EMDR and the Relational Imperative

The Therapeutic Relationship in EMDR Treatment

Mark Dworkin

• Publisher: Routledge
• Year: 2013
• ISBN:
  9781136749117
• Edition: 1
• Topic: Psychology
• Subtopic: Psychotherapy
• Index: Psychology

In this groundbreaking work, Mark Dworkin, an EMDR teacher, facilitator, and long-time practitioner, explores the subtle nuances of the therapeutic relationship and the vital role it plays in using Eye Movement Desensitization and Reprocessing (EMDR) with traumatized clients. Showing how relational issues play a key role in each phase of EMDR treatment, the author provides tools for the therapist to more efficiently apply this method in the treatment of trauma victims and form a stronger and healthier relationship with the patient. A standard reference for all practitioners working to heal the wounds of trauma, this book will be an essential resource for the effective application of EMDR.

CHAPTER 1

The Relational Imperative in EMDR

1.1 Introduction

Clinicians are happy to think that our professional experiences, theoretical knowledge, and clinical skills affect our clients’ progress, but we are distinctly less comfortable admitting that our personal histories also play a role in the therapeutic process. Ever since Freud sat back in silence while patients lay on his couch talking about their troubles, some clinicians have preferred to see themselves as keen observers, wise counselors, and perhaps kind listeners, but definitely separate persons from the anguish that often is played out in their consulting rooms. While relational psychoanalysts have been correcting this issue for decades, there are those in the EMDR community who interpret “staying out of the way” as harkening back to being separate from the client.

Yet even in EMDR, which first took root in the soil of cognitive–behavioral therapy, who clinicians are — and how well we know ourselves — matters. And it matters deeply. In each of the eight phases of EMDR, relational issues play a vital role.

The therapeutic relationship is a critical aspect of EMDR; it has been assumed from the beginning that licensed mental health clinicians already have good understandings of the need to have this relationship in place in order to work with traumatized clients. The EMDR Institute’s trainings were designed to teach the principles, protocols, and procedures of EMDR methodology within the context of the attuned relationship. My goal is to flesh out what has not been fully written about. The working alliance is an important part of the therapeutic relationship; it is necessary, but not sufficient for work with traumatized clients, as I will elaborate further in this chapter. Alliances are formed when people walk shoulder to shoulder toward a common goal. Relationships are formed when people stand face to face. An alliance is not a strong enough container for a traumatized client who comes to us short on trust, long on isolation, and knowing he will be asked to reveal and feel — perhaps for the first time, if he dissociated during the original trauma — the most terrible moments of his life. The client’s degree of fear is identical to the degree of connectedness he needs with his therapist in order to feel safe.

This is because the essence of psychological trauma is sudden exposure to extreme danger, whether that danger is a tsunami, a rapist, or a raging parent. This terrifying experience causes victims of post-traumatic stress to negotiate their lives around feeling safe. They know they are vulnerable to extreme harm, so they isolate themselves out of fear of being harmed again and out of shame at their previous vulnerability. Many victims of interpersonal trauma believe — no, they know — they are bad people: They were to blame, after all, for what happened to them (or so they believe). This leads trauma victims to make faulty self-assessments in the present and to shut down their ability to respond appropriately to new situations if these situations stimulate the neural networks where their old pain is stored. Thus, to maintain their internal balance, many traumatized people defend against past pain by limiting their ability to feel in the present.

This is why, when an EMDR clinician establishes a therapeutic relationship with a trauma client, it is essential that he or she anchor that person in the present, in a safe relationship from the first session on, with emphasis on the real relationship, rather than the transferential one. (And this absolutely must occur before the client begins bilateral stimulation.) This anchoring is one of the two focal points for the dual attention essential to EMDR. (The other is the client’s simultaneous concentration on a state-dependent memory that is held in a dysfunctionally excited state. I will go into detail about this later.) Active trauma work (phases 3–6 in EMDR methodology) can be successful only in an atmosphere of safety. When it is done in the context of a therapeutic relationship, the client no longer experiences himself or herself as alone with the horror. The pain can now be shared, and the activities necessary to begin accelerated information processing are laid down. The working alliance, with its emphasis on goals, tasks, and bonding, optimally creates the kind of safety between the two parties in which the work is to be done. This bond, however, will be subject to many potential ruptures that go beyond what an alliance can hold. Identifying potential ruptures, preparing for them or repairing them, and managing transference and countertransference are essential parts of the work in EMDR.

The relational imperative is what makes EMDR — despite appearances — a two-person psychology. To call EMDR a one-person psychology is a “straw man argument,” as all psychotherapies are two-person events. However, some clinicians and researchers discuss EMDR from the perspective of method alone. Some clinicians and researchers disagree. They view EMDR as a one-person psychology, with the one person, of course, being the client. A one-person psychology works like this: The client comes in. The clinician takes the client’s history and prepares the client for the procedure. The clinician tells the client what he or she needs to do; the clinician respects the client and builds an alliance. The client goes through the procedural steps, perhaps with a few blocks that need clearing up along the way, and improves. All is clean, crisp, and clear-cut.

This is not my interpretation of Shapiro’s intent. EMDR will never be a one-person psychology as long as there are two people in the room. Even in the no-nonsense realm of physics, we know — thanks to the Heisenberg Uncertainty Principle — that the mere presence of an observer affects the results of the experiment that is being observed.

So it is with EMDR. Common sense, clinical experience, and hard science present convincing arguments that the presence of the clinician affects the traumatized client — and vice versa — and that these variables affect the progress of the therapy. There is simply no escaping the I–Thou nature of our work. Picture this scenario, which was given to me during my psychoanalytic training: A slender, 4'10" male behavioral therapist is about to meet a new client. When he hears the client’s knock, he opens his door and is confronted by a man who is 6'5" and weighs 350 pounds. The therapist has an atavistic moment of pure terror, but he promptly pulls himself together when he sees that his new client has noticed his fearful reaction. The therapist steps back, swings open the door, and says, “Well, come in anyway!”

Bingo. In that moment, a one-person psychology — behaviorism — turns into a two-person psychology. We are human. We can’t help but have an effect on each other, whether we intend to or not. The bottom line is, whenever two human hearts are beating in the same room, you have a two-person process, no matter how crisply you attend to principles, protocols, and procedures. And because it is a two-person process, it is relational.

Norcross (2002) states that, “We unanimously acknowledged the deep synergy between technique and relationship. They constantly shape and inform each other… the relationship does not exist apart from what the therapist does in terms of technique, and we cannot imagine any techniques that would not have some relational impact.”

1.1.1 From Working Alliance to Therapeutic Relationship

The beginning of the therapeutic relationship starts with a good working alliance. This embodies a facilitation of the definition of the client’s goals, an explicit understanding of the co-collaboration of the shared tasks between each party, and the different roles and responsibilities each commits to making. This makes for a positive bond, based upon the mental model of a good enough attachment relationship that the client hopefully enjoyed from infancy. With higher functioning clients, this alliance may take a session or two; with more disturbed clients who suffered from early forms of preoccupied, dismissive, disorganized, disoriented, and fearful attachments, it will take longer. The working alliance is only a part of the relationship in therapy, and it does not take the transference or countertransference phenomenon into account theoretically, though the beginnings of this phenomenon may begin at the onset of the first phone call from prospective client to clinician. This alliance may become strengthened or weakened by the shared agreement of tasks and goals, and how both client and clinician carry out these tasks together in their respective roles, based upon the kind of treatment approach the alliance is embedded in. Gelso and Hayes delineate three basic types of alliances; the nurturing alliance, in which the clinician is directive and supportive, insight-oriented, in which the clinician stimulates the client’s self-understanding through the clinician’s insight-oriented approach, and the collaborative alliance, which is marked as a joint venture between clinician and client working together on shared goals. In EMDR I believe that the collaborative alliance is what is developed as a prelude to, and as a continuation of the work throughout.

The working alliance goes by different names, but the variations should be seen as more similar than different. Horvath and Bedi (Shapiro, in press), found that the mean correlation across 89 studies between the “therapeutic alliance” and therapy outcome was 0.21, which they considered to be a modest but very robust association. The therapeutic alliance, which they refer to, embodies the quality and strength of the collaborative relationship between client and therapist, typically measured as agreement on therapeutic goals, consensus on treatment tasks, and a relationship bond (which has the same characteristics as the collaborative alliance).

Gelso and Hayes also point to the significance of the alliance being different in different phases of the work. In EMDR the importance of the alliance is there from the beginning, in Phase 1, when client and clinician develop an action plan with their roles and responsibilities spelled out. In Phase 2 its importance exists as the clinician continues to act as educator to the client of the process. In Phases 3–5, assessment, desensitization, and installation, the alliance is crucial, for here is where the some of the most daunting and challenging parts of the work occur in EMDR. These are the phases of active trauma work. Though of continued importance, the alliance may not be as crucial in Phases 6–8, during the body scan, closure, and re-evaluation, since the lion’s share of detraumatizing and reprocessing will hopefully be completed. These are general statements, as each therapeutic encounter will have its own set of circumstances. It is from the starting point of the working alliance that all other aspects of the therapeutic relationship emerge.

1.1.2 The Adaptive Information Processing Model of EMDR

However, it is important first to note that EMDR is based on the adaptive information processing model, which posits that there is a self-healing quality in all humans and that it is the negative experiences in living that inhibit these innate neurobiological functions.

Shapiro states, “When someone experiences a severe psychological trauma, it appears that an imbalance may occur in the nervous system, caused perhaps by changes in neurotransmitters, adrenaline, and so forth. Due to this imbalance, the information processing system is unable to function optimally and the information acquired at the time of event, including images, sounds, affect, and physical sensations, is maintained neurologically in its disturbing state. Therefore, the original material, which is held in this distressing excitatory state-specific form, can be triggered by a variety of internal and external stimuli and may be expressed in the form of nightmares, flashbacks, and intrusive thoughts—the so-called positive symptoms of PTSD” (Shapiro, 2001, p. 31).

Howard Lipke, in his book EMDR and Psychotherapy Integration, describes information processing in generally easy terms. He states, “Information, usually in the form of sensation or perception, is taken in by a person, it interacts with the person, change occurs, and usually at some point there is an output of activity, such as language, or other behavior” (Lipke, 2000, p. 13). “The goal of information processing psychologies is to explain that when an event occurs in which the individual is stimulated, positively or negatively, there is an interaction between this state and other states of mind that are associated in the client’s consciousness. As a result of this interaction, a series of evaluations occur in the brain prompting certain actions and behaviors.” (Lipke, p. 13).

It is from that starting point that we may view Shapiro’s idea of adaptive information processing. She states

Specifically, there appears to be a neurological balance in a distinct physiological system that allows information to be processed to an adaptive resolution. By adaptive resolution I mean that the connections to appropriate associations are made and that the experience is used constructively by the individual and is integrated into a positive emotional and cognitive schema.

The purpose of EMDR is to restore that neurological balance, so that information can be processed to an adaptive resolution. Where there is a trauma there is often dissociation.

1.2 State-Dependent Memory

Throughout this book I use the term state-dependent memory in a more limited way than might be generally accepted in academic psychology. In my way of explaining the different quantities of traumatic experience, I use this term to connote memories held in dysfunctional states where the visual, auditory, and sensory motor aspects are held by the brain in a way that is separated from semantic or autobiographical memory and that is not accessible to left-brain logical linear thinking. One of the great harms humans do to one another (and clinicians may do this inadvertently) is to try to talk others out of their “irrational” ways of experiencing aspects of their lives. Were it that straightforward, treatment might not be necessary for a great number of people. Take a moment and notice your own unpleasant experiences. How many times have you said to yourself, “Get over it,” only to find yourself on the frustrating end of knowing that you are reacting irrationally but that you do not have the capacity to “snap out of it”? We risk retraumatizing ourselves and others through this misguided form of advice.

The brain works on the principle of association. People over 45 years of age, when they hear the phrase, “Winston tastes good,” will automatically respond, “like a cigarette should.” It seems that these associations become so embedded in the brain that extinction is a very difficult process.

1.3 Early History of Trauma Treatment

I was introduced to treating trauma in 1975 when as a young man of 24 I was hired by the Department of Psychiatry at the Bronx Veterans Administration Medical Center to be trained to help Vietnam veterans who were suffering as a result of their war experiences. The formal diagnosis of post-traumatic stress disorder (PTSD) would not be established until 1980, and at the time I was hired, it was common just to say that these men had been “dramatically affected,” or were experiencing “post traumatic stress” by the war.

The outpatient mental health department where I worked was a hundred yards down the street from the building site for a new VA hospital. In digging the foundation, the builders had encountered a small problem. About 30 feet down, they hit solid rock. Their only recourse was dynamite. So several times a day, we would hear two short whistles, followed by a very loud BANG! and a long “all clear” whistle. Can you imagine what that was like for our combat veterans? We were told to instruct our clients carefully that they would be hearing these sounds and to reassure them that they would be all right. You can guess how effective that was. When the whistles blew and the dynamite roared, some ended up under my desk. Others went into flashbacks. It was clear that exposure to aspects of the trauma in the here and now could be retraumatizing, even in the presence of a safe enough relationship.

Looking back, it is shocking how little was known at the time about traumatic stress. Sometimes it seems as if even common sense was absent in the way we were trained to handle clients. In those days, many vets were applying for war-related disability benefits, and in order to screen out fraudulent claims, the VA hired consultants to teach us how to test for startle sensitivity, a classic sign of “shell shock.” We were instructed that during our initial consultation we should casually walk behind the combat veteran and slap our hands together loudly to assess his startle sensitivity. I am surprised that I am alive to report this story. Those poor men must have jumped five feet. Many of them (after their heart rate had returned to normal) told me their initial impulse was to defend themselves — by killing me.

We were not successful in ameliorating the symptoms of PTSD in those days. Most vets were put on medication. Many had comorbid symptoms of depression or drug and alcohol abuse, as well as a severe sense of isolation from society. Arthur Egendorf, a Vietnam veteran himself, studied this population in the 1970s and found that the only place they were really comfortable was at the Vietnam veterans outreach centers just starting to be opened at the time. These men could only relate to and get a sense of community from their peers (Egendorf, 1985). Perhaps those peers provided a relational aspect that had been lacking elsewhere.

Twenty years later, having been trained in EMDR and become known for my success using it with clients, I got another wake-up call about the vital importance of the therapeutic relationship.

A well-respected colleague asked me to do a consultation with a high-functioning client who had a phobia that they had been unable to resolve. After an initial consultation with this business executive, whom I will call Dan, I agreed to use EMDR with him to resolve his fear of driving over rainy bridges. After we had completed our preliminary work and begun bilateral stimulation, Dan started to remember upsetting events from earlier in his life. Although EMDR is not a method of memory retrieval, any EMDR clinician can tell you that when you use a target memory to stimulate a memory network, other memories associated with the target can emerge. I had explained this possibility to Dan during Phase 2, the preparation phase, but he was still not prepared for the memory that came up. He became quite agitated, and we stopped doing the eye movements.

We then went through all the steps to close down processing and end our incomplete session. I made sure Dan was able to drive home and called him that night to check that he was okay. He said he was. In short I had fulfilled all the requirements of Phase 7, closure, and all the requirements of the collaborative alliance. At our next session, though, Dan read me the riot act. He was not here for anything but to cure his phobia, he declared vehemently. Under Dan’s verbal assault, I found myself in an induced state of countertransference. I froze and was una...

Table of contents

• Cover
• Halftitle
• Title
• Copyright
• Dedication
• Contents
• Foreword
• Preface
• Acknowledgments
• Chapter 1: The Relational Imperative in EMDR
• Chapter 2: The Therapeutic Relationship and Its Underlying Neurobiology
• Chapter 3: Using EMDR Relationally in Daily Clinical Practice
• Chapter 4: Phase 1: Client History Taking and Treatment Planning (Trauma Case Conceptualization)
• Chapter 5: Phase 2: Client Preparation (Testing Affect Tolerance and Body Awareness)
• Chapter 6: Phase 3: Assessment (Trauma Activation Sequence)
• Chapter 7: Phase 4: Desensitization (Active Trauma Processing)
• Chapter 8: Countertransference, Transference, and the Intersubjective
• Chapter 9: The Relational Interweave and Other Active Therapeutic Strategies
• Chapter 10: Phase 5 Through Phase 8: Installation (Linking to the Adaptive Perspective), the Body Scan (Intensive Body Awareness), Closure (Debriefing), and Reevaluation
• Appendix A: Trauma, PTSD, and Complex PTSD
• Appendix B: The EMDR International Association and the Definition of EMDR
• Appendix C: Myths and Realities About EMDR
• Appendix D: EMDR Clinical Applications for Diverse Clinical Populations © EMDR Institute, Inc.
• Appendix E: Confusion Regarding Research on EMDR
• Appendix F: Trauma Case Conceptualization Questionnaire
• Appendix G: Clinician Self-Awareness Questionnaire
• Appendix H: International Treatment Guidelines and EMDR Research
• Appendix I: EMDR Clinician Resources: The Humanitarian Assistance Program
• Glossary
• References
• Notes
• Index