The therapeutic relationship in EMDR therapy—A survey

Hase, Michael; Brisch, Karl Heinz; Solomon, Roger M.; Hase, Adrian

doi:10.3389/fpsyg.2025.1519665

BRIEF RESEARCH REPORT article

Front. Psychol. , 17 March 2025

Sec. Psychology for Clinical Settings

Volume 16 - 2025 | https://doi.org/10.3389/fpsyg.2025.1519665

This article is part of the Research Topic Present and Future of EMDR in Clinical Psychology and Psychotherapy – Volume III View all 11 articles

The therapeutic relationship in EMDR therapy—A survey

Michael Hase¹^*

Karl Heinz Brisch^2,3

Roger M. Solomon⁴

Adrian Hase⁵

¹EMDR Center, Lüneburg, Germany
²Institute for Early Life Care, Paracelsus Medical University, Salzburg, Austria
³Dr. von Hauner Children’s Hospital, University of Munich, Munich, Germany
⁴EMDR Institute, Watsonville, CA, United States
⁵Section of Medicine, University of Fribourg, Fribourg, Switzerland

The history of EMDR therapy goes back to 1987, when it was introduced as EMD, a novel treatment for PTSD by Francine Shapiro. Over the course of time EMD developed into the comprehensive therapy approach named EMDR therapy. The development of the Adaptive Information Processing (AIP) Model, the model of pathogenesis and change of EMDR therapy, was a milestone in this development from technique to psychotherapy approach. Lately a description of the therapeutic relationship in EMDR therapy has been proposed based on attachment theory. The therapeutic relationship has been described as a core element of EMDR Therapy, and seems to be related to the structure of EMDR Therapy. An internet-based survey of EMDR therapists in several waves was used to evaluate whether EMDR therapists support the above mentioned description of the therapeutic relationship in EMDR therapy. The self-experience of the EMDR therapists in EMDR therapy as elicited in the survey seems to support the description of the therapeutic relationship in EMDR therapy. Even if the survey was only conducted with EMDR therapists, thus limiting the informative value on the patient population in general, it offers valuable insights into the therapeutic relationship in EMDR Therapy. Implications for treatment, training and research will be discussed.

Introduction

Eye Movement Desensitization and Reprocessing therapy (EMDR) consists of a structured set of treatment plans and procedures based on the Adaptive Information Processing (AIP) model (Solomon and Shapiro, 2008). EMDR was introduced as EMD in 1987 (Shapiro, 1989) as a treatment for PTSD and was developed into the comprehensive therapy approach named EMDR therapy over the following years. Shapiro intended EMDR therapy to be compatible with all major orientations of psychotherapy.

The theory currently used to guide EMDR Therapy treatment effects is called the Adaptive Information Processing (AIP) model. The AIP model was developed to explain the rapid change toward positive resolution that can be seen in the EMDR memory reprocessing (Shapiro, 1995, 2001, 2018). The AIP model assumes “the physiological systems of the brain that attend to the assimilation of experience are no different from other systems” and “The movement toward health and balance is sustained unless there is a block or repeated traumatization” (Shapiro, 2002, p. 8). The term information as used in EMDR therapy refers to affect, cognition, sensory, somatosensory or other internal or external input as perceived at the time of the event leading to memory formation. In EMDR therapy, it is presumed that the activity of the adaptive information processing system leads to the integration of dysfunctionally encoded information toward functional encoding and adaptive state of memory, in consequence contributing to reduction in distress and/or negative emotions. The AIP system may be hindered or blocked by trauma, other severe stress, or other like the influence of psychoactive drugs in consequence leading to formation of the maldaptively stored memory, which is assumed to be foundational for psychopathology. Shapiro described the adaptive information processing system an ‘innate’ system. But even if we assume that the adaptive information processing system is active from birth, we should take into account that every system like speech, movement, e.g., needs to develop. A developmental perspective of the adaptive information processing system is still missing in EMDR therapy.

In contrast to a common, but limited perception of EMDR therapy that the AIP model is only a model of inadequately processed memories, it also involves adaptive information, or to say of resilience (Solomon and Shapiro, 2012). Reprocessing procedures promote the linking in of positive, adaptive information into the maladaptively stored information, promoting adaptive resolution and integration into the wider memory network.

Shapiro stressed the fact that the client would need sufficient positive memory networks, which are present and accessible, for successful memory reprocessing (Shapiro and Laliotis, 2017). When there is a lack of adaptive information or integrative capacity, it seems straightforward that we need to install adaptive information prior to reprocessing. Common procedure are Resource Development and Installation (RDI) (Korn and Leeds, 2002) and the Instant Resource Installation (IRI) procedure (Hase, 2021).

Regarding posttraumatic stress disorder (PTSD), memory deficits, negative beliefs concerning the self, avoidance or suppression of memories, and negative interpretation of memory symptoms could explain impairment of access to adaptive memory networks (Brewin, 2011). The mere activation of malaptively stored memory could initiate a stress response altering the brains capacity to access adaptive memory or resulting in the loss of dual attention (Shapiro, 2018; Brewin, 2018). But it is not only PTSD, which can be the cause behind impaired access to adaptive memory. Survivors of early neglect show impaired capacities to tolerate and integrate moments of shared positive interpersonal experience. Into positive emotional states and positive self-concepts. They tend to make use of overt or covert avoidance strategies and minimization responses to avoid the discomfort, anxiety, or confusion connected to positive experiences. This defensive avoidance significantly contributes to symptom maintenance. EMDR therapy includes a preparation and stabilization Phase (Phase 2 of EMDR therapy) and involves providing interventions to enable to meet readiness criteria for EMDR memory work, such as the ‚Positive Affect Tolerance and Integration Protocol (Leeds, 2022). In general EMDR therapy preparation and resourcing interventions aim to expand the brain‘s integrative capacity and strengthen adaptive memory networks (Shapiro and Laliotis, 2017, p. 10, 18). Further, it is important to build a strong enough therapeutic relationship in preparation for the upcoming reprocessing of maldaptively stored information.

Shapiro was even more precise regarding the importance of the ability to access adaptive memory networks for reprocessing to occur. The 2017 edition of the EMDR Institute Basic Training Manual, and the current 2023 edition, emphasize the necessity of present and accessible adaptive memory networks and the importance of the therapeutic relationship as an source of adaptive information. “Adaptive memory networks need to be present and accessible for reprocessing to occur. Therapeutic relationship is part of an adaptive memory network” (Shapiro and Laliotis, 2017, p. 13).

Interestingly Shapiro (2007) discussed the therapeutic relationship in her textbook (2018), even more explicitly than in the EMDR Basic Training Manual, and advised that the therapist behavior be “optimally interactive (p. 76),” but refrained from describing the therapeutic relationship in EMDR therapy in detail or on how to establish a secure therapeutic relationship prior to memory reprocessing in detail. As the therapeutic relationship is of great importance regarding the outcome in psychotherapy (Orlinsky et al., 1994) this issue needs to be addressed. Hase and Brisch (2022) provided a description of the therapeutic relationship in EMDR therapy based on attachment theory (Bowlby, 2005). Predictability of the attachment figure is a good basis for the development of the infant. One could assume, that the predictability of therapist behavior in the manualized procedures of EMDR therapy contributes to the development of the therapeutic relationship in EMDR therapy.

According to Brisch (2002) the development of attachment between the infant and caregiver is related to the sensitivity of the caregiver. The caregiver with the most sensitive properties will become the primary attachment figure of the infant. Sensitivity facilitates the development of attachment. How could one define sensitivity? Brisch (2002) outlined that sensitivity shows in speech, rhythm, eye contact and touch. Most important the caregiver has to be able to perceive the infants’ signals while not misinterpreting them, and react immediately and appropriately. This is only possible if the caregiver is emotionally available for the needs, affects and signals of the infant. In EMDR therapy as therapists we offer speech, but even more important, rhythm. We keep eye contact, while being not intrusive. Sometimes we offer touch. But most important, we perceive our clients’ signal, being aware not to intrude, while reacting promptly and appropriately, which will certainly facilitate the development of a secure therapeutic relationship. The therapeutic relationship not only results from the above-mentioned behaviors, but also develops through procedures and protocols within EMDR therapy. Given the therapeutic relational factors described above, EMDR can be described as a ‚sensitive‘psychotherapy approach. Table 1 shows EMDR therapy actions in relation to sensitive behavior.

Table 1

Table 1. Sensitivity and EMDR therapy.

These actions can explain at least to a great extent the specific therapeutic relationship in EMDR therapy, which often develops rapidly and provides a safe shared space, allowing our clients to reprocess, to grow and to get past their past. This article describes the results of an internet-based survey eliciting information on the self-experience of therapist during their training in EMDR therapy in order to evaluate the sensitivity factors facilitating the development of the therapeutic relationship in EMDR therapy.

EMDR therapy basic training as offered by the EMDR Institute Inc. or following the standards of EMDR Europe (website) consists of 52 h. These are divided into 22 h of theory and 20 h of a supervised practical self-experience, the so-called practicum, followed by 10 h of clinical case consultation. The 42 h of theory and practicum are mostly offered in two blocks of 3 days each. Within the practicum the attendees are advised to rotate through the roles of client, therapist and observer. In the role of client, the attendee is asked to bring up his own distressing memories which will be reprocessed with the help of the therapist. The attendee should experience the therapeutic action of EMDR therapy procedures, mostly the standard EMDR protocol, including the reprocessing on their own memories. This self-experience is an important part of the EMDR therapy basic training. For successful completion of the basic training an attendee is expected to be at least in the role of client and therapist once on each block. One can assume that after completion of the 42 h of theory and practicum each attendee has provided self-experience as a client in EMDR therapy memory reprocessing at least two times. In addition, the attendee has been in the role of client regarding diagnostic and preparatory procedures in the practicum. This is a minimum of self-experience in EMDR therapy basic training. Attendees are encouraged to engage in additional self-experience, but this not mandatory. As a result, the therapist practicing EMDR therapy after attending an EMDR therapy basic training could be questioned regarding their experience.

Methods

We made up a questionnaire describing core elements of the therapeutic relationship according to the above-mentioned sensitive factors in EMDR therapy. The EMDR therapist was asked to rate if they would disagree or agree on a five point scale. Responses were scored on a 5-point scale (1 = Strongly disagree, 2 = Disagree, 3 = Neutral, 4 = Agree, 5 = Strongly Agree) regarding a statement describing their experience as client in EMDR therapy. In addition, we asked for the number of EMDR sessions in the role of client and some demographic information as age and gender. The questionnaire was distributed in a pilot run and two waves in a modified Delphi-approach (Niederberger and Spranger, 2020). The results of each wave were used as feedback in order to modify the questionnaire. The results of wave one were also analyzed statistically contributing to another modification which led to the final version called BET 5.2. BET stands for „Beziehungserleben in der EMDR Therapie “which could be translated as „Relational Experience in EMDR therapy“. The BET 5.2 was tested in the second wave of the survey. Even if the survey was only conducted with EMDR therapists, thus limiting the informative value on the patient population in general, it could offer valuable insights into the therapeutic relationship in EMDR therapy. One has to keep in mind, that psychotherapist are of course suffering from mental health problems. In a study on clinical, counseling, and school-psychology faculty and trainees overall rates of mental disorders were similar to or greater than those observed in the general population (Victor et al., 2022). With more than 80% of respondents (n = 1,395 of 1,692) reporting a lifetime history of mental-health difficulties, and nearly half (48%) reporting a diagnosed mental disorder the burden of mental-health problems seems high. Among the reported concerns the most common were depression, generalized anxiety disorder, and suicidal thoughts or behaviors. A recent study suggested a better overall mental health profile for Austrian psychotherapists compared to the population in general (Schaffler et al., 2024). Still quite a number of psychotherapists in this study exhibited scores beyond the cut-off for clinically significant mental disorders like depression, anxiety or insomnia. A survey among UK-based psychologist revealed, that Two-thirds of the participants had experienced mental health problems themselves (Tay et al., 2018). Disclosing and help-seeking were impaired by concerns about negative consequences for self and career. The reported rates of mental-health problems seem to make the psychotherapists in our sample a reasonably representative group, though most likely not representing the severly disordered, multiply traumatized client.

A preliminary version of the questionnaire was distributed in a pilot trial as an online survey (implemented via surveymonkey.com) to 16 experienced therapists who had participated in an online seminar on the therapeutic relationship in EMDR therapy. This version consisted of 13 descriptive items plus the additional demographic items. Feedback from this group of experts led to a questionnaire of 12 items describing the experience in the role of client. This questionnaire was then used in the following two survey waves to optimize the questionnaire using statistical methods.

Participants

The first author used an e-mail list of EMDR therapists. The minimum requirement to become member of this list is completion of the first part of the EMDR Therapy basic training. There were 1,348 therapists registered on the email list. Out of the 1,348, 118 responded in the first wave. The first wave of the survey comprised 118 individuals (82.2% female) who had experienced between one and five EMDR sessions (M = 2.28, SD = 1.15). Participants’ age ranged from 26 to 80 years, with the majority (61.2%) being between 40 and 59, 32.8% between 60 and 79, and 6.0% between 20 and 39 years old.

Materials

We tested in the beginning 12 descriptive items to measure the experience of the therapeutic relationship in EMDR therapy. These items were developed by a senior EMDR trainer with 25 years of experience in EMDR therapy and had been tested in a pilot study. Responses were scored on a 5-point scale (1 = Strongly disagree, 2 = Disagree, 3 = Neutral, 4 = Agree, 5 = Strongly Agree). Table 1 presents item contents and descriptive statistics. According to results in the trial run and first wave the number of items was reduced to nine.

Procedure

After the trial run the preliminary descriptive items were distributed in an online survey (implemented via surveymonkey.com) to the participants via an email list. Participants at first responded to 12 core survey items in the first wave. The statistical analysis suggested reducing the number of items to nine. In the second wave of the survey, the nine descriptive items and other information about the number of EMDR sessions experienced and demographics were acquired. The second wave of the survey was sent out via the same email list and 149 individuals responded. Table 2 shows the item content and descriptive statistics.

Table 2

Table 2. Item contents and descriptive statistics.

Statistical analysis

All statistical analyses were conducted in RStudio, version 2023.12.1. We used the fa.parallel() function of the psych package to conduct exploratory parallel analysis to determine the recommended number of factors and create scree plots (Revelle, 2024). We then used the base R function fa() with the maximum-likelihood factor analysis factoring method, varimax rotation, and a maximum of 100 bootstrap iterations to assess the underlying factor structure and corresponding fit indices in an exploratory factor analysis specifying the previously recommended number of factors. We visualized the factor structure of the recommended model in factor loading plots using the fa.diagram() function of the psych package. We applied a significance level of α = 0.05.

Results

Figure 1 presents scree plots from the parallel analysis, which recommended a one-factor solution. The exploratory factor analysis for the one-factor solution showed a satisfactory fit for the recommended model, TLI = 0.912, RMSEA = 0.054, 95% CI: < 0.001, 0.097. The factor score adequacy was acceptable with a regression score-factor correlation of 0.88 and a multiple R² of scores with factors of 0.77. Figure 2 presents the factor loading plot for the recommended one-factor solution.

Figure 1

Figure 1. Parallel analysis scree plots (wave one).

Figure 2

Figure 2. Factor loading plot (study 1).

Wave two

The aim of wave two was to validate the one-factor solution identified in wave one. We hypothesized that the one-factor model would be confirmed in an independent sample and exhibit acceptable psychometric properties.

Method and participants

To validate the factor structure found in the first study, the modified nine core item version of the questionnaire was sent out via the same email list. A total of 149 individuals (81.0% female) participated in the second wave. Participants’ age ranged from 26 to 80 years, with the majority (51.7%) being between 40 and 59, 41.6% between 60 and 79, and 6.7% between 20 and 39 years old. The experience in the role of client with EMDR therapy was rather balanced, with most participants having experienced a moderate number of sessions (38.3% between 5 and 12 sessions, 30.2% between 0 and 4, 20.1% between 13 and 24, 8.7% between 25 and 50, and 2.7% more than 50 sessions).