallen to zero.

In her later book (2013), developing the specific concept of ‘Attachment-Focused EMDR’—a term suggested by Dr Dan Siegel, a leading global figure in neuropsychiatry—Parnell further developed these ideas around five core principles: client safety; the importance of the therapeutic relationship; working in a client-centered way; developing reparative neural networks through Resource Tapping; and using what she called Modified EMDR (EMDR-M, particularly in relation to Phase 3). However, AF-EMDR has been the focus of some controversy within the EMDR field, at times being perceived as deviating from the Standard Protocol and threatening the integrity of the core EMDR approach endorsed by randomized controlled trials (RCTs) and national health bodies. See Table 1 for an overview of the two approaches. As noted above, the effectiveness of EMDR has been demonstrated since the late 1980s in a range of published research articles, both qualitative and quantitative, including RCTs, case studies, and systematic reviews (Cuijpers et al., 2020; Jowett et al., 2016; Sepehry et al., 2021; Yunitri et al., 2020). Aside from the many books written about ideas developed by EMDR practitioners during client-based practice (Hensley, 2016; Knipe, 2018; Luber, 2015; Parnell, 2007, 2013), there have been fewer qualitative research explorations of EMDR (Marich et al., 2020; Whitehouse, 2021). Although these studies provide useful insights into how and why EMDR works, to our knowledge this would be the first published study aiming to explore the perceptions and experiences of EMDR clinicians in the UK and Ireland with a particular emphasis on attachment.

**METHOD**

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

**Study design**

This study used a qualitative design, with data collected through individual semi-structured interviews with eight EMDR Europe Accredited Consultants selected through purposive sampling. Purposive sampling was considered the best approach for establishing a homogeneous group of participants (Marshall and Rossman, 1999). Ethical approval was obtained from the University of Warwick.

**Data collection**

Individual semi-structured interviews were conducted by the second author in 2018 using the online videoconferencing platform Zoom. The inclusion criteria were as follows: (a) being an EMDR therapist accredited by EMDR Europe; (b) having received training in AF-EMDR and actively using it; (c) agreeing to audio recording; and (d) agreeing to an interview conducted in English. Participants were identified and invited to participate from the second author’s database of accredited Consultant colleagues trained in the Attachment-Focused approach to EMDR by either the second author or Dr Parnell. The eight professionals participating in the study had an average of 15 years’ experience in EMDR Therapy (Table 2). Interviews were conducted over an intensive period beginning in 2018, and all were structured around a common set of questions established at the outset of the research project, with additional questions asked for clarification when necessary. The study did not seek to achieve data saturation, as this is not a concept supported in reflexive thematic analysis (Braun and Clarke, 2019). Before the interview, the researcher explained the aims of the study and their personal role, both verbally and in writing. All participants provided written consent, and interviews ranged in length from 33 to 68 minutes (mean = 45 minutes). Interviews were audio-recorded and transcribed verbatim by the second author. The semi-structured interview guide covered a range of questions about therapists’ experiences of using EMDR and, in particular, their perceptions of AF-EMDR. Semi-structured questions allowed questions to be adapted in the service of fuller and more focused answers. The interview guide, listed in Table 3, was updated as the interviews progressed. Transcripts were checked against the audio recordings.

**Data analysis**

Because the study aimed to explore ‘shared meanings’ of EMDR among interviewees, with a particular focus on AF-EMDR, the data were analyzed using reflexive thematic analysis (Braun and Clarke, 2006; Clarke and Braun, 2017). Thematic analysis consists of six steps, beginning with familiarization with the data in step one, followed by the generation of initial codes in step two. Analysis proceeds through the third and fourth steps of identifying shared meanings and organizing them into themes. In the fifth step, themes are finalized, named, and checked for accuracy before being written up in the sixth step. The research team read and reread the transcripts to ensure full familiarity with their content. The first author then used NVivo software to identify initial codes through an inductive, data-driven approach. As analysis progressed, codes were continually updated and grouped into themes through discussions within the research team.

**Reflexivity/researcher positionality**

The authors acknowledge their personal experiences and their potential influence on data collection and analysis, a process described as reflexivity (Mosselson, 2010). The study was conducted by two authors experienced in using EMDR in their own practice, who could be regarded as advocates of psychological therapies for developmental trauma. The first author is a doctoral candidate in the Clinical Psychology program at the University of Manchester. The second author, who designed and carried out data collection for this study, is an accredited EMDR Consultant and an interpersonally trained psychotherapist with a personal interest in practicing and teaching AF-EMDR, which was also known to the interviewees. The authors acknowledge that this may have influenced expectations during the interview process. For example, the second author’s personal interest in attachment theory may have led to a greater focus on the relational aspects of AF-EMDR. To maintain a more balanced tone and enhance credibility, the first author, who had no clinical AF-EMDR experience, continually conducted and reviewed the analyses. In addition, regular meetings gave the research team the opportunity to reflect on their assumptions and motivations in order to uncover any personal biases and keep the analyses data-driven. Nevertheless, given the debate still prevalent at the time about the use of AF-EMDR within established EMDR, and noting the absence of published research, the authors considered the benefits of proceeding with this pioneering, albeit still limited, research to outweigh the qualifications concerning EMDR.

**FINDINGS**

Three main themes and several subthemes were developed through data analysis. The themes are summarized in Figure 1 and discussed in greater detail below, with quotations from the interviews.

**Perceptions of AF-EMDR**

This theme encompasses the portrayal of AF-EMDR as experienced by interviewees, focusing on their motivations for using AF-EMDR and its techniques.

**Making the connection**

Several interviewees reported the usefulness of the Standard EMDR Protocol and its success in treating a range of mental health problems. However, they also highlighted several caveats that prompted them to use AF-EMDR. This was particularly apparent when working with more complex clients. The factors mentioned could be categorized as manual-related, therapist-related, and client-related. At the most basic level, AF-EMDR offered them a wider range of knowledge and techniques.

**Interviewee 1**: 'When working with more complex clients, EMDR often gets going too quickly. So, for many people, it is too sudden, too fast, and too quick, and they become dysregulated, and even just doing the safe place is not enough for many clients. And so, she (Parnell) introduced the concept of additional resourcing, and thinking about really going at the client’s pace and staying very connected to the client certainly became important.

Attachment-informed client preparation in Phase Two of EMDR’s Standard Procedural Steps, through the installation of imaginary figures with nurturing, protective, and wise qualities, was valued by several interviewees, laying the groundwork for smoother adaptive processing in phase four.

**Interviewee 3**: 'With more complex clients, I felt that another element was needed for this. So I felt it was necessary; I needed something more relational'.

Several interviewees reported that, despite some initial doubts, they found AF-EMDR warmer, more vibrant, and more supportive of the therapeutic alliance.

**Interviewer 4**: 'AF-EMDR is very spiritual. I liked it because the standard protocol is exciting too, but, as I said, it is very dry. But AF-EMDR brought it to life'.

**Interviewee 1:** 'Overall, I think the Modified Protocol is much gentler, more elegant, and more helpful'.

Several interviewees identified barriers to using the wording and structure of the Standard EMDR Protocol with more complex clients, highlighting the solutions offered by AF-EMDR through postponing the identification of an explicit pre-processing Positive Cognition and a numerically defined Validity of Cognition (VoC on a scale of 1–7 in Phase Three).

**Interviewer 4:**'When people have chronically destructive core beliefs about themselves, they cannot imagine having a positive belief about themselves or the situation. So, when this modified protocol came out, I was very excited about it'.

**Interviewer 3:** 'I felt that everything I had found frustrating over the years could lead to potential blocks, like the VoC, and people would get stuck on the VoC and feel they could not get an answer right, and sometimes it frustrated me that the PC was not right. I felt these parts were creating problems in my therapy, and when I used the Modified Protocol, it removed those barriers and made it easier.

**The value of attachment-based resources**

Attachment-based resources in the form of imaginary Nurturing, Protective, and Wise figures (Parnell, 2013), installed or ‘tapped in’ during the second phase of the standard eight-phase EMDR protocol, were reported to be powerful in improving processing and enhancing feelings. During subsequent phase four work, several interviewees found that these resources could serve as a fundamental processing support for what the Standard Protocol calls “cognitive interweaves,” with clients presenting with trauma-informed attachment narratives from earlier in life.

**Interviewee 6:** 'It just enhances the work. It helps the client process it. So when processing stops, what would your wise figure say, what do you need in this situation—it makes a very soft, flat process much richer'.

**Interviewee 2:** 'So, by tapping in attachment resources before moving on to desensitization, I think you help the client access that adaptive information more easily. For me, I think it really speeds up processing.

Two interviewees also found that this form of resourcing with a range of imaginary figures provided a stronger sense of safety and control during subsequent processing than the safe place in Shapiro’s original protocol.

**Interviewer 5:** 'When you do this kind of resourcing with figures, it brings a whole magical sense of control. It is much more powerful because they choose someone or something that is probably the ultimate example of what they cannot feel. They have more of a connection, so they can feel it more strongly because it is their own.

**Interviewee 3:** 'I knew that the standard protocol had a safe place, but I felt it was somewhat lacking. And that was where these things came in, and it was the complex side of patients that really needed the attachment resources.

Interviewees also discussed the specificity of the resources, supporting their routine installation to prepare clients for trauma reprocessing.

**Interviewee 1:** 'You have to build up your clients first, don’t you? You could argue that the Standard Protocol says all of this is part of Phase 1, Phase 2. But there are no specific instructions about what that means. AF-EMDR gives very clear things for that. It just fills in what Phase 1 and Phase 2 are.

In line with the preceding points, several interviewees also highlighted a perceived shortcoming of the safe place, as it effectively invites clients to move away from focusing on the trauma narratives requiring reprocessing. Consistent with the previous subthemes, interviewees found imaginary figures more grounding and safer because they reflected previously untapped resources within the client’s inner world.

**Interviewer 7**: 'Yes, I just do a peaceful or safe place, and off we go. And people became incredibly dissociated; they were not sufficiently stabilized'.

**AF-EMDR strengthens autonomy**

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

**Interviewer 3**: 'They bring their own resources, often things we would not even think of, you know, they bring their own resources, and the power of empowerment comes for them in their own healing. And I feel that this fits nicely within us, with natural healing, with the adaptive information processing process.

**Interviewee 2:** 'From my perspective, I think it fits the AIP model very well, particularly in terms of resources. Because when you tap in resources for the client, the client brings out their existing resources. So you are not giving them anything new from yourself. You are literally tapping into things clients already have access to, but when the person is overwhelmed by the traumatic memory, they lose that connection.

**Bridging is found to be more targeted**

Several interviewees noted the grounding of what Parnell calls the “bridging” technique in the floatback and affect bridge of standard EMDR training, appreciating the specificity of its targeted nature.

**Interviewee** 6: 'For me, it is about making connections. It gives the person the idea that there is a connection to link back to, to bridge to, rather than wandering aimlessly and floating back. We are not directing them to look for something in that way.

**Previous experiences**

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

**Interviewer 7:** 'I suppose, coming from a sensorimotor background, it felt like quite a solid understanding of trauma that clicked for me. So AF-EMDR fits very well with that in terms of the mind and body’s way of processing traumatic memory'.

**Interviewer 5:** “…… part of my earlier training was in psychotherapy and ego state work. It just fits, so I use them, and they work through imagining ideal parents, including imaginary parents.

**Interviewee 1:** 'I used to read Parnell’s books about transpersonal EMDR because my training was transpersonal. That is how I was drawn to her and her books, and I was drawn to attachment and to working with complex, somewhat complex clients.

**AF-EMDR meets expectations**

Interviewees were troubled by how they felt Phase Three of the Standard Protocol might be experienced by clients as a shift from the left brain to the right brain and back again during activation of trauma-informed processing targets (for an exploration of brain lateralization, see McGilchrist, 2012 ), describing relief on encountering the modifications of AF-EMDR.

**Interviewer 4:** 'When Parnell came along, it was wonderful, it was as though someone else was validating the way I worked. And I think every time I went to one of her trainings, it was an affirmation of that. You know, it is okay to do it this way. You know, there is someone else out there, yes...'

**Interviewer 8:**'I am already very attachment-oriented, and reading the book, it was all very gentle. Anyway, I thought I wanted this three-day training just to consolidate my reading and to think that it fitted very well with what I felt should be done.

Another interviewer also reported feeling relieved to see their approach being taught and integrated into EMDR.

**Interviewer 2:** 'I think I use my systemic thinking all the time. So even when I deliver very straightforward EMDR, I am still wearing my systemic hat, and it is certainly informed by that. So, as a systemic psychotherapist whose focus is very much on relationships, whether the therapeutic relationship or the relationships between the client and the system around them, AF-EMDR felt a little like coming home, really'.

Learning and knowing the Standard Protocol of EMDR remains essential for effective EMDR practice; 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 emphasized the importance of adhering to EMDR’s Standard Eight-Phase model.

**Interviewer 4**: 'You need the Standard Protocol as a foundation in training'.

**Interviewer 5:** 'I like to use all the phases. I like getting a result at the end and knowing what the numbers are. And I get the sense of using that for research, and I still do it. I use all eight phases every time'.

Some interviewees reported reassurance in experiencing the Standard Protocol as a safety net for supervising best-practice EMDR. They also felt, at times, discouraged from engaging with these modifications, at least until they had achieved accredited Practitioner status.

**Interviewee 2:** 'We need to know the Standard Protocol, and when putting them (supervisees) forward for accreditation, it is my responsibility to be able to say that they know how to use it, are familiar with it, and use it, and if they make adaptations, they can explain to me why they are doing that within EMDR, within the AIP model. And that seems to satisfy people.

**Compatible with and complementary to the EMDR Standard Protocol.**

Interviewees agreed that they experienced AF-EMDR as consistent with the core principles of Standard Protocol EMDR. The two approaches were seen as sharing the same theoretical background, prioritizing the role of Dual Attention Stimuli/Bilateral Stimulation in working through clients’ trauma narratives.

**Interviewee 3:** 'I believe they are the same process. It is EMDR. What else could it be? You start with a trauma memory. The affect is high. It is located in the body. It is just done differently. So I see it as one and the same thing, but one is structured around dealing with trauma in a kind of targeted, sequential way, and the other is a little more innovative'.

**Interviewer 6: '**I see them as almost synonymous with one another because the resources we use, and the client’s skills and strengths, are actually integral to helping them overcome the trauma. Because the clients I work with have very few resources. So they do not have the resources to say, well, what do you think. They need a lot of interweaves to help them get through.

Interviewees welcomed modifications and adaptations to the Standard Protocol that had supported the development of EMDR since its introduction by Shapiro in 1989. They noted that EMDR had not started out in its present form, having initially been simply EMD, without Shapiro’s later emphasis. Many participants viewed the AF-EMDR approach as an enhancement to their practice.

**Interviewee 1:** I do not think what Parnell says is new. I think it fits within the Standard Protocol. She has simply expanded it to have a much more proactive approach....'

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

Several interviewees stated that they did not view EMDR as an either/or proposition and saw AF-EMDR as an addition to their practice.

**Interviewee 1:** 'I think, like any good theory, it should evolve and change to adapt. So relational psychoanalytic thinking is now far removed from what Freud did. Just as Attachment-Focused EMDR is seen by some as far removed from the Standard Protocol. But it does not have to be either/or; it can simply be an evolution. So I think, you know, the more options we have, the better. The Standard Protocol works wonderfully. The Modified Protocol works wonderfully. The Flash technique works, great'

**The spirit of EMDR is innovation**

This theme brings together participants’ perceptions of EMDR under three subthemes.

**EMDR therapists value creativity**

Many interviewees described why they valued EMDR and welcomed different approaches.

**Interviewee 3:** 'When you hear people arguing about what is better and what is 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, as therapists, cannot do that, what chance do our patients have? It is about sharing good practice, being open, and for me all the political stuff has got in the way of that'.

Although several interviewees acknowledged the effectiveness of the Standard Protocol, some questioned the need for rigidity. Interviewees were troubled by the idea that EMDR is not effective unless performed in a very specific sequence.

**Interviewee 7:** 'When you cling so tightly to your working model, then, you know, I think we have a responsibility to ask why, why are we holding on so tightly?

**The need for individualized approaches**

Interviewees also recognized the need to remain aware of individual differences among clients and adapt EMDR to the person they were working with and how that person processed traumatic experiences.

**Interviewer 7:** 'EMDR can be done in different ways, and it needs to be adjusted to the person you are working with. Some people need much more stabilization and resourcing; they need much more creative kinds of work'.

The analysis highlighted how these interviewees were motivated to find the most effective approach for clients rather than applying the Standard Protocol exactly as they had been trained. Interviewees found what might be called a “one-size-fits-all” approach unproductive.

**Interviewee 1**: 'Trying to squeeze a client into a theory and model is actually poor practice. Here is the theory, here is what we are supposed to do, but when it does not work, our job is to find a way of working with the person in front of us that will help them. And so we can explore other ways of working'.

**EMDR should be warm and vibrant, not a mechanical process**

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

**Interviewee 3:** 'There is something about attunement. I just feel that the more paperwork you have, the more didactic you are, so the more structured you are, the less attuned you are. And, from an attachment trauma perspective, that is simply not what is needed.

**Interviewee 8:** “I have had referrals from psychiatrists before, saying, can you see this person, they are ready for EMDR.” And then I saw them for a session and thought, this person is not ready at all. But because of their training, they thought, right, I have done this, I have done that, let us get into it.

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

**Interviewee 3:** 'The Standard Protocol is structured, and it feels as though you are following a script, and it pulls you away from attunement toward that, and I think Laurel Parnell’s work (AF-EMDR) frees you up so you can actually connect.

**DISCUSSION**

Like Shapiro’s AIP model, attachment theory recognizes the profound influence of early life on an individual’s later functioning. In particular, attachment theory proposes that views of the self and others are influenced by children’s early experiences with primary caregivers (Ahn and Jun, 2007; Albert and Bowlby, 1982; Bowlby, 1973, 2005). The overlap between the two theories creates a new direction for EMDR and provides the foundation for the subsequent development of AF-EMDR. Despite this overlap, AF-EMDR has been criticized in recent years for lacking research evidence for its modifications to the core Standard Protocol and, therefore, threatening the integrity of EMDR as endorsed by RCTs and national health bodies. This research was therefore conducted to explore the understanding and perceptions of therapists actively using AF-EMDR in their practice. Analysis of the data using reflexive thematic analysis generated three broad themes and 11 subthemes. Figure 1 illustrates the overlap and relationships between these themes. Overall, across the dataset, a sense of affirmation and positive experience characterized the principal perception and experience of AF-EMDR, alongside various personal and professional factors contributing to its use 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 AFEMDR approach and its modifications to Phase Three (Assessment). This choice may have been moderated by interviewees’ previous theoretical orientations, as several highlighted how they incorporated their previous experiences into their AF-EMDR practice. Interviewees also reported that the resources installed in Phase Two enabled patients to experience a sense of control, an important part of any trauma treatment, particularly for developmental trauma (Herman, 2015).

Similarly, Phase Two resources were identified as an important factor in managing client dissociation. It is noteworthy that interviewees found therapeutic attunement stronger in AF-EMDR than in Standard Protocol EMDR. This may be attributed to AF-EMDR’s attachment-related focus, echoing the findings of an earlier study of Standard EMDR suggesting that clients associated success less with their relationship with the therapist than with their procedural perceptions of EMDR (Edmond et al., 2004). Omitting the Positive Cognition in Phase Three and rearranging the sequence from NC/PV/VoC/Emotions/SUDs/Body to Emotions/Body/Belief were particularly endorsed by participants in this research and appeared to help therapists and clients avoid previously common experiences. The therapeutic process appeared to improve in this way because difficulties in verbally expressing traumatic experiences and associated emotions were avoided (Ehlers & Clark, 2000; Van der Kolk, 2000). Despite the perceived advantages of AF-EMDR and its modifications, participants also affirmed their commitment to all eight phases of the Standard Protocol to provide the sense of control and safety essential for successful EMDR (Whitehouse, 2021).

This was examined by interviewees in the context of AF-EMDR’s position within the UK EMDR community at the time of the interviews (2018). Throughout the interviews, participants demonstrated awareness of negative perceptions of AF-EMDR, which they experienced as reflecting both bias within the field and the previous lack of research evidence. As well as regarding the Standard Protocol as necessary for accreditation, respondents looked forward to future basic EMDR training that routinely incorporated AF-EMDR principles, helped regulate therapist anxiety, and supported cultural flexibility within the EMDR community regarding new approaches.

**Limitations**

Although, to our knowledge, this is the first study of therapists’ perceptions of AF-EMDR, several important limitations need to be considered. The study used purposive sampling, and the authors acknowledge that responses may have been biased. In addition, the sample was small and represented only therapists for whom AF-EMDR was central to their work. Therapists trained in EMDR but not actively using an Attachment-Focused approach were not surveyed. Further research is needed to explore the interaction between therapists’ own experiences and enthusiasm and their effectiveness, perceptions, and experiences of Attachment-Focused EMDR, as their views about AF-EMDR may color their perceptions and experiences.

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Kaynak / Source: https://alisanburak.com/en/ceviri-makalesi-klinisyenlerin-baglanma-odakli-emdr-terapisine-dair-algilari-kalitatif-bir-calisma

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