EMDR Therapy Quarterly

EMDR therapy was developed as a treatment for single incident trauma (Shapiro, 2018) but it has developed rapidly to treat many highly complex psychological problems including severe dissociative disorders, recurrent depression and psychosis (Shapiro, 2018). Clients seeking therapy frequently present with multiple, often indistinct, trauma memories along with severe mood disturbance and problems with relationships and physical difficulties. Thus, whilst EMDR clinicians are encouraged to take comprehensive histories (Leeds, 2016; Shapiro, 2018) it can be easy for them, no matter how experienced, to feel overwhelmed by the client’s history and to feel at a loss to know where to start with treatment plans and identifying appropriate targets for reprocessing.

Case formulation and its role in therapy

The organisation of the information for treatment planning within a hypothesised model of psychopathology is known as the case formulation or case conceptualisation (the terms are generally used interchangeably) and the purpose of good case formulation, as Sperry and Sperry (2020) summarise, is to guide how clinicians:

1. Obtain and organise the case history.
2. Explain the clients’ difficulties to themselves and possibly to the client.
3. Guide and focus treatment.
4. Anticipate obstacles and challenges
5. Prepare for treatment termination with reference to key goals and treatment targets and manage attachment issues which may influence disengagement.

All mainstream psychotherapies develop case formulations but they differ in the extent to which these rationales are written down and/or made explicit to clients. The more psychodynamic and humanistic therapies may place less emphasis on making the case formulation explicit in treatment and tend to prioritise the moment-by-moment interpersonal experience in the therapeutic encounter. However, the more cognitive therapies place greater emphasis on more explicit formulation (Eells, 2007; Sperry and Sperry, 2020; Pearsons, 1989). Arguably, as in Cognitive Behavioural Therapy (CBT), EMDR tends towards a more nomothetic and categorical approach rather than a more fluid and idiographic approach to formulation. This categorical approach is exemplified by the development of multiple testable EMDR “protocols” for different conditions (e.g., Luber, 2009, 2010, 2011, 2016), along with explicit notions of normal versus abnormal behaviour (adaptive versus maladaptive). It should be noted, however, that all protocols are understood within the core eight-phase Standard Protocol that Shapiro (2018) originally developed for single-incident traumas. This more categorical ontology, together with assumptions about adaptive and maladaptive responses to triggers for unwanted behavioural responses, is incorporated in the AIP model on which EMDR treatment is based and thus EMDR case formulation may be relatively amenable to explicit written representation.

Adaptive information processing

The AIP model assumes that there is an information processing system which assimilates new experiences into pre-existing memory networks whereby “…incoming sensory perceptions are … connected to related information… allowing us to make sense of our experience. What is useful is stored in memory networks with appropriate emotions and made available to guide the person in the future…” (Solomon & Shapiro, 2008, p. 316). Solomon and Shapiro (2008, p. 316) go on to say that negative behaviours and “dysfunctional” personality characteristics are understood as symptoms of unprocessed earlier life experiences which are “… manifestations of the physiologically stored perceptions stored in memory and the reactions to them…” . Thus, the aim in EMDR case formulation is to collect the data required to reactivate the state-specific perceptions and cognitions that give rise to problematic responses in the present. In addition, information about currently held adaptive information is required for successful processing, as well as an understanding of the client’s preferred response to present triggers.

Methods for capturing formulations: Forms versus

box-and-arrow

As indicated above, the collection of the required data for EMDR processing can be overwhelming; accordingly, systems for collating information and identifying which memories will provide the means to address the client’s treatment goals have been developed. Some of these are in the format of forms (e.g., Shapiro, 2014), but more recently, attempts have been made to adopt the box-and-arrow format of CBT formulation diagrams. These box-and-arrow diagrams both capture data for processing as well as indicating systemic relationships within the data and these, in turn, guide treatment priorities (Datteri & Loudisa, 2014).

Some of the most common questions in the supervision of EMDR practice relate to target selection and stuck points when processing isn’t progressing as anticipated. It therefore seems possible that having access to a clinically valid and easy to use formulation diagram, which would capture the AIP system and indicate a rationale for stuck points and target selection, would be a valuable tool for collaborative clinical practice and reflective supervision.

Box-and-arrow diagrams in EMDR literature

A search of available published box-and-arrow EMDR formulation diagrams identified four, the Leeds diagram (Leeds, 2016), the De Jong Two Method Approach (De Jongh et al., 2010), the Santos EMDR Case Formulation Tool (Santos, 2019) and the Jarecki  Seed-to-Weed Technique (Jarecki, 2014). The Jarecki diagram offered a more pictorial representation of the AIP system than the box-and-arrow approach and so it was excluded. In addition, the author attended a training event given by Matt Wesson (Senior UK-based EMDR trainer) during which he drew out a box-and-arrow flow diagram for capturing the AIP data and Wesson kindly agreed to draw up his diagram for the training event, although this is currently unpublished. Thus, in total, four diagrams were selected for the training See Figures 1-4). During the preparation of the Leeds’ model, it was felt that Leeds’ original diagram was too complicated with 40 boxes and 12 arrows (Leeds 2016, p. 88) and so a simplified diagram was developed by Rachel Edwards (Clinical Psychologist and EMDR Practitioner) and Jenny Arthern (Counselling Psychologist and EMDR Consultant) (See Figure 1).

Figure 1: Andrew Leeds’ Symptom Focussed Case Formulation diagram adapted by Rachel Edwards and Jenny Arthern

Method

A three-hour online workshop was delivered via Zoom to 23 participants. The workshop comprised:

• A 25-minute presentation on the AIP model, summarising the paper by Solomon and Shapiro (2008).
• A 15-minute presentation of the Leeds approach taken from Leeds (2016, pp. 84-92) with a modified diagram of the method developed by Rachel Edwards and Jenny Arthern.
• A 15-minute presentation of the diagram taken from De Jongh et al. (2010).

Figure 2: Diagram of De Jongh’s Two Method Approach (redrawn)

• A 15-minute presentation of the Santos diagram taken from Santos (2019).

Figure 3: Santos Case Formulation Tool (Santos, I. (2019). EMDR case formulation tool.
Journal of EMDR Practice and Research, 13 (3), 221–231)

• A 20-minute recorded video presentation of the Wesson diagram (unpublished).

Figure 4: The Wesson Diagram for formulating a treatment plan for complex PTSD ©EMDR Academy

The participants and the presenters were then divided into four breakout groups, each consisting of five or six participants, and asked to use a complex composite case study (see Case Study) to test the four diagrams. Each breakout group was given one of the four diagrams to use, but they had copies of all four diagrams with which to compare other approaches during their discussion. The breakout groups were given 45 minutes for the task and the following instruction for their diagram:

1. Use the diagram to create a formulation for the case study below and
2. Consider the questions:
   • “Does this formulation provide all that I need for target selection and processing with EMDR?”
   • “Is it clear how to select targets for processing?” –  and following from this:
3. Identify three pros and three cons of formulations within this diagram. Be prepared to give approximately 5 minutes feedback to the main group.

At the end of this small group task, participants re-joined the main group to feed back their conclusions. The large group feedback took 40 minutes. Matt Wesson also joined the group for the feedback session. Participants’ observations and comments were recorded and transcribed anonymously for the results of the study.

Results

The tables below summarise the transcriptions of the comments made in the feedback and discussion period of the study. Comments made in relation to one diagram may also be applicable to other diagrams. Further comments were provided in the written Survey Monkey feedback comments and later discussion; these are given below in Figures 5a-5d.

Figure 5a: Participants’ assessment of the adapted Leeds diagram

Figure 5b: Participants’ assessment of the Two-Method Approach

Figure 5c: Participants’ assessment of the Santos Case Conceptualisation Tool

Figure 5d: Participants’ assessement of the Wesson Three-Prong Approach

Additional comments and observations

Intellectual demands, discussion and engagement

• Case formulation requires thinking.
• Collaboration with client – the diagrams invite discussion and reflection with the client which was seen as helpful for developing rapport and client engagement.
• Case formulation diagrams promote the development of a narrative for shared understanding of emotional problems.
• Diagrams may help you to organise, record, develop thinking and collaboration – but the picture we draw is just one part of the therapy.

Visual impact

• Visual image of the diagram – this has a significant impact on clinicians’ motivation to use the diagram.
• Visual acceptability – there is a trade-off between representing simple intuitive relationships between elements of case formulation and capturing sufficient data.

Representation of core data for AIP model

• Past, present, future – core concepts in EMDR case formulation and treatment; these need to be shown in the diagram.
•  Shapiro – past, present, future – where are the traumas driving the symptoms and where are the traumas stopping them getting to where they want to go
• Emotions and body sensations as well as cognitions (thoughts and images) – prompts within the diagrams need to include a range of triggers, not only cognitions.
• Importance of resources and resilience – but very little mention of “adaptive information”.
• Arrows help to explain causal relationships within the data to facilitate negotiation on where to start and how to order. This is influenced by:
  • Client’s ability to manage distress
  • Symptom relief
  • Chronology
• Shapiro’s emphasis on flexibility between protocols – flexibility versus fidelity, but not therapy drift.
• Trauma time-line – Problematic memories are those indicated by a ‘bend’ in the timeline graph – need to select those which are unprocessed and thus still problematic.

Simplification and clarity versus detail

• Compass versus road map – case formulations can guide the pathway towards the clients’ goals and maybe indicate the highways, but flexibility may be needed to navigate specific emotional events.
• What is left out of the diagram and what is included in the formulations? – balance between simplification and complexity.
• Simplicity invites dialogue and sharing to arrive at idiosyncratic formulation – too many boxes can leave you feeling ‘boxed-in’, too few may not prompt sufficient thinking.
• Model as prompt for data collection can skew focus or become too complex.
• How to capture non-verbal information via model using medium of language – body sensations, fleeting interpersonal reactions.

Discussion

Discursive case formulations versus box-and-arrow diagrams and the impact of both on the quality of therapeutic thinking and flexibility

 There is something interesting about the relationship between the AIP model as a discursive hypothetical model which accounts for “. . . the rapidity with which clinical results are achieved with EMDR therapy and the consistency of the many patterns of response to it . . .” (Shapiro, 2018, p. 15) and the human instinct to create an abstracted pictorial representation to understand the relationships within the model more clearly. A similar approach to representing case formulation in pictorial form has been developed in CBT and perhaps this arises from the more categorical and normative ontology shared by CBT and EMDR.  As outlined above, the AIP model assumes that “. . . most pathologies [are] derived from earlier life experiences that set in motion a continued pattern of affect, behaviour, cognitions and consequent identity structures . . .” (Shapiro, 2018, p. 15) and that there is “. . . an information-processing system that is intrinsic and adaptive . . .” (Shapiro, 2018, p. 17). The problem for clinicians is how to recognise and intervene most effectively in the key memories of earlier life experience whilst keeping in mind the way in which the intrinsic information processing system responds to present triggers which may derail or cause the processing system to shut down.

The aim of case formulation then is to represent the AIP model and the key relationships between present problems/symptoms and earlier experiences and their impact on what the client wishes to be able to achieve in future. In addition, it provides a framework for incorporating resources’ that can be drawn on to maintain resilience within the psycho-neurological system as processing recommences. It is the multi-faceted, recursive nature of this process in complex cases that can confound attempts at linear box-and-arrow representation. Take, for example, the kind of box-and-arrow diagram which Leeds provides to illustrate his case conceptualisation and treatment planning in his article in ETQ Vol 3 No 2 (Figure 3 in that article). In clinical practice this would be a way for the clinician to organise and prioritise target selection, though the Leeds’ diagram, as it stands, comprises 38 boxes and 10 arrows without mentioning and linking in the clients’ goals. It is thus contended by this article that there are two issues for the clinician to be aware of in developing case formulation diagrams:

1.  Visual representations of prompts for gathering and organising client information must be simple enough to hold in mind but not so simple that important information is missing. Achieving this balance is challenging. Edwards and Arthern have attempted this with their two-piece diagrams of the “funnel” and the “template”.

2. Organising client information in this essentially verbal and visual left-brain way, may skew or disrupt how clinicians learn about the client and respond therapeutically to their verbal and non-verbal communication. As the science philosopher Alfred Korzbyski (1933, p.58 ) observed, “A map is not the territory it represents, but, if correct, it has a similar structure to the territory, which accounts for its usefulness” and, in psychological therapy, the map-making is even trickier as the perceivable territory is in a constant state of flux.

Impressions of the clinical utility of four diagrams

In general, our study indicated wide appreciation and support for the Leeds and Santos diagrams, and features of the Wesson and De Jongh diagrams were seen as having value. The workshop was presented for a second time in May 2021, in a slightly modified format in response to participants’ comments in February. In this second workshop a poll of the 42 participants found that, in their clinical practice, half the participants intended to use the Leeds’ diagrams, 38% would use Santos’, 10% would use De Jongh’s and 2% would use Wesson’s. For supervision, 48% of participants preferred the Santos diagram,  40% preferred Leeds’, 7% Wesson’s and 5% would use De Jongh’s diagram. These data indicate that there may be no single diagram format that meets clinical needs and clinician preferences universally.  However, the availability of a diagram was appreciated as a focus for talking through and organising present symptoms and problems with the client and for stimulating thinking about which memories/experiences may be most likely to be driving the symptoms, as well as thinking through what might be blocking future goals. Thus, the diagrams become a focus for collaborating with a client in developing the case formulation and a framework for holding the key information required by the AIP model for processing.

In addition to the general comments above, participants identified specific strengths and weaknesses of the four diagrams.

The adapted Leeds diagram was very helpful for identifying treatment targets and selecting which of these to prioritise, but it didn’t capture a client’s resources and resilience experiences.

The De Jongh diagram was liked for its visual simplicity but was found to lack a prompt to identify future goals and it was considered that the diagram was misleading in implying that “symptoms” relate to method 1 and not to method 2. Participants thought this diagram provided a quick method for target selection but risked missing a lot of data. 

The Santos diagram was found to capture most of the key information needed for collaborative case formulation and treatment planning and the prominent “resilience” box was felt to highlight the centrality of adaptive information in EMDR treatment. However, the diagram lacked a box for treatment goals / desired future behaviour and participants felt it was therefore unclear how to prioritise the selection of treatment targets.

The Wesson diagrams were found to be visually simple and were valued for elucidating the links between past experiences and present symptoms/ behaviours and what the client hopes to be able to do differently in the future. However different diagrams were provided for different levels of complexity; this was seen as cumbersome. Moreover, there was no explicit prompt to explore resource experiences and sources of resilience.

Summary of required features for a diagram

From the above comments, we may conclude that a satisfactory case formulation and treatment planning diagram should comprise the following elements:

• Past experiences (clusters and/or timeline), present symptoms and problem / (maladaptive coping) behaviours and desired future goals.
• Adaptive information in the form of personal strengths and positive coping behaviours. This enables the client to maintain memory processing under stress, incorporate new material into problem memories and/or to develop new resources for emotional resilience. These resources help clients both to withstand the reprocessing of distressing memories and cope better with present or future distress triggers. This element was highlighted in the Santos diagram and, to a lesser extent, in the De Jongh diagram; however, it perhaps deserves as much prominence in a case formulation as trauma memories, as it is the availability of the adaptive information that is the key to recovery in the AIP model.
• A means to indicate clear relationships between goals and problem memories, as treatment planning and target selection derives from the clients’ priorities and the identification of memories that currently ‘jam’ the system.

Case formulation and protocols

Although the De Jongh et al. diagram was found lacking in its ability to capture sufficient data for a comprehensive case formulation within the AIP model, its purpose might be seen as primarily related to target selection rather than generic case formulation. The Two Method Approach provides a quick way of distinguishing between simple and complex trauma treatment; the former being where there is a simple chronological relationship between present symptoms and past events. In complex trauma, the Two Method Approach takes the view that the pervasiveness of negative experience across the lifespan has resulted in low self-esteem, characterised by ‘negative core beliefs’ and repeated interpersonal difficulties. The negative core belief is then selected as the target and relevant formative memories “ . . . which prove . . .” the negative core belief (De Jongh et al., 2010 p17), are identified for reprocessing. In principle, the negative core belief is taken as a symptom which gives rise to unwanted behaviours.

This method appears to have considerable clinical utility for which the 2010 paper, and similar approaches (e.g., Hofman et al., 2014), provide some evidence. In a workshop entitled Case conceptualisation and target selection for EMDR treatments, held on 17 March 2021, Ad De Jongh and Suzy Matthijssen presented an extension of the Two Method Approach encompassing six different options for target selection, adding The intrusion path, The flashforwards path, The emotion path and The floatback path to the two paths outlined in the Two Method Approach (the ‘timeline path’ and the ‘dysfunctional core beliefs path’). In personal correspondence, De Jongh confirmed that there are published data only for the Two Method Approach and Flashforwards (Logie & De Jongh, 2014).

Whilst undoubtedly providing a valuable heuristic for target selection, the case conceptualisation flowchart (March 2017) presented by De Jongh and Matthijssen in this training gives rise to two concerns: firstly that the evidence base or peer reviewed arguments for their six methods appear to be incomplete and secondly, that their focus appears predominantly to be target selection without a strong AIP case-formulation rationale, which may undermine the authority of the AIP model.

Perhaps, however, this observation is useful for highlighting the relationship between case formulation and treatment protocols. Flashforwards and the dysfunctional core beliefs methods are more like protocols, that is, specific interventions for specific conditions. In contrast, case formulation seeks to organise data relevant to the client’s presenting problems in line with a testable theory or model of psychopathology which, for EMDR, is the AIP model. Protocols are the steps required to test the efficacy of the interventions proposed by the theoretical model. Thus, evidenced-based treatment protocols are essential for establishing the effectiveness of EMDR interventions, but as Persons & Lisa (2015) point out in relation to CBT practice, the specificity of treatment protocols limit their application in clinical practice.

Persons & Lisa explain that protocols often do not meet all of the clinician’s needs for treatment planning because:

1. Protocols generally target a single DSM disorder whereas in clinical practice “ . . . comorbidity is the rule rather than the exception . . .” (p. 1).

2. Many patients receive more than one therapy simultaneously (e.g., physiotherapy, pharmacotherapy and psychological therapy).

3. Patients often have unique needs not addressed by the disorder-focused protocol. Here, Persons & Lisa give the example of a client who presents with social phobia, but his goal is to begin to date in order to find a partner to marry and she tells us that “ . . . a treatment for finding a life partner will likely include interventions that are not part of the EST [empirically supported treatment protocols] . . . for social phobia . . . ” (Persons & Lisa, 2015, p. 1).

4. There may be social or environmental factors which the protocol doesn’t take into account, and so on.

Thus, with complex cases, we need to think in terms of “. . . multiple moving parts . . .” (Barton, Armstrong, Wicks, Freeman, & Meyers, 2017). Consequently, Persons & Lisa suggest that having a robust case formulation allows the therapist to draw on the formulations and interventions validated in the ESTs whilst helping the therapist “. . . make many of the clinical decisions that are not directly addressed in the ESTs . . .” (Persons & Lisa, 2015, p. 1).

For example, taking Leeds’ composite case study mentioned above, should we begin with the client’s axis 1 panic attacks and use the ‘time-line path’, or use the ‘intrusion path’ for flashbacks and nightmares, or the ‘flashforwards path’ for anticipatory fears of being humiliated by her boss? Leeds and Wesson would suggest that the answer lies within the case conceptualisation and particularly with reference to the client’s goals; given the client’s presenting problems, what are her priorities for treatment and does she have the adaptive information to reprocess the ‘system jammer’ experiences. If the client’s priority is to regain restorative sleep and stop her flashbacks and panic attacks, we may decide to use the intrusion path, which take us back to the rape, but what if the client isn’t able to stay within the window of tolerance for this memory? We may find that we need another protocol-based intervention first, such as the ‘Flash/Blink technique’ (Manfield, Lovett, Engel, & Manfield, 2017) to enable the client to process this memory. Thus, empirically-supported treatment protocols sit within the overall case formulation.

Divided focus group methodology

The somewhat opportunistic methodology of using a training workshop to gather data had the research advantage that participants are readily able to provide their opinions on clinical utility and ease of use as they have had recent brief exposure to the models. However, the data collected is ‘first impression’. Given more time to try out the diagrams, participants may have formed different views, although it is quite likely that first impression of such diagrams has a significant bearing on whether they will continue to be used in clinical practice. Although all groups were asked to consider the same questions when appraising the diagrams, the focus of each group’s feedback suggested that, to some extent, different groups focused on different aspects of the AIP model.

The presentation of the Wesson diagram was given five minutes more than the other diagrams as this was presented via a pre-recorded video by the originator, rather than live presentation by the researchers (as was the case for the other three diagrams) and it is possible that this somewhat biased participants’ recall of the Wesson diagrams. It is also possible that the different styles of presentation of the five presenters influenced how the information was received.

Due to time constraints, it was not intended that sub-groups compare diagrams, although some groups did. Enabling a comparison between diagrams may have yielded richer data. However, an unquantified impression of data from the second presentation of the workshop which took place in May 2021 would indicate that more systematic comparison did not generate significantly different appraisals. In the May workshop, participants were given 60 minutes to consider two diagrams. Although data was not collected from the second workshop in the same way as the first workshop, participants’ comments about the diagrams were very similar, suggesting that even when participants only focused on one diagram, the knowledge from the earlier training was sufficient to prompt wide-ranging critical thought.  It would be interesting to collect further data on whether participants have continued to use the diagrams in clinical practice some months after the training.

Further study: It would be interesting to develop a composite diagram from the study participants’ feedback and assess whether this is preferred overall, or whether preferences are, in fact, quite individual, so that there can be no definitive version.

Summary and conclusion

The workshop format enabled participants to form a first impression of the clinical utility and ease of use of four different diagrams for case formulation in the AIP model and EMDR treatment. Clinicians were able to identify the elements they valued in case formulation diagrams and which elements helped them to select targets and plan treatment. What is visually appealing to one clinician may differ for another and so this comparison method allows clinicians to select and adapt models to meet their personal preferences. A list of essential elements was developed from the focus group data.

It was notable that despite the possibility of losing some interpersonal attunement in the therapy relationship by reducing clients’ experiences to a diagram, participants’ feedback suggested that the focus which the diagrams gave for dialogue and collaboration with clients felt as though it would strengthen rapport. In addition, it was felt that a good case formulation helped the clinician to communicate the AIP model succinctly as well as organise treatment elements and select appropriate targets.

The relationship between case formulation and treatment protocols was considered and the notion that treatment protocols sit within the broader case formulation was proposed.

Paul Gilbert (2020, p. 25) suggests that “. . . the therapist is not there to “fix things gone wrong” but rather to help people to re-pattern, rewire and reprogram themselves in ways that are more conducive to dealing with suffering and promoting well-being . . .” If we reflect on the meaning of this for EMDR case formulation, perhaps it encourages us to keep the balance between focusing on traumatic experience and on building adaptive information, the knowledge of how to overcome past trauma and manage future adversity.  

Required statements

Ethical statements

Participants in the workshop were informed that anonymous comments may be incorporated in the planned Journal article report. The case study was wholly fictional, being a composite of many clients.

Conflict of interest

There were no conflicts of interest.

Financial support

Participants paid £25 to Beds Bucks and Herts EMDR Regional Group for a place on the workshop from which profits go to supporting EMDR Association activities and research.

The author wishes to thank Russel Hurn, Jenny Arthern and Rachel Edwards for collaboration in presenting the workshop and their helpful comments on the manuscript. And also wishes to thank Christine Habermehl, Sarah Chadwick, Shirley Hemmings, Abi Methley, Steph Pagio and Helen Coote for their help with running the workshops.

Jo Ploszajski is a Counselling Psychologist and EMDR Europe Accredited Consultant and Supervisor with a Private Practice in Bedford, UK. The workshop in the study was put on as a training event by Beds Bucks and Herts EMDR Regional Group https://www.emdrbedsbucksherts.org.uk/