AIP, Attachment Theory Handout

© 2009 Andrew M. Leeds, Ph.D.
Attachment theory and The importance of case

case formulation in the conceptualization in
treatment outcome
EMDR approach to
psychotherapy
In the EMDR approach, clinical results depend
not only on fidelity and skills in applying the

Andrew M. Leeds, Ph.D. standard EMDR procedural steps,
1049 Fourth St, Suite G
20th EMDRIA Conference
Santa Rosa, CA 95404 but on good case conceptualization and treatment
August 29 , 2009
Phone: 707-579-9457 planning.
Atlanta, Georgia E-mail: ALeeds@theLeeds.net
www.AndrewLeeds.net
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Patients vary
tremendously in their
needs at intake
Some show good overall behavioral stability.
Others need extensive preparation before they meet
readiness criteria for EMDR reprocessing due to:
poor impulse control,
severe anxiety or depression,
affect dysregulation or affect phobia,
depersonalization, derealization or structural
dissociation.
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Inappropriate case Appropriate case formulation

formulation can lead to provides significant benefits
several kinds of complications for Clinicians
Lack of progress due to frequently altering the focus of Clinicians are better able to anticipate likely clinical
attention as other memories or issues emerge during challenges before they arise.
reprocessing or between sessions without resolving prior
targets. Clinicians are more confident and better prepared to
face unavoidable clinical challenges.
Chronically blocked responses during reprocessing.
Clinicians are better able to manage risk by avoiding
Increased risk of relapses or increases in substance foreseeable clinical complications and technical errors.
abuse, tension-reduction or self-injurious behaviors.
Clinicians can better prepare patients for each phase of
Patients tend to become reluctant to resume EMDR or treatment.
terminate prematurely when they are:
Clinicians can better present the rationale for their
discouraged from lack of progress or treatment plans to clinical supervisors, consultants,
overwhelmed by emerging material. third party payors, and other case reviewers.
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Attachment Theory and Case Formulation in the EMDR Approach to Psychotherapy nowadays2@gmx.com
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Appropriate case formulation Myths about EMDR case

provides significant benefits conceptualization and
for patients treatment plans
Patients are reassured when they understand the
Understanding the AIP model is not important.
foundation of their treatment plans.
EMDR is a simple technique and it’s application does not
Patients are better able to tolerate challenging require an overall case conceptualization.
phases of treatment when they understand the Case conceptualization is not necessary because EMDR
rationale for the work they are doing in treatment. can only be used in cases of PTSD and all PTSD cases are
essentially the same.
Patients gain confidence and a stronger therapeutic Case conceptualization is not necessary. Just apply EMDR
alliance when your case formulation and treatment reprocessing to whatever material the patient presents
plan leads to predicted symptomatic gains and because “the patient’s brain will always guide the healing
challenges. process.”
Understanding the AIP model is the only conceptual
framework you need for EMDR case conceptualization.
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Potential Sources of Potential Sources of

difficulty in developing a difficulty in developing a
case conceptualization and case conceptualization and
following a treatment plan following a treatment plan
Clinicians with backgrounds in client-centered approaches: Clinicians with a cognitive behavioral orientation:
May allow each session to unfold from the patient’s May be more focused on their patients’ predominant
current concerns and select a new target from the “issue maladaptive beliefs than on developing a case
of the week.” conceptualization based on etiology.
Reprocessing on these targets is seldom “completed” in May select targets based primarily on current stimuli
one session. that give rise to current maladaptive beliefs.
Incompletely reprocessed targets remain unresolved and May fail to pay attention to identifying and reprocessing
continue to be a source of residual symptoms when the etiological events and experiences that are the sources of
next “issue of the week” becomes the focus. the onset and reinforcement of these beliefs.
Avoided issues and avoided etiological experiences may This increases the risk of inefficient and incomplete
never be addressed in a comprehensive treatment plan. reprocessing due to unidentified etiological targets.
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Potential Sources of Essential elements of

difficulty in developing a case conceptualization
case conceptualization and
following a treatment plan Case conceptualization requires:
Clinicians with backgrounds in a behavior therapy:
Thinking beyond the patient’s immediate
May be inclined to reprocess only current instances of symptoms (maladaptive attitudes, thoughts,
maladaptive behaviors. behaviors and defensive emotional responses)
May fail to give attention to identifying or reprocessing
the memory networks of etiological events and To form a mental model of these problems
experiences that establish the template and remain the grounded in a model of psychotherapy.
source for these source of these current maladaptive
behaviors.
This increases the risk of inefficient and incomplete
reprocessing due to unidentified etiological targets.
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Attachment Theory and Case Formulation in the EMDR Approach to Psychotherapy 2

The NeuroAffective Therapy Model

A NeuroAffective
model of therapy
Leeds, 2002 EMDR
Trauma
EMDR
Processing
the adaptive information processing model
a neurophysiological model Resource
Development
Shapiro, 1995, 2001 and Installation
Attachment theory
a neuro-developmental model
Positive Affect Distress
Schore, 1994, 2000 Tolerance Tolerance
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case conceptualization The relationship of

produces a mental diagnosis and case
conceptualization
model that leads to a
treatment plan Case conceptualization is informed by, but is not based on
the diagnosis alone.
The mental model of the patient’s difficulties–based
on AIP, attachment theory and other conceptual Most diagnoses (including PTSD) are based on meeting a
frameworks–leads to a set of hypotheses about the minimum number of criteria from within subsets of
causes of the patient’s symptoms. symptoms.
These hypotheses provide the outline for building
Different patients meet the same diagnosis in different ways.
the treatment plan.
If these hypotheses are correct and the Most patients have one or more co-occurring diagnoses.
methodology is correctly applied then the patient’s This is especially true with PTSD (Kessler et al., 1995).
symptoms should improve.
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foundations of case Differences between

conceptualization Etiological and
Contributory Experiences
Case conceptualization is based on Both etiological and contributory experiences are
encoded in maladaptive memory networks (before
a functional analysis of the patient’s symptoms, EMDR reprocessing).
Etiological experiences directly lead to the onset of
their etiology,
clinically significant Axis I symptoms that are now a
focus of attention.
their current manifestations and
Contributory experiences create vulnerabilities to the
hypotheses about the underlying functional structure of later emergence of clinically significant symptoms –
patients’ adaptive and maladaptive memory networks. sometimes years or decades later.
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Flexibility in case Case conceptualization

conceptualization within the AIP model
As new information arises, the case conceptualization or the Memory networks are viewed as the primary basis for
treatment plan may need to be modified. health and pathology.
When the case formulation and treatment plan are correct, The central concern is an understanding of the
skillfully applied preparation phase interventions and relationship between:
EMDR reprocessing lead to symptom reduction.
1) the etiological events and contributory experiences
Lack of treatment progress can:
that contribute to
implicate technical errors in the selection or application of
the method (preparation phase interventions or EMDR 2) the formation and maintenance patient’s symptoms.
reprocessing) The sequence in which experiences have been encoded
or can suggest that the case conceptualization is into adaptive and maladaptive memory networks is an
incomplete or incorrect. important element in case conceptualization and
treatment planning.
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Earlier experiences Attachment Patterns

establish patterns of and AIP
response
In the AIP model it is clear that earlier experiences
establish patterns of response available to be
drawn on during later experiences. Attachment experiences are the earliest and most
influential experiences in establishing foundational
When earlier experiences provide opportunities for
patterns of response available to be drawn on
adaptive coping responses, these tend to be
during later experiences.
encoded as adaptive memory networks and serve
as resources for resiliency to later events.
The patterns of attachment shaped by early
When earlier experiences provide no opportunities caregiver experiences influence all later adaptive
for adaptive coping responses or overwhelm and maladaptive coping responses.
available coping response these tend to be encoded
as maladaptive memory networks.
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The NeuroAffective Therapy Model

Trauma, adverse life
experiences and neglect Reprocessing
maladaptive memory
networks
Shapiro (2001) has proposed that we consider applying of EMDR
EMDR reprocessing to adverse life experiences that meet Trauma
Criterion A for PTSD--large “T” experiences and those that Processing
Reprocessing
do not--small “t” experiences.
adaptive memory
networks
Clinical experience with EMDR reprocessing shows that Resource
adaptation to chronic small “t” experiences are generally Development
more challenging to resolve than discrete large “T” and Installation
experiences.
Reprocessing
Can the effects of persistent early neglect be considered defenses and
solely from the perspective of large “T” and small “t” Positive Affect developing self-
Distress
experiences that produce symptoms in an individual with an capacities
Tolerance Tolerance
intact adaptive information processing system?
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Insecure attachment and Early shared positive affect is

impaired emotional self- essential to the development
regulation of emotional self-regulation.
The inability of survivors of neglect to regulate
Shared maternal-infant positive interpersonal affect
their emotional states is not solely the result of
the adverse effects of traumatizing events. most typically involving mutual gaze and episodes
of play and
Their deficits are significantly linked to lack of associated with the formation of secure attachment
exposure to a secure, developmental attachment in the first two years of life
sequence needed to foster neurobiologically triggers elevated levels of endogenous opiods and
mediated capacities for self-regulation. dopamine in both mother and child and
See: Alexander, 1992, 1993; Fonagy et al., 2002; appears to be essential to the development of right
Schore, 1994, 1996, 1997, 2000, 2001a, 2001b; prefrontal orbital mediated capacities for emotional
Siegel, 1999; Teicher, 2000, 2002; Teicher et al., self-regulation (Schore, 2003a, 2003b).
1993; Teicher et al 1997.
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Attachment Attachment theory

and self regulation history
Attachment theory is, in essence, a regulatory theory. . .
Emotions are the highest order direct expression of
bioregulation in complex organisms (Damasio, 1998), and Bowlby (1969, 1973, 1980) was the first to theorize
attachment can thus be defined as the dyadic regulation of about the impact of early attachment experiences on
emotion (Sroufe, 1996). adult functioning
! ! - Alan N. Schore (2001)
Carlson & Sroufe (1995), Demos, E. V. (1988) and
All psychopathology constitutes primary or secondary others have shown the persistence of childhood (at 12
disorders of bonding or attachment and manifests itself as months) attachment patterns into adolescence and
disorders of self and/or interactional regulation. adulthood.
! ! - James S. Grotstein (1986)
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Attachment status Attachment Status -

as a model for Strange Situation
case formulation Ainsworth et al. 1978
Since attachment status represents a working model of self and
significant others, by definition it is the template by which the secure (B) majority of infants cry, miss mother during
person processes information regarding self-regulation and her absence in SS, are quickly comforted on reunion.
interpersonal stressors.
insecure: avoidant (A) a minority of infants show
When treating survivors of significant early neglect or abuse, little or no distress during separation from mother in
clinicians’ case formulation and treatment planning need to
be founded on what the patient’s attachment status reveals
SS, & actively avoid contact on her return. Mothers
about the patient’s working model of self and other. reject attachment behavior at home.
By forming an adequate “working model” of the patient’s insecure: resistant-ambivalent (C) a minority of
attachment status, the clinician can infants are highly distressed during separation, on
reunion are not quickly soothed by mothers who are
minimize significant and avoidable errors in treatment plan
and selection of procedure and unpredictably available & intrude on exploration.
more readily and adequately repair unavoidable problems in insecure: disorganized-disoriented (D)
attunement and empathy.
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Insecure Attachment (D): Insecure Attachment (D):

Liotti (1992) Liotti (1992)
disorganized-disoriented disorganized-disoriented
Insecure: disorganized-disoriented (D) Liotti (1992) proposes that the child’s attempts to
adapt to this situation gives rise to “multiple working
A subset of insecure avoidant infants display odd and conflicting models of self” which he believes are a necessary
behavior patterns in parent’s presence such as approaching parent
with head averted suggestive of contradictions in intention or
precursor to the development of a dissociative
sudden immobility accompanied by a dazed expression indicating disorder.
a lack of orientation to the present environment. Such infants may
show another (more oriented and organized) pattern in the same Barach (1991) suggests clinicians treating dissociative
situation at the same period in life with the other parent. disorders give much greater attention to the role of
failures of attachment in the development of problems
Liotti (1992) proposed the disorganized-disoriented pattern is the
result of frightened or frightening parental behavior which may be in living and in treatment strategies than previous
the result of unresolved parental grief or parental PTSD. authors in the dissociative disorders field.
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Adult Attachment Interview - Infant Strange Situation &

George, Kaplan & Main (1984, Adult Attachment Interview
1996). Terms
The AAI is a research instrument which assigns adults to
one of four attachment categories by analyzing the Strange Situation AAI
content and narrative style of a transcript of a
structured interview. Infant Adult
Longitudinal studies show Ainsworth’s Strange
Situation strongly predicts AAI results. Secure Secure-autonomous
AAI results do not correlate with measures of adult
personality. Avoidant Dismissing
This supports the hypothesis that adult attachment
status is based primarily on early (and some adult) Resistant- Preoccupied
experience more than on genetic contributions to ambivalent
temperament. Disorganized- Unresolved-
disoriented disorganized
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Bartholomew & Horowitz (1991) Bartholomew (1991) Four-

Four-Category Model Category Model of Adult
Attachment
Model of Self
(Degree of Dependence) Cell I indicates worthiness plus the expectation others are
generally accepting and responsive (secure).
Positive Negative
Cell II indicates a sense of unworthiness with a positive
(Low) (High)
evaluation of others (preoccupied-enmeshed).
Cell III indicates unworthiness with an expectation that others
Positive will be untrustworthy and rejecting (fearful-avoidant).
Cell I Cell II
Secure Preoccupied
Model of Other (Low) Cell IV indicates love-worthiness with a negative disposition
towards others. With counter-dependence they avoid closeness,
(Avoidance) maintain independence and invulnerability (dismissive-
Negative Cell IV Cell III
Dismissing Fearful avoidant).
(High) counter-dependent socially avoidant
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Bartholomew (1991) Self- Bartholomew (1991) Self-

Report Attachment Style Report Attachment Style
Prototypes Prototypes
Secure. “It is easy for me to become emotionally close to Fearful. “I am uncomfortable getting close to others. I want
others. I am comfortable depending on others and having emotionally close relationships, but I find it difficult to trust
others depend on me. I don’t worry about being alone or others completely, or to depend on them. I worry that I will
having others not accept me.” be hurt if I allow myself to become too close to others.”
Preoccupied. “I want to be completely emotionally intimate Dismissing. “I am comfortable without close emotional
with others, but I often find that others are reluctant to get as relationships. It is very important to me to feel independent
close as I would like. I am uncomfortable being without and self-sufficient, and I prefer not to depend on others or
close relationships, but I sometimes worry that others don’t have others depend on me.”
value me as much as I value them.”
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Attachment classification Unresolved/disorganized

Attachment classification does not
as a continuum of affect fit on the continuum of affect
regulation and structure regulation and structure
Avoidant/ Secure/ Resistant/ Unresolved/disorganized attachment classification
Dismissing Autonomous Preoccupied has been linked to Dissociative Identity Disorder
Minimal free Structure and Heightened free by Barach (1991) and Liotti (1992).
expression of affect are in expression of
both negative balance. especially Different aspects of the personality may at
and positive negative affect. various times show different, even conflicting
affect. attachment classifications.
Structures for Affects can be Absence of
represented and structures for
suppressing Structures for affect regulation may vary across
affect are rigid acknowledged regulating
with a flexible, affect. different aspects, from apparently rigid and
and highly
organized. coherent highly contained, to apparently fluid and highly
narrative. (Slade, 1999) permeable.
Adapted with permission Exhibit 4.11 Leeds, 2009 p 69
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Narrative style in Recognizing patients with

dismissing attachment dismissing attachment
organization organization
They constrict rather than contain emotional Partial list of criteria include (Main, 1996):
experience.
difficulty describing their relationships to their
They are strangers to feelings, motivations or inner life. parents;
When clinicians suggest such patients may be feeling difficulty remembering events from their childhood to
sad, longing or angry they tend to respond: “I guess so. justify their description of happy memories;
I suppose so.” “Maybe I do but I really don’t feel it
right now.” (Slade, 1999) tendency to minimize the importance of early parental
relationships;
When describing (their often few remembered)
tendency to idealize or devalue (or both) early
traumatic childhood events or abandonments their
relationships;
narratives gloss over the bare surface of events with no
references to the inner emotional impact of these lack of awareness of emotional and physiological
experiences in the past or overt expression of affect responses to perceived abandonment or threat of
about them in the present. abandonment until it reaches the point of crisis.
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Narrative style in Impact of Secure

preoccupied attachment Attachment Status in
organization Phases of Treatment
They often seem overwhelmed and tormented by feelings. Individuals with a secure/autonomous attachment status are
capable of making use of therapy in a “secure” way.
Their narratives reflect an absence of structures to
contain their abundant emotions. They are readily able to join with the therapist and are
prepared to experience the therapeutic alliance as a safe and
They present themselves as needy and dependent, and supportive environment in which they can offer coherent
demand much of attachment figures and clinicians. narratives and work through their traumatic experiences.
Yet, structure offered by others, including clinicians, They seldom need more than the minimum amount of
seems to be completely inadequate or to disappear, preparation.
leaving intense affect in its place (Slade, 1999).
They easily find a “calm place” and respond well to the calm
When describing traumatic childhood events or
place exercise.
abandonments, their narratives emphasize the
intolerability of these experiences and a sense of Their responses to EMDR reprocessing are generally
hopelessness for recovery. straightforward and uncomplicated.
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Impact of Preoccupied Impact of Dismissing

Attachment Status in Attachment Status in
Phases of Treatment Phases of Treatment
Attempts by patients with Preoccupied patterns to reestablish In the early stages of treatment of patients with Dismissing (avoidant)
attachment within the therapeutic alliance will be accompanied insecure attachment,
by clinicians’ attempts to generate increased positive affect (about worth
significant anxiety, or mastery) or a stronger therapeutic alliance (accurate empathy and
intimacy) may give rise to dismissing responses or to increased
attempts to cling, and anxiety (fearful).
a readiness to interpret appropriate therapeutic neutrality as a
RDI may lead to no observable response (but internal physiological
rejection. distress) or overt paradoxical responses of confusion or panic.
They may demand rapid intervention with EMDR reprocessing,
Work with Positive Affect Tolerance (Leeds, 2006, 2007) may be helpful
but if offered will tend to have chronically incomplete sessions in toward softening overly regulating structures and helping to permit
early phases of treatment leading to risks of premature authentic connections with others, but must be introduced gradually.
termination.
In middle stages of treatment, these patients may experience emerging
Preparation phase work often needs to be extended to manage attachment conflicts in the therapeutic alliance and begin to show
current crises and develop self-capacities. stronger protest (anger) or dismissing behavior in the form of missing,
Work with RDI is generally well-tolerated. forgetting or rescheduling appointments with apparent equanimity.
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Impact of Disorganized- Measures of Adult

disoriented Attachment Status
in Phases of Treatment Attachment
Disorganized-disoriented (Unresolved-disorganized) are highly For a review of adult attachment scales see:
variable and often unpredictable in their responses.
They may turn out to be more complex in their internal system than is Stein, H., Jacobs, N. J., Ferguson, K. S., Allen, J.
initially apparent due to a tendency to hide or be incapable of G., & Fonagy, P. (1998). What do adult attachment
describing their actual degree of internal disorganization. scales measure? Bulletin of the Menninger Clinic, 62
(1), 33-82.
They often present with secondary or tertiary structural dissociation,
that is with Dissociative Disorder NOS or Dissociative Identity
Disorder. See also The Adult Attachment Scale Revised (AAS)
in Collins, N. L. (1996). Working models of
Focused history taking and work on reprocessing should be attachment: Implications for explanation, emotion,
postponed until clinicians have overcome early challenges to develop and behavior. Journal of Personality and Social
consistent methods for establishing communication and cooperation
and later challenges to build self and affect regulating structure. Psychology, 71, 810-832.
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Clinical Assessment of
Adult Attachment Status
Case A
based on reported behaviors of childhood
and adult attachment figures “No one can help me”
History
Inconsistent
Consistent Prolonged suggestive of
Consistent contingent
absence of Periods of disorganized
Reported history
contingent
supportive
supportive
behaviors
contingent
supportive
Frightened or
Frightening
attachment
with periods of
• A 34 year old nurse in a 5 year-long engagement to be married, presented
behaviors mostly not
behaviors behaviors physical or
for treatment with generalized anxiety, nightmares, and passivity in social
supportive
sexual abuse situations.
• She was in stable recovery from alcohol abuse.
Suggestive of
Attachment classification
Suggestive of
secure
Suggestive of
insecure
Suggestive of
insecure
Suggestive of
secondary or
tertiary
• She had been verbally abused by her alcoholic father in childhood.
with that attachment figure disorganized
attachment preoccupied avoidant structural
dissociation
• Her mother was consistently kind to her but did not protect her from her
father’s intermittent verbal abuse and occasional vague threats of violence.
Mother or other primary • Her first romantic relationship had been with an angry alcoholic man who
Childhood Maternal figure was verbally abusive and made vague threats of violence.
Father or other primary
Childhood Maternal figure • Her fiancee was gentle and supportive, but tended to be passive in their
Significant attachment relationship.
figure from primary family
First adult romantic • How would you categorize her attachment style in relationship to the
attachment figure behaviors of these four significant figures: father, mother, first romantic
Second adult romantic relationship, and fiancee?
attachment figure
Most recent adult romantic
attachment figure
Adapted with permission Figure 4.12 Leeds, 2009 p 71
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Case B
and adult attachment figures “Can’t stand the pain”
History
Inconsistent
contingent supportive
Reported history contingent Frightened or attachment
supportive behaviors
supportive Frightening with periods of
supportive
sexual abuse • A 28 year old woman presented with nightmares.
• She reported childhood memories of pervasive emotional neglect by a
Suggestive of depressed mother, chronic physical abuse by step-father and two rapes.
Suggestive of Suggestive of Suggestive of secondary or
Attachment classification Suggestive of
with that attachment figure
secure
attachment
insecure
preoccupied
insecure
avoidant
disorganized
tertiary
structural
• Her first boyfriend had been consistently verbally abusive toward her
dissociation and physically abusive toward her on several occasions.
Mother or other primary

• Her second boyfriend lived in another city and they seldom saw each
Childhood Maternal figure
X other. Their relationship ended when he said he wanted to date other
X
women. She is single at present.
Significant attachment • How would you categorize her attachment style in relationship to
figure from primary family the behaviors of these four significant figures: mother, stepfather,
First adult romantic
X first boyfriend, and second boyfriend?
attachment figure
Second adult romantic
attachment figure
X
attachment figure
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Case C
and adult attachment figures “everyone victimizes me”
History
Inconsistent
Reported history
Consistent
contingent
contingent
supportive
absence of
contingent
Periods of
Frightened or
disorganized
attachment
• A 54 year old divorced grandmother presented for EMDR
supportive
behaviors
behaviors
mostly not
supportive Frightening with periods of treatment for a life-long series of victimization experiences.
supportive
sexual abuse • She was the only and adopted child of two teachers at an exclusive
prep school. Her mother was chronically depressed. She reported
Suggestive of both parents had narcissistic personality traits. They were
Attachment classification
Suggestive of
secure
Suggestive of
insecure
Suggestive of
insecure
Suggestive of
secondary or
tertiary
preoccupied with her social presentation and showed no interest in
with that attachment figure
attachment preoccupied avoidant
disorganized
structural her feelings, insecurities, problems, hopes or ambitions.
dissociation
• Before their divorce, her husband had encouraged her dependence
X
on tranquilizers and alcohol.
X
• She had been sexually abused in primary school, high school and
college by other students and teachers. She had been exploited
Significant attachment
sexually by her sadomasochistic accountant for many years.
attachment figure
X • How would you categorize her attachment style in relationship to
the behaviors of these four significant figures: mother, father,
attachment figure
X
husband, accountant?
attachment figure
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and adult attachment figures
History
Inconsistent
supportive
sexual abuse
Suggestive of
secure insecure insecure tertiary
dissociation

X
X
X
attachment figure
X
attachment figure
attachment figure
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Models of EMDR The Eight Phase Model

treatment planning and the Consensus Model
of Treatment for PTSD
Shapiro frames EMDR treatment within eight phases that
Data from a large number of randomized clinical begin with
trials and meta-analyses indicate the standard Phase 1 - History Taking followed by
PTSD protocol (past, present, future) and Phase 2 - Preparation before starting EMDR reprocessing
standard EMDR procedural steps provide an with
effective and efficient treatment for posttraumatic Phase 3 Assessment of the Target to be reprocessed.
stress disorder.
This model is applicable to some cases of PTSD--such as
American Psychiatric Association, 2004; Bisson, Ehlers, single or few incident cases.
Matthews, Pilling, Richards & Turner, 2007; Department of
Veterans Affairs & Department of Defense, 2004; Foa, Keane & More complex cases require Phase 2 Preparation-
Friedman, 2000; Shapiro, 2001. Stabilization before Phase 1 History Taking and Treatment
Planning can be completed.
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The standard EMDR

The Consensus Model procedural steps
(Shapiro, 2001)
In trauma-related syndromes, the “consensus Generally used within the standard EMDR PTSD
model” recognizes it is essential to provide protocol (Shapiro, 2001)
adequate stabilization and ego strengthening
before and during uncovering and resolving to treat maladaptive responses (cognitive,
traumatic memories to avoid “overshooting the affective, sensory, or somatic intrusive re-
therapeutic window” Briere (1996). experiencing and avoidant behavior)
For more on the “consensus model” see: Brown, associated with (i.e., believed to be caused by)
Scheflin, & Hammond, 1998; Chu, 1998; Courtois, an identifiable, discrete conditioning (traumatic)
1999. event or cluster of such events.
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The standard EMDR PTSD The “Inverted Protocol”

protocol (Shapiro, 2001) Hoffman (2004)
In 2004 Dr. Arne Hoffman (2004, 2005) presented the concept of
the “inverted protocol” for cases of Complex PTSD.
Shapiro (1995, 2001) proposed a general treatment
planning principle called the three-pronged protocol: The inverted protocol reverses the standard PTSD protocol to
address the needs of patients with profound hopelessness and
Past: first, standard EMDR procedural steps are used to severe dysregulation who do not meet readiness criteria at intake.
reprocess maladaptively encoded memories
hypothesized to be etiological to the onset of PTSD. Future: Begin with developing and installing the “future
self” (Korn & Leeds, 1998, 2002; Popky, 2005) as a resource
Present: later, after experiences from the past are for hope and the possibility of a positive outcome.
resolved, EMDR reprocessing is used to reprocess
current external or internal cues that still evoke Present: Develop and install resources to strengthen self-
maladaptive responses. capacities for basic self-care, affect regulation, and impulse
control until the patient achieves stable day-to-day functioning
Future: finally EMDR reprocessing is used for imaginal and meets readiness criteria.
rehearsal of more adaptive responses in the future.
Past: Reprocess memories associated with current symptoms.
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From the Three Pronged Three Models for EMDR

Protocol to treatment treatment sequencing in
planning Shapiro (2001)
How do we apply the Three Pronged Protocol to
treatment planning?
Start with childhood. -- This model proposes targeting
childhood memories (“touchstone” events) before
When there are multiple targets in the past linked to
adolescent and adult experiences, while initially
different or unrelated presenting complaints, the three
avoiding both memories before ages four to five as well
pronged protocol does not offer guidelines on selecting
as somatosensory memory fragments (p 118).
and sequencing targets.
Chronological targeting of the worst 10 memories before
How do we identify and select the actual sequence of memories pivotal to the patient’s symptoms (p 118).
targets to be reprocessed?
The Strategic Developmental Model (Kitchur, 2000,
2005; Shapiro, 2001, p 118).
First, consider treatment sequencing models found in the
standard reference text.
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Limitations of Models for a symptom informed EMDR

sequencing EMDR treatment planning model
treatment in Shapiro (2001) Korn, Weir & Rozelle (2004)
Korn was the first to propose a symptom informed EMDR
These three models of sequencing EMDR treatment are not treatment planning model at an EMDRIA Conference
linked to specific diagnostic categories or specific case
(Korn, Weir & Rozelle, 2004).
conceptualizations.
Other than the generic “past, present, future model,” none of the This symptom informed treatment planning model is the only
specific treatment sequencing models proposed and listed by detailed treatment sequencing model for treating PTSD to
Shapiro (2001) have been formally subjected to empirical have empirical support from controlled research.
evaluation in controlled research.
This was the model used in the double blind floxetine and
The limitations and strengths of these different models for placebo controlled EMDR PTSD treatment outcome study
treatment sequencing therefore remain anecdotal. (van der Kolk, et al., 2007).
These divergent proposals together with the absence of a
research-supported model of treatment planning had left EMDR Leeds (2004) also developed a symptom informed model of
trained clinicians to select treatment planning and target treatment planning first presented as an EMDRIA approved
sequencing models without sufficient outcome data to guide them. continuing education program that same year.
65 66
65 66

the symptom informed EMDR Four foundational

treatment planning model Principles for symptom
for cases with an axis i focus informed treatment planning
An emerging community standard for treatment sequencing.
1) Earlier experiences set the foundation for responses to later
The symptom informed model is founded on Shapiro’s events.
generic three-pronged protocol: past, present, future.
2) First reprocess the memory (or cluster of memories)
This model is proposed as applying to cases of PTSD, partial associated with the most debilitating of the patient’s
PTSD, and some other Axis I diagnoses such as Panic symptoms.
Disorder without Agoraphobia where patients substantially
meet readiness criteria for EMDR reprocessing.
3) Focus on adverse and traumatic events that are clearly
distressing to the patient--known as “activated” memories.
It is not suitable--or must be significantly modified--for cases
where the focus is an Axis II disorder or for cases meeting
4) A treatment plan must be a collaboration between the
clinician and the patient.
full criteria for OCD or Panic Disorder with Agoraphobia.
68
67 68
symptom informed symptom informed

treatment planning treatment planning
1)Earlier experiences set the foundation for responses to later events.
2)First reprocess the memory (or cluster of memories) associated
Starting with experiences related to the worst symptom, reprocess with the most debilitating of the patient’s symptoms.
earlier traumatic events before later events. If there is more than one distinct memory in this cluster, begin
Reprocess the worst experience after the earliest experience has reprocessing with the earliest experience.
been reprocessed to completion. Then check for other “activated” After the earliest memory has been reprocessed to completion,
memories related to that symptom. then target the worst memory (If there is no worst memory,
After past etiological events have been fully resolved, maladaptive select a representative memory).
responses to current stimuli can remain. Then, check other memories in the cluster and reprocess as
needed.
Next, reprocess current stimuli related to the worst symptom.
Then reprocess current stimuli related to the worst symptom.
After current stimuli no longer give rise to maladaptive responses, if After the most debilitating symptom has been alleviated, shift
the symptom remains, explore additional treatment goals with attention to the memory (or cluster of memories) associated with
imaginal rehearsal to expand the scope of future behaviors,
the next most debilitating symptom.
integrate new skills or constellate a new self-image.
69 70
69 70
symptom informed symptom informed

treatment planning treatment planning
4) A treatment plan must be a collaboration between the clinician
and the patient.
Patients can have fears and concerns about addressing their
3)Focus on adverse and traumatic events that are clearly traumatic past.
distressing to the patient--known as “activated” memories.
Early childhood experiences may have contributed to patients’
Clinicians may hypothesize that certain memories for adverse symptoms in ways that may seem obvious to the EMDR
events are etiological to current symptoms. clinician, but are not at all obvious to the patient.
However, if these memories are not overtly disturbing to the Patients may want to begin with a recent traumatic memory
patient, they need not be included in the initial treatment when overt symptoms first appeared rather than reopen early
plan. childhood memories.
Contributory experiences can be directly addressed after such
patients realize that their symptoms can only be fully alleviated
when they reprocess these early, etiological memories.
71 72
71 72

A Schematic of EMDR Symptom Informed Treatment Planning
Past Present Future Four Domains of Symptoms,

Past events from History or Floatback Presenting Complaints Treatment Goals
Goals and Concerns
Earliest Later Other Symptom Symptom Symptom
Goal 1 Goal 2 Goal 3
events events event A Worst B Serious C Milder
Behavioral, Affective, Cognitive and Somatic.

Feeder Earliest History Log report
memory event taking
Avoided What is the patient doing, feeling, thinking or
Recent event event
Cluster of
related
or stimuli
RDI for new
experiencing that he or she wants less or wants
events Picture self-image more?
NC
Floatback PC
History taking What is the patient unable to do, feel, think or
VoC
experience that he or she wants to be able to?
Floatback Emotion
Recent Skills New
What concerns does the patient or the clinician
SUD event building behavior
have about these goals?
Floatback Location
Events linked
to blocking Inquiry due to Earliest
blocked response linked event
belief
AIP, Attachment Theory ,and EMDR Case Conceptualization Copyright 2008 Andrew M. Leeds, PhD Page
Adapted with permission Figure 4.1 Leeds, 2009 p 78 74
73 74
Name: _______________________________________ Date: _____________

Patient Handout – List of memories
Treatment Goals and Concerns
Name: ___________________________________ Date: __________________
Behavioral: Wants more Wants less Concerns
Please list your most significant life experiences starting with the earliest. Include
positive and negative experiences. For each negative experience, see if you can list at
least one person, situation or experience that helped you cope with it.
Significant achievements,
Age at Ongoing stressors and
people who supported you, and
time. traumatic life experiences
experiences that helped you cope.
Affective: Wants more Wants less Concerns
Cognitive: Wants more Wants less Concerns
Somatic: Wants more Wants less Concerns
Adapted with permission Exhibit 4.4 Leeds, 2009 p 59 Adapted with permission Exhibit 4.5 Leeds, 2009 p 60
75 76
Name: _Gladys A. (MVA)______________________________ Date: _____________

Name: _____________________________________________ Page: _____ of ______
Bilateral Stimulation
Mode Visual Auditory Kinesthetic Willingness to drive alone at Decrease avoidance of certain MVA occurred on winding road.
Speed night or on winding road. driving situations Unknown source night anxiety.
Variation Direction ! " # $ Tone Location Stopped hi paid analyst job a
Notes few months ago due to burnout
Hopes to become pregnant in a
Record of Treatment by Session few months.
# Date Session Pre Post NC, (final) PC

Focus VoC SUD SUD VoC Emotions, final Body Scan
1
Calm and secure at home alone Fearful at home when alone In shower can’t hear if
2 someone tries to break in house
Relaxed, calm and alert when Fearful driving on winding
driving roads, and at night in the rain.
3
Fearful of father, location
unknown,
4
5
I can cope I am helpless Fears father. Averse to
6 processing childhood trauma.
I am safe I am not safe
7
I am strong I am weak Background boundary issues
with unstable brother
8
9
To fall asleep easily Dependence on Ambien Reluctance to deal with
10 nighttime anxiety “on her own”
11
12
Adapted with permission Figure 4.4 Leeds, 2009 p 59 AIP, Attachment Theory ,and EMDR Case Conceptualization Copyright 2008 Andrew M. Leeds, PhD
EMDR Treatment Made Simple Copyright © 2004, 2007 Andrew M. Leeds, Ph.D. 8 77 78

Name: _Gladys A. (MVA)______________________________ Page: __1__ of _1____ A Schematic of Gladys Treatment
Bilateral Stimulation
Mode Visual Auditory Kinesthetic Past Present Future

Speed 22 NA 22-26
Variation Direction ! " # $ Tone NA Location hands Fearful of Dad Boundary problems
Notes Only hand stim worked NA Effective: eyes open location unknown w/unstable brother
Record of Treatment by Session Past events from History Presenting Complaints Treatment Goals
# Date Session Pre Post NC, (final) PC
Driving
Focus VoC SUD SUD VoC Emotion, final Body Scan Witnessed Fearful Insomnia -
Anxiety: Ability to
1 10/ Intake, history, safe tried HT MVA 5 months before. At fault. Dad when dependent Drive with Sleep w/
MVA winding face her
24 place home Dx PTSD EM Best She alone injured: arms cut. assault home on comfort out Rx
roads & in fears.
Mom alone Ambien
2 10/ 7 y/o witness assault 3-4 6 0 7 I’m weak. I’m strong. I can get rain
31 Processed MVA. over it. Clear BS. CI Resp 12 sets.
3 11/ Anx when spouse 0.5 T1 stable. Current stimuli ID: in

07 away. (Dad) Tx plan. rain 5, front car sudden stop 4-5. History taking
4 11/ (Dad) Processed 4 8 0 7 I’m not safe. I’m safe. BS sense of
14 recent fear on road pressure on right side.
Contributory Single No history
experience. incident: MVA History of similar Future
5 11/ Insomnia, Depends Wants to reduce use. Sleep
21 on Ambien still. hygiene & self control methods. Memory of in daylight taking
symptoms template -
assault. curving road before MVA Drive to LA.
6 12/ Future Template: 1 3-4 0 7 I’m not safe. I’m safe. BS clear.
04 drive LA. Ready to curl up like a cat. Deferred Ready to curl RDI for new self-
target. Any other up like a cat.
7 12/ Ready to process T 1 7-8 0 7 I’m not safe. I’m OK I’m calm. BS
trauma?
image. On beach:
12 Dad hit mom 7 y/o clear. 18 sets. 2 CI resp.
History taking "I can face my
8 12/ Going for help for 1 9 0 7 I’m helpless, can’t cope. I can fears and deal
19 mom 7 y/o in rain handle this, powerful. BS clear.
Hypothesis: linkage to
childhood trauma with them."
9 01/ Running for help 2 5 0 7 I’m not OK. I’m OK. BS clear.
09 thunder 7 y/o
Aftermath of
10 01/ MV anx much better 1 7 0 7 I’m going to get hurt. I’m OK. BS assault - running Current stimuli:
16 Current MV stimuli clear. (feeder: lightening fear)
to Grandma's in driving at night
11 01/ Early T rain 7 y/o: 7 0 7 y/o: I can’t deal with this. I can. lightening & crossing hiway
23 Current stimuli MV 6 1 0 7 I’ll be hurt. In control. BS clear
thunder storm.
12 01/ Fears absent. RDI to Beach. I can face my fears & deal
30 consolidate gains. with them. Heart & mind clear.
AIP, Attachment Theory ,and EMDR Case Conceptualization Copyright 2008 Andrew M. Leeds, PhD
AIP, Attachment Theory ,and EMDR Case Conceptualization Copyright 2008 Andrew M. Leeds, PhD
79 80
Treatment Plan modifications Treatment Plan modifications in

in Preoccupied insecure Dismissing insecure attachment with
Recurrent Major Depression and
attachment with Complex PTSD probable Axis II issues
Limit initial exploration of patient history. It is possible take a superficial patient history,
but it is not possible to get a full picture of the actual
Focus on exploring current coping deficits and extent of exposure to early trauma or neglect
resources and building structures for regulating or for patients to acknowledge the impact of these adverse
affect--especially negative affect. experiences in early phases of therapy.
(Conscious experiencing and expression of affect is overly
Develop and install resources until current coping, regulated.)
self-care, and negative affect regulation skills are
Actively monitor self-care and current dysfunctional coping
sufficiently developed to tolerate a more thorough
behaviors.
history taking, development of an initial targeting
sequence, and reprocessing of etiological Extend preparation phase. Postpone reprocessing early
contributory or etiological experiences.
experiences.
81 82
81 82
Treatment Plan modifications in A look forward with

Dismissing insecure attachment with
Recurrent Major Depression and constructive avoidance of
probable Axis II issues contributory experiences
Focus initially on exploring current coping deficits and In cases of Panic Disorder with Agoraphobia or
resources and building tolerance for experiencing and Panic Disorder with a co-occurring anxiety
expressing affect--especially shared positive affect.
disorder or an Axis II disorder, a two-layered
Be cautious in considering applying RDI due to potential Model II treatment plan will generally be
positive affect intolerance.
necessary.
Look for evidence of developing capacities for tolerating and
integrating shared positive affect into the model of self and
experiencing social connectedness in patient’s daily life. The Model II treatment plan requires clinicians to
Begin with contained reprocessing focused on current
assess emerging patient readiness based on
negative or later adverse adult life experiences. treatment gains before making a transition from
Limit associations to early contributory or etiological
selecting targets based directly on experiences of
experiences until there is clear and consistent evidence panic attacks themselves to targets based on
over several weeks of stability of patient current coping. contributory memories from childhood.
83 84
83 84

and adult attachment figures
History
Inconsistent
supportive
sexual abuse
Suggestive of
secure insecure insecure tertiary
dissociation

attachment figure
attachment figure
attachment figure
Adapted with permission Figure 4.12 15

Adapted with permission Figure 4.12 Leeds, 2009 p. 71
Leeds, 2009 p. 71
A Schematic of EMDR Symptom Informed Treatment Planning
Past Present Future

Past events from History or Floatback Presenting Complaints Treatment Goals
Earliest Later Other Symptom Symptom Symptom

Goal 1 Goal 2 Goal 3
events events event A Worst B Serious C Milder
Feeder Earliest History Log report

memory event taking
Avoided
Recent event event
Cluster of or stimuli
related RDI for new
events Picture self-image
NC
History taking
Floatback PC
VoC
Floatback Emotion
Recent Skills New
SUD event building behavior
Floatback Location
Events linked
to blocking Inquiry due to Earliest
blocked response linked event Adapted with permission Figure 4.1
belief Adapted with permission Figure 4.1 Leeds, 2009 p 78
Leeds, 2009 p 78
16
Name: _______________________________________ Date: _____________
Adapted with permission Exhibit 4.4

Leeds, 2009 p 59
17
Patient Handout – List of memories
Name: ___________________________________ Date: __________________
Please list your most significant life experiences starting with the earliest. Include
positive and negative experiences. For each negative experience, see if you can list at
least one person, situation or experience that helped you cope with it.
Significant achievements,
Age at Ongoing stressors and
people who supported you, and
time. traumatic life experiences
experiences that helped you cope.
Adapted with permission Exhibit 4.5

Leeds, 2009 p 60
18
Session 33 August 30, 2009 20th EMDRIA Conference Atlanta

Andrew M. Leeds, PhD
Adaptive Information Processing, Attachment Theory and
EMDR Case Conceptualization
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23

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© 2009 Andrew M. Leeds, Ph.D.

Attachment theory and The importance of case

not only on fidelity and skills in applying the

Inappropriate case Appropriate case formulation

Appropriate case formulation Myths about EMDR case

Potential Sources of Potential Sources of

Potential Sources of Essential elements of

Attachment Theory and Case Formulation in the EMDR Approach to Psychotherapy 2

The NeuroAffective Therapy Model

case conceptualization The relationship of

foundations of case Differences between

Attachment Theory and Case Formulation in the EMDR Approach to Psychotherapy 3

Flexibility in case Case conceptualization

Earlier experiences Attachment Patterns

The NeuroAffective Therapy Model

Attachment Theory and Case Formulation in the EMDR Approach to Psychotherapy 4

Insecure attachment and Early shared positive affect is

Attachment Attachment theory

Attachment status Attachment Status -

Attachment Theory and Case Formulation in the EMDR Approach to Psychotherapy 5

Insecure Attachment (D): Insecure Attachment (D):

Adult Attachment Interview - Infant Strange Situation &

Bartholomew & Horowitz (1991) Bartholomew (1991) Four-

Attachment Theory and Case Formulation in the EMDR Approach to Psychotherapy 6

Bartholomew (1991) Self- Bartholomew (1991) Self-

Attachment classification Unresolved/disorganized

Narrative style in Recognizing patients with

Attachment Theory and Case Formulation in the EMDR Approach to Psychotherapy 7

Narrative style in Impact of Secure

Impact of Preoccupied Impact of Dismissing

Impact of Disorganized- Measures of Adult

Attachment Theory and Case Formulation in the EMDR Approach to Psychotherapy 8

Mother or other primary

Attachment Theory and Case Formulation in the EMDR Approach to Psychotherapy 9

Mother or other primary

Models of EMDR The Eight Phase Model

The standard EMDR

Attachment Theory and Case Formulation in the EMDR Approach to Psychotherapy 10

The standard EMDR PTSD The “Inverted Protocol”

From the Three Pronged Three Models for EMDR

Limitations of Models for a symptom informed EMDR

Attachment Theory and Case Formulation in the EMDR Approach to Psychotherapy 11

the symptom informed EMDR Four foundational

symptom informed symptom informed

symptom informed symptom informed

Attachment Theory and Case Formulation in the EMDR Approach to Psychotherapy 12

Past Present Future Four Domains of Symptoms,

Behavioral, Affective, Cognitive and Somatic.

Name: _______________________________________ Date: _____________

Affective: Wants more Wants less Concerns

Cognitive: Wants more Wants less Concerns

Somatic: Wants more Wants less Concerns

Name: _Gladys A. (MVA)______________________________ Date: _____________

# Date Session Pre Post NC, (final) PC

Attachment Theory and Case Formulation in the EMDR Approach to Psychotherapy 13

Mode Visual Auditory Kinesthetic Past Present Future

3 11/ Anx when spouse 0.5 T1 stable. Current stimuli ID: in

Treatment Plan modifications Treatment Plan modifications in

Treatment Plan modifications in A look forward with

Name: ___________________________ Date: _

Name: _Gladys A. (MVA)__________________ Date: _

Name: ___________________________ Date: _

Name: _________________ Date: