“Early experience, structural dissociation, and emotional dysregulation in borderline personality disorder: The role of insecure and disorganized attachment.”

Persistent problems in emotional regulation and interpersonal relationships in borderline patients can be understood as developing from difficulties in early dyadic regulation with primary caregivers. Early attachment patterns are a relevant causal factor in the development of Borderline Personality Disorder (BPD). Links between attachment issues, early history of neglect, and traumatic experiences, and symptoms observed in patients with BPD as per the DSM-5 classification (American Psychiatric Association: Diagnostic and statistical manual of mental disorders: DSM-5 (Fifth ed.). Washington, D.C; (2013)) are described in this article, while delineating possible pathways from attachment disruptions to the specific symptomatology of these patients. The theory of structural dissociation of the personality (TSDP) provides an essential framework for understanding the processes that may lead from insecure early attachment to the development and maintenance of BPD symptoms.
Dyadic parent–child interactions and subsequent modulation of emotion in the child and future adult are considered closely related, but other factors in the development of BPD, such as genetic predisposition and traumatic experiences, should also be considered in conceptualizing and organizing clinical approaches based on a view of BPD as a heterogeneous disorder.

Open access: Mosquera, D., Gonzalez, A., & Leeds, A. M. (2014). Early experience, structural dissociation, and emotional dysregulation in borderline personality disorder: The role of insecure and disorganized attachment. Borderline Personality Disorder and Emotion Dysregulation, 1(15), 1-8. doi:10.1186/2051-6673-1-15

“Application of EMDR therapy for borderline personality disorder.”

There is a growing interest in the use of eye movement desensitization and reprocessing (EMDR) therapy beyond posttraumatic stress disorder (PTSD) where its application is well established. With strong scholarly consensus that early traumatic and adverse life experiences contribute to the development of borderline personality disorder (BPD), EMDR would appear to offer much to the treatment of persons with BPD. However, given the specific characteristics of these clients, the application of EMDR therapy to their treatment can be challenging and necessitates several minor adaptations of the standard EMDR procedures for PTSD. This article provides an orientation to principles and strategies for safely and effectively preparing clients with BPD for EMDR therapy and for accessing and reprocessing the traumatic origins of BPD. Clinical examples are provided throughout.

Mosquera, D., Leeds, A. M., & Gonzalez, A. (2014). Application of EMDR therapy for borderline personality disorder.
Journal of EMDR Practice and Research, 8(2), 74-89. doi:10.1891/1933-3196.8.2.74

“The Future of EMDR.”

The articles in this special issue entitled “Breaking New Ground” represent noteworthy efforts to w open up new fertile ground for the brain-based science of eye movement desensitization and reprocessing (EMDR). These articles offer preliminary findings and recommendations for further experimental studies to confirm (or disconfirm) results.

Open access: Leeds, A. M. (2013). The future of EMDR. Journal of EMDR Practice and Research, 7(3), 118-120. doi:10.1891/1933-3196.7.3.118

“Case consultation: Traumatized pregnant woman.”

Case consultation is a new regular feature in the Journal of EMDR Practice and Research in which a therapist requests assistance regarding a challenging case and responses are written by three experts. In this article, Amy Robbins, a certified eye movement desensitization and reprocessing (EMDR) therapist from Atlanta, Georgia, briefly describes a challenging case in which a pregnant woman seeks treatment for trauma suffered in a tornado. The clinician asks if it is advisable to provide EMDR treatment and what concerns she should be aware of. The first expert, Carol Forgash, provides some general information about pregnancy and psychotherapy and outlines considerations, concerns, and contraindications for proceeding with EMDR. She recommends that if treatment is chosen, the therapist proceed with a recent trauma protocol to specifically target the traumatic memories of the recent tornado. The second expert, Andrew Leeds, comments on the absence of randomized controlled trials (RCTs) or other scientific reports exploring the safety of EMDR treatment of pregnant women. He states that pregnant women with symptoms of posttraumatic stress should understand that there is a high probability that EMDR will improve maternal quality of life and that the risks of adverse effects on stability of pregnancy are probably low, but that these remain unknown. The third expert, Claire Stramrood, explains that the few case studies that evaluated EMDR during pregnancy have found positive effects but pertained to women with posttraumatic stress disorder (PTSD) following childbirth. She asserts that once obstetricians have been consulted, women have been informed about possible risks and benefits, and, given their informed consent, they should be able to choose to commence EMDR therapy during pregnancy.

Open access: Forgash, C., Leeds, A. M., Stramrood, C. A. I., & Robbins, A. (2013). Case consultation: Traumatized pregnant woman. Journal of EMDR Practice and Research, 7(1), 45-49. doi:10.1891/1933-3196.7.1.45

“Developmental pathways to dissociation: Are we forgetting something?”

Is early trauma the root cause of dissociative disorders?
Most of the literature and research on pathological forms of dissociation focuses on trauma as the root cause of the DSM IV-TR (American Psychiatric Association, 2000) dissociative disorders, and many studies show an association between dissociation and trauma (Putnam, 1997). Yet this view by no means tells the entire story as emerging research on attachment, evolutionary psychobiology, and the neurobiology of dissociation continues to influence the field. Recent research emphasizes an interesting observation: “The fact that nontraumatized individuals sometimes demonstrate dissociation and that not all trauma survivors dissociate suggests that there may be more to the etiology and development of dissociation than trauma alone” (Dutra, Bianchi, Siegel, & Lyons-Ruth, 2009, p. 84). If early trauma is not the unique cause of pathological dissociation, then what else could cause it? Although chronic and severe traumatic exposure is central to the development of complex dissociative disorders (Van der Hart, Nijenhuis, & Steele, 2006), we should not ignore emerging data on the relationship between attachment and pathological dissociation. The goal of this brief review is to promote reflection on the significant role of non-traumatic factors in the vulnerability to the development of trait dissociation.

Leeds, A. M. (2012). Developmental pathways to dissociation: Are we forgetting something?
ESTD Newsletter, 3(1), 4-9.

View this article here.

“A commentary on Hornsveld et al. (2011): A valid test of resource development and installation? Absolutely not.”

Researchers have published evidence supporting both the “working memory” and the “REM/Orienting Response” hypotheses as mechanisms underlying the documented treatment effects of EMDR on patients with posttraumatic stress disorder. Hornsveld et al. (2011) provide additional evidence of the impact of eye movements (EMs) on aspects of positive memory recall, but overstate their findings relevance to resource development and installation (RDI: Korn & Leeds, 2002) and to the interhemispheric interaction hypothesis (Propper & Christman, 2008). Most likely multiple mechanisms underlie the observed effects of EMDR and RDI. The needed RDI test is to randomly assign patients with Disorders of Extreme Stress not Otherwise Specified with measured coping difficulties to alternate conditions: one an RDI procedure without bilateral (or other distracting) sensory stimulation and one with bilateral EMs.

Open access: Leeds, A. M., & Korn, D. L. (2012). A commentary on Hornsveld et al. (2011): A valid test of resource development and installation? Absolutely not. Journal of EMDR Practice and Research, 6(4), 170-173. doi:10.1891/1933-3196.6.4.170

“EMDR treatment of panic disorder and agoraphobia: Two model treatment plans.”

This article, condensed from Chapter 14 of
A Guide to the Standard EMDR Protocols for Clinicians, Supervisors, and Consultants (Leeds, 2009), examines applying eye movement desensitization and re- processing (EMDR) to treating individuals with panic disorder (PD) and PD with agoraphobia (PDA). The literature on effective treatments for PD and PDA is reviewed focusing on cognitive and behavioral therapies, pharmacotherapy, and EMDR. Case reports and controlled studies of EMDR treatment of PD and PDA are examined for lessons to guide EMDR clinicians. Two model EMDR treatment plans are pre- sented: one for cases of simple PD without agoraphobia or other co-occurring disorders and the other for cases of PDA or PD with co-occurring anxiety or Axis II disorders. A more extensive literature discussion, detailed treatment guidelines, and client education resources can be found in the original chapter.

Open access: Leeds, A. M. (2012). EMDR treatment of panic disorder and agoraphobia: Two model treatment plans. Journal of EMDR Practice and Research, 6(3), 110-119. doi:10.1891/1933-3196.6.3.110

“Resources in EMDR and Other Trauma-Focused Psychotherapy: A Review.”

Andrew M. Leeds, Ph.D., Private practice
Open access: Journal of EMDR Practice and Research, 3(3), 152-160, 2009.

The present review examines how resources have been used in trauma-focused psychotherapy with an emphasis on their use in eye movement desensitization and reprocessing (EMDR). Current practices of EMDR-trained clinicians are presented in a historical context and considering a range of contemporary approaches to ego strengthening. This article describes the use of resources as presented in the EMDR literature along with research findings. The review concludes with a call for controlled research on widely used resource-focused procedures and practice guidelines for their use in clinical applications of EMDR.

EMDRIA Members may view this article online. Log into member area and click link to the Journal of EMDR Practice and Research.

"Principles and Procedures for Enhancing Current Functioning in Complex Posttraumatic Stress Disorder with EMDR Resource Development and Installation."

Andrew M. Leeds, Ph.D., Private practice
The EMDRIA Newsletter, Special Edition. December 2001. pp 4 -11.

Note: This article contains an updated version of the RDI protocol together with explanatory material originally written for the Appendix of Shapiro, F. (2001). Eye Movement Desensitization and Reprocessing, Basic Principles, Protocols and Procedures. (2nd ed.). New York: The Guilford Press. Due to space constraints, the explanatory material had to be omitted from Shapiro (2001). This updated version of the RDI protocol is the same as that which appears in Korn & Leeds (2002, see below). This updated version benefited greatly from Dr. Korn's rewording of the early more conceptual version (Leeds, 1997) to a more user friendly version in which key phrases can be selected and read verbatim by the clinician.

Stabilization and the consensus model

When developing a treatment plan, clinicians need to be able to recognize not only the specific effects of trauma but to consider symptoms reflecting limited capacities for emotional self regulation. Such problems are often found when client histories include significant childhood neglect or other disruptions of early childhood attachment (Damasio, 1999; Schore, 2000; Siegel, 1999). Clients with a history of insecure attachment appear to be more vulnerable to PTSD (Alexander, et al., 1998; Muller, Sicoli, & Kemieux, 2000) and initially need to be addressed with procedures different than those for trauma specific symptoms. Therefore in the consensus model of posttraumatic treatment (Brown, Scheflin, & Hammond, 1998; Chu, 1998; Courtois, 1999) clinicians are urged to focus on clients' personal safety, stabilization, and the development of client capacities for tolerating and modulating strong affect in the early phases of treatment.

Indeed, the complexity of problems with affect regulation in survivors of early neglect and abuse have led to calls for a new diagnosis of Complex PTSD (Herman, 1992) or Disorders of Extreme Stress, Not Otherwise Specified (DESNOS) (Pelcovitz et al, 1997). A new diagnostic framework for DESNOS, spanning DSM axes I and II, was evaluated in field trials (Roth, et al., 1997), and was ultimately included in the DSM IV but only as a set of associated features of "simple" PTSD (American Psychiatric Association, 1994) and not as a separate diagnosis. Further, some have suggested that individuals meeting criteria for Complex PTSD (DESNOS) may not be able to tolerate trauma focused therapy at all and should only receive psychoeducation and therapeutic interventions aimed at building affect regulation skills such as in the approach proposed by Linehan (1993a, 1993b). This article proposes that with some individuals who meet criteria for Complex PTSD (and for Borderline Personality Disorder) it may be possible to strengthen affect regulation capacities and to resolve traumatic memories with an approach to treatment that begins with an EMDR related procedure known as Resource Development and Installation."

EMDRIA Members may view this article online from the December 2001 special issue. Log into member area and click the Newsletter link.
EMDRIA Member may order this special edition for US $7.50, non-members for US$10.00 from:
EMDR International Association
Phone (512) 451-5200 Fax (512) 451-5256

Preliminary Evidence of Efficacy for EMDR Resource Development and Installation in the Stabilization Phase of Treatment of Complex Posttraumatic Stress Disorder.
Deborah L. Korn, Psy.D., Private practice,
Andrew M. Leeds, Ph.D., Private practice
Journal of Clinical Psychology. (2002).
Volume 58, Issue 12, pp1465-1487.

This article reviews the complexity of adaptation and symptomatology in adult survivors of pervasive childhood neglect and abuse who meet criteria for the proposed diagnosis of Complex Posttraumatic Stress Disorder (Complex PTSD) also known as Disorders of Extreme Stress, Not Otherwise Specified (DESNOS). A specific EMDR protocol, Resource Development and Installation (RDI), is proposed as an effective intervention in the initial stabilization phase of treatment with Complex PTSD/DESNOS. Descriptive psychometric and behavioral outcome measures from two single case studies are presented which appear to support the use of RDI. Suggestions are offered for future treatment outcome research with this challenging population.

View this article online.

Address reprint correspondence to:

Deborah L. Korn, Psy.D.
240 Concord Avenue, Suite 2
Cambridge, MA 02138

Reprints may also be ordered for US$5.00 from:
Andrew M. Leeds, Ph.D.
1049 Fourth Street, Suite G
Santa Rosa, CA 95404

EMDR and Resource Installation: Principles and procedures for enhancing current functioning and resolving traumatic experiences.

Andrew M. Leeds, Ph.D., Private Practice
Francine Shapiro, Ph.D., Senior Research Fellow, Mental Research Institute, Palo Alto.

Chapter 16, pp 469-534 in John Carlson & Len Sperry (Eds.), (2000) Brief Therapy Strategies with Individuals and Couples: Zeig, Tucker, Theisen, Inc. Publisher, Phoenix AZ.

"This chapter presents an overview of EMDR, a research validated treatment for posttraumatic stress disorder and a related set of procedures known as Resource Development and Installation which have been reported to be useful in ego strengthening and stabilization. First, the extant research on EMDR, its theoretical model and the eight phases of EMDR treatment will be sumarized. The principles and theoretical foundations of Resource Development and Installation will then be discussed. Two cases will be presented. The first case illustrates a simple application of Resource Development and Installation to supplement the standard EMDR PTSD protocol in the brief treatment of a marital crisis. The second case summarizes the brief, strategic use of Resource Development and Installation to stabilize a patient with complex posttramatic stress disorder referred for collaborative treatment and to build a foundation for comprehensive EMDR treatment."

Reprints available for US$3.00 from
Andrew M. Leeds, Ph.D.
1049 Fourth St., Ste G
Santa Rosa, CA 95404

"Lifting the burden of shame: Using EMDR Resource Installation to resolve a therapeutic impasse."
Andrew M. Leeds, Ph.D.

Chapter 11 pp 256-282 in Philip Manfield, Ph.D. (Ed.), (1998)
Extending EMDR, A case book of Innovative Applications, W. W. Norton, New York.

Chapter 14 pp 320-346 in Philip Manfield, Ph.D. (Ed.) (2003)
EMDR Casebook, expanded second edition, W. W. Norton, New York.

Note: This was the first published description of Resource Installation. I do not have reprints of this chapter. The entire book remains a useful resource for EMDR trained clinicians.

"Meredith was in her early twenties when she first came to see me. She was a slender woman with pale skin and sorrowful eyes. During her initial sessions, she emphasized concerns with depression, social isolation and a sense of hopelessness about her life. As I worked with her over time I found that the clinical tools available to me were inadequate to helping Meredith fully resolve her depression. Eventually I developed a new clinical tool which turned out to be the missing piece I needed to help her move through her impasse."