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AIP and the Intersubjective Matrix: Implications for Practice and Training in EMDR

Mark Dworkin CSW, LCSW

Psychotherapist

EMDR Institute Facilitator

HAP Trainer

EMDRIA Approved Consultant

 

251 Mercury St.

East Meadow, NY 11554

516-731-7611

Fax: 516-579- 0771

Email: Mark@MarkDworkin.com

 

 

 

 

 

 

AIP and the Intersubjective Matrix: Implications for Practice and Training in EMDR

 

Abstract: Developmental and interpersonal neurobiology and attachment research add the intersubjective dimension to AIP and memory networks both adaptive and dysfunctional. This dimension begins through early interactional patterns between caretaker and infant, and has been linked to the patterns of interaction between client and clinician. The mirror neuron system, elaborates the intersubjectivity of these networks. AIP, guides EMDR practice, and sets the groundwork with a memory network/information processing framework which allows an elaboration of this intersubjective matrix. This elaborated framework suggests the need to expand instructions to clinicians to include their activated memory networks as intrinsic to the intersubjective matrix in EMDR. An explication of these issues within this framework can allow clinicians a greater understanding of their role in the therapeutic process, and suggests ways clinicians can best self monitor and make needed adjustments to expedite their clients’ progress.

Key Words: Adaptive Information Processing, Intersubjective, Mirror Neurons

 

 

 

 

 

Adaptive Information Processing and the Intersubjective Matrix: An Elaboration of AIP with Suggestions for Practice and Training

Introduction

Is it possible to “stay out of the way,” as is taught in EMDR trainings while “the train is moving down the tracks?” The answers from interpersonal neurobiology, including research on mirror neurons, are obviously no. The clinician may be able to inhibit compassionate verbal reflections of empathic attunement while implementing the protocols and procedures of EMDR; however, to suggest that our very presence, our unspoken thoughts and feelings, our non-verbal behavior can be kept out of the way ignores this research and the contributions from attachment and intersubjectivity. As it is taught and sometimes practiced, EMDR appears to be a one-person psychology. That is the issue of continual relatedness, or “how my memory networks affect your memory networks, which affect my memory networks” has barely been dealt with, and it is author’s EMDR definition of intersubjectivity.

The term “intersubjective matrix,” as defined by Daniel Stern, is used in this article to elaborate interactions of adaptive and dysfunctional memory networks between clinician and client. This intersubjective matrix is encoded in memory networks through all significant life experiences. While not explicitly spelled out in Shapiro’s explanation about AIP and memory networks, it is implicit in her writings and teachings (Shapiro 2007). The attachment researcher Lyons-Ruth (1998) terms this part of the memory network “implicit relational knowing.” Implicit relational knowing is, in AIP terms, a non-conscious part of a memory network that holds interpersonal experiences and sets expectations of how to be with others. In his discussion of attachment theory, Siegel (1999) states a similar point of view, defining mental models as “a fundamental way in which implicit memory allows the mind to create generalizations and summaries of past experiences. These models are then used to bias present cognition for more rapid analysis of an ongoing perception, and also help the mind anticipate what events are likely to happen next” (p. 71-72).

The addition of interactions of memory networks between client and clinician with the protocols and procedures of EMDR, whether adaptive or dysfunctional, elaborates the basic tenents of AIP. Adaptive to adaptive connection activates the resonance circuit of the social brain (Cozolino, 2006; Siegel, 2007), causing mental state resonance (Siegel, 1999) which is an attunement of states of mind between client and clinician. This attunement of states is non-verbal and allows the client to feel safe and understood deeply (Siegel, 1999, p. 69-70). This attunement of states of mind is the basis for collaborative contingent communication between caretaker and infant; client and clinician (Siegel 1999). When this co-constructed state is stable, the protocols and procedures of EMDR Reprocessing can be applied, and the chances for productive reprocessing of trauma to an adaptive conclusion are enhanced.

 

AIP posits that there “appears to be neurological balance in a distinct physiological system that allows information to be processed to an ‘adaptive resolution… Essentially, what is useful is learned and stored with the appropriate affect” (Shapiro, 2001, p. 30). Pathology is results of unprocessed experiences, stored in their own neural networks, unable to link up naturally with anything more adaptive. (Shapiro 2001, Solomon & Shapiro, 2008). Implicit in the definition of AIP is that at least two people are involved in the beginnings of what will become a human being’s self-organizing abilities. Self organization is only a function of adaptive communal living (i.e. the family). Infants are incapable of developing adaptive memory without a caretaker who attends to them sufficiently. According to Bowlby, inherent in human beings is an attachment behavior system (Cassidy and Shaver 1999). Dr. Shapiro gives interpersonal examples of how dysfunctional memory networks may develop, but limits what she describes to how experiences in living between people can impact AIP (Shapiro, 2001, 2007a). What is missing in AIP’s definition is the explicit and inherent two person system. The purpose of this paper is to propose an elaboration in the definition of AIP, to an explicit two person model and to discuss its implications for the practice of EMDR and the training of new EMDR participants.

Literature Review

EMDR came into existence as a result of Dr. Shapiro’s research first published in the Journal of Traumatic Stress Studies, (Shapiro1998a) and the Journal of Behavior Therapy and Experimental Psychiatry, (Shapiro 1998b). At that time, EMDR’s underlying conceptualization was “Accelerated Information Processing.” It remained that way through the publication of the first edition of Eye movement desensitization and reprocessing: Basic Principles, Protocols, and Procedures (Shapiro, 1995). In her second edition, the term “accelerated” was changed to “adaptive.” She states, “This model is offered as a working hypothesis only and is subject to modification based on further laboratory and clinical observation” (Shapiro, 2001, p. 30). She also notes that the term “memory networks” is used instead of “neuro networks” to include “cognitive/emotional strata” (Shapiro, 2001, p 30). Many studies have proven EMDR’s efficacy. Indeed any controversy EMDR’s effectiveness ended when Effective Treatments for PTSD: Practice Guidelines from the International Society for Traumatic Stress Studies, 2nd edition (Foa, Keane, Friedman, & Cohen, 2009) was published, and an “A” rating was given to it by its critics.

Lyons-Ruth (1998) introduces the concept of implicit relational knowing. Siegel (1999) discusses mental models. These concepts both share an understanding that humans relate to the other from past experiences encoded in memory. Traumatized patients could experience “therapists are dangerous,” since they may have been hurt by others who they trusted in their past. Insecure attachment relationships occur as a result of being hurt by the other. This “knowing” has implications for how a traumatized client may have attachment problems with the clinician: “I would view intersubjectivity as a parameter of human mental functioning that cannot be deactivated. The human brain cannot develop and sustain itself without relatedness, which is a continuously active condition of mental life” (Lyons-Ruth, 2005, p. 7).

Working with traumatized clients often holds the possibility for difficult interactions that may result in ruptures of attunement. In intersubjective terms, a “rupture of attunement” is defined as a “now moment,” or an affectively charged interaction between client and clinician (Stern, 2004, p. 245). The intersubjective concept of “moments of meeting” is defined as “something that happens in the present moment that potentially resolves the crisis created by this now moment and alters the intersubjective field” (Stern, 2004, p. 244). This moment of meeting is the relational repair of the rupture of the therapeutic alliance.

It is now time to open a discussion on the role of interpersonal and developmental neurobiology in elaborating AIP. This elaboration explicitly includes the role relationships play in AIP, including the recent developments in the mirror neuron research. Siegel (1999) states that “Relationship experiences have a dominant influence on the brain because circuits responsible for social perception are the same as or tightly linked to those that integrate the important functions controlling the creation of meaning, the regulation of bodily states, the modulation of emotion, the organization of memory, and the capacity for interpersonal communication” (p 21). Corticolimbic connections between the more mature brain of the caretaker and the developing brain of the infant during early period of postnatal development have been demonstrated in the development of affect regulation as a result of positive attachment experiences (Schore, 1994). Similarly, less than optimal attachment experiences can result in problems of affect regulation (Lyons-Ruth, 2006; Schore, 1994; Wallin, 2007). Porges (2003) elaborated a model of how positive social engagement may decrease sympathetic arousal, mediated through the ventral vagal components of the parasympathetic nervous system. Courtois and Ford compare the developmental trajectories of the learning brain, open to novelty, and the post traumatic stress brain’s trajectory focused on harm avoidance (Courtois and Ford 2009).

Within the EMDR community Leeds (2009) states that “an examination of the attachment literature in the context of the AIP model suggests that patterns of attachment shaped in early caregiver experiences influence all later adaptive and maladaptive coping responses” (p. 67), and Wesselman, (2007) makes positive comparisons between an AIP framework and attachment issues from childhood.

Researchers discovered that mirror neurons play a crucial role in social connectivity (Gallese 2009, Iacoboni 2008, Rizzolatti and Sinigaglia 2006). These neurons activate motor neurons when attuned to an intention of another. This motor neuron activation creates an inner experience of the “other,” called embodied simulation. Gallese states that “through embodied simulation we experience our connectedness to others.” (Gallese, 2009, p. 524). This is the neural basis for empathy, defined as a matching of inner and outer experience, is developed as a result of mirror neuron activation. Through empathy we “know” the experience of the other through our internal experiences of them (Damasio 2003, Rizolatti and Sinigaglia 2006; Wicker et. al 2003).

The mirror neuron system activates the resonance circuitry of the “social brain” of both parties (Cozolino, 2006; Siegel, 2007). According to Siegel (2007) this neural circuit is the basis for mental state resonance. “As two individuals’ states are brought into alignment, a form of what we can call mental state resonance can occur, in which each person’s state both influences and is influenced by that of the other.” (Siegel 1999). This is a state of mind where the client feels felt by the clinician, and is the mutual state of mind when productive reprocessing of traumatic memories occurs (Dworkin 2005). The resonance circuitry of the social brain “has been shown not only to encode intention (memory networks), but also to be fundamentally involved in human empathy, and also in emotional resonance, “the outcome of attunement of minds” (Siegel, 2007, p. 165-166). Compaq

According to Lyons-Ruth (2005), “Therefore, there is now a convergence of developmental, behavioral, biological, and evolutionary arguments for enlarging our model of the attachment motivational system to include positive components of the infant-caregiver relationship, components that also serve to down-regulate fearful arousal in early life” (p. 6).

The research on attachment has strong implications on the practice and training of EMDR clinicians. Infant researchers and intersubjective psychoanalysts also agree that patterns of early attachment influence how one interacts with others through their lifetime. (Lyons-Ruth, 2006; Stern, 2004). These early attachment patterns may be repeated in the EMDR client-clinician encounter.

Shapiro has instructed the clinician to “optimally interactive,” (Shapiro 2007a p 76) with the client during EMDR. Any problems in doing so have only been incorporated into training and practice through Resource Development and Installation (R/D/I.) Leeds (1996) discusses “countertransference” in EMDR with attachment disordered clients and candidly admits his activated dysfunctional memory networks. His difficulties with an attachment disordered client led him to develop “EMDR resource installation” (p 268), as another way to promote healing. He was influenced by Barach (1991), reorienting his clinical focus to stabilize clients with early attachment problems. In EMDR methodology attachment issues are dealt with R/D/I and researched successfully by Korn and Leeds 2002. R/D/I strategies have been spelt out by Leeds, in Shapiro 2001, (p 434-440). While these strategies are useful and now incorporated into EMDR methodology, the attachment difficulties between client and clinician remain unaddressed through R/D/I methodology. Gelinas (2003) has addressed the need to take more time to form an effective alliance with the attachment disordered clients who suffers from complex PTSD. Dworkin (2005) elaborated these issues as well. For example when an EMDR clinician attempts to obtain too much detail about specific traumas in the history taking phase, before establishing a good enough therapeutic alliance, the traumatized client may interpret this behavior as a desire on the clinician’s part to use this information in a hurtful manner (harm avoidance Coutois and Ford 2009).

The formation of a strong enough therapeutic (or collaborative) alliance has been stated as necessary in EMDR methodology (Shapiro 2001), but not the problems of rupture and relational repair of the bond (Norcross 2002). In their chapter on repairing alliance ruptures, Safran, Muran, Samstag, and Stevens (2002) highlight Bordin’s (1979) transtheoretical conceptualization of the collaborative working alliance as having shared goals, differentiated tasks, and therapeutic bonding. For the sake of convenience, the term “therapeutic alliance” will be used to represent both concepts. Alliance ruptures have been shown to strengthen the therapeutic bond when there is relational repair (Safran et al., 2002). A significant conclusion of their research is that patients have negative feelings about their relationship with the therapist and that they fear alienating the therapist and that therapists need to be mindful of these ruptures and take the initiative in exploring what has occurred and that poorer outcomes can be expected when these issues are not dealt with (Safran et al., 2002).

From Neurobiological Research, Attachment and Intersubjectivity to EMDR Practice

Developmental and interpersonal neurobiology, attachment and mirror neuron research demonstrate that the clinician’s memory networks are always interacting with the client’s; hence, EMDR protocols and procedures cannot be set apart from the memory networks of client and clinician. Research on the therapeutic bond dictates the necessity of dealing with ruptures of attunement with relational repairs.

Shapiro (2001) stresses that EMDR is not a “cookie cutter” approach but must be tailored to each client (p 381); she stresses the need for continued study and consultation after finishing the Basic Training in EMDR, and that clinician factors affect the application of EMDR methodology (p 381).However when she states that some of the procedures in EMDR may be too disturbing to clinicians who might have difficulty “staying out of the way” during reprocessing, she cites “previous training, (p 381), and not the activation of the clinician’s dysfunctional memory networks. In other writing she acknowledges “countertransference” and credits this author with methods of dealing with it (Shapiro 2007a p 76). While gratifying to be recognized it is the desire of this author to have the intersubjective matrix an explicit part of Basic Training in EMDR.

Now, through the research of neuroscience, clinical judgment in EMDR can be expanded to include understanding attachment processes between client and clinician, identifying attunement and resonance as necessary to continue the progression of preparing and reprocessing traumatic experiences, and intervening in this intersubjective matrix when ruptures to attunement and resonance occur.

This author has defined transference and countertransference in information processing terms as “the activation of state dependent memories (or dysfunctional memory networks) in the client or clinician, or both, that have been activated by the client, intentionally or not” (Dworkin, 2005, p. 126). The clinician’s attachment patterns; intersubjective consciousness (which include the bi-directional re-entry loops between client and clinician communications) (Stern, 2004, p. 243); memory networks; and information processing system differ from those of his client’s. Each makes ongoing appraisals of the other. An appraisal is an evaluation about an interaction between self and other, based upon mental models, (Siegel, 1999, p. 124-125) of the other’s intentions. When these appraisals of the intentional attunement of the other become activated, what may become embodied in either party, or both, may be the dysfunctional activations of unprocessed trauma causing misattunements, or now moments, requiring moments of meeting to repair the relational rupture.

 

Rupture and Repair To the Therapeutic Alliance

One question this author raises in mirror neuron research involves the interpretation of the intentional attunement of the other. When dysfunctional memory network activations occur what may become embodied is the activation of thoughts, feelings and sensations of old memories “transferred” to the alliance. A simple example of a rupture may occur when the clinician holds up his hand to demonstrate eye movements (EM’s). While the intent may be a teaching point, the client, who may have been physically abused by a man, might flinch at the sight of a male therapist raising his hand. It may implicitly activate his mirror neuron system with the incorrect interpretation of intentional attunement of dysfunctional memories of being beaten. The clinician needs to use his somatic awareness when this occurs, and immediately evaluate what has occurred. Often this type of rupture is minor, with both parties being sensitized to the intersubjective nature of their experience.

When more considerable ruptures occur significant complexities arise causing an intersubjective block to the progression of evaluation, history taking, preparation, and reprocessing. These will be described through case examples in phases one, two, four, and seven. The EMDR clinician should take the adequate amount of time, not only to test the client’s affect tolerance abilities, but also to develop, and check the level of the therapeutic alliance during many of the phases of EMDR psychotherapy. There needs to be a firmly established alliance that will carry through, and be tested, before, during, and after the active trauma reprocessing phases (Dworkin, 2005, Gelinas 2003, Safran et al 2002). This alliance will be tested and will change during the course of treatment. (Safran et al 2002, p. 245).

 

 

“Now Moments” and “Moments of Meeting” in History Taking

Client and clinician are neurobiologically connected in a two-person, subject-to-subject, ongoing bidirectional, nonlinear experience. An example during the History Taking phase may be found on page 22 of the March 2009 EMDR Approach to Psychotherapy: Part One of the Two Part Basic Training Manual, “Developing Appropriate Negative Beliefs (Cognitions NC).”

“Gary” requested EMDR psychotherapy to help relieve the beliefs and feelings associated with being inadequate due to the present day trigger. He is a 28-year-old male patient who is single and working as a teacher for special needs children. He recently received a poor evaluation by a supervisor and became quite anxious, believing that he would lose his job for being stupid. The EMDR clinician evaluated the client’s whole clinical picture and began to develop a Targeting Sequence Plan. Starting with the present day trigger, the client reported that the image he sees is of his supervisor frowning. The current instructions next call for obtaining a negative cognition: “When you think about of (repeat description… supervisor’s frown…) what negative belief do you have about yourself?” The clinician received this reply, “I feel ashamed of myself.” The clinician then responded, “What does that say about you as a person?” The client said, “I hate myself.” Now the clinician started to become a little frustrated and said, following the EMDR Institute Part One manualized instructions, “What negative belief goes with that emotion (of hating yourself)?” (p 22). “Well, I have hated myself since I’ve been a child.” The frustration (and failure memory networks of the clinician now became more pronounced) and the clinician replied (with a little irritation starting to creep into his voice), “not what you believed about yourself then, what do you believe about yourself now?” The clinician’s frustration continues to increase and he said, with irritation in his voice, “Gary, when you see your supervisor’s frown, in your worst moment, what negative belief you have about yourself when you think of that event?” Gary’s visual and auditory mirror neurons sensed the clinician’s irritability, and his failure memory networks became activated by the clinician’s frustration. His appraisal of the clinician’s irritability is correct, but it activated a subservient memory network and he responded, “I’m doing this all wrong now, aren’t I?”

This previous dialogue is an example of a rupture of attunement. At this moment the clinician’s visual and auditory neurons now became activated empathically to his client’s activated failure memory networks. He recognized that his irritation was the result of his own failure networks, and his adaptive memory networks containing compassion became activated and he responded, “I know that this question is difficult for you to answer the way I want you to; is it possible that my responses to you made you feel like you were failing again?” Gary shrugs his shoulders and nods. “So maybe the questions, or the way I was asking them, made you experience your negative beliefs now. Let’s see if we could try this again a little differently. Would that be okay?” Both experienced relief in this moment, and they repaired this rupture. Implicitly, the clinician is letting the client (and himself) know that misattunements can be resolved creatively through a moment of meeting; hence, misattunements do not equal failure and “I am here for you”). This is a “moment of meeting” that repairs the rupture of attunement. A moment of meeting cannot be manualized. It is the creative solution that the clinician develops to find the solution to this rupture. In this case the clinician was able to use Gary’s words, “I’m doing this all wrong” as a way to find a negative cognition, “I’m a failure.” It is the interaction of activated adaptive and dysfunctional memory networks, with mirror activations, appraisals, interpretations of intentional attunement occurring in each party, and self-corrections happening as each reflected as to what their part in the process might have been. The standard EMDR instruction to “strive for optimal attunement,” may be better modified to suggest that the clinician mindfully notice how his subjectivity (memory networks) starts and continues to influence the client’s subjectivity (memory networks.)

Overtly, the clinician was following the standard instruction to elicit a negative belief during the Targeting Sequence Plan. However, while Gary was trying to following the instruction, in parallel process it exposes his implicit relational knowing to the clinician “in the moment” that “people think I’m stupid (and therefore I’m ashamed of myself)…” “‘Moments of meeting’ involves a response that is well-fitted to the particular crisis. It cannot be a general technical response…” (Stern, 2004, p. 244). The instructions, “When you think about yourself, …what negative belief do you have about yourself as a person;… what does that say about you as a person; what negative belief goes with that emotion…?” etc, are all general technical responses, and therefore do not meet criterion for a moment of meeting.

This “now moment” puts Gary’s and the clinician’s alliance in jeopardy, and “a well fitted response” (moment of meeting) was needed to solve the intersubjective crisis. (“So maybe the questions, or the way I was asking them, made you experience your negative beliefs now. Let’s see if we could try this again a little differently. Would that be okay?” At first they both enacted the exact problems Gary and the clinician both experienced, only this time it happened “in the moment.” The EMDR clinician needed to become aware of this repetition, with awareness of his dysfunctional memory network activations; otherwise, Gary’s implicit relational knowing would have been reinforced. Another failed dyadic experience would occur because the clinician was not taught to pay attention to his own implicit relational knowing (“people treat me like I don’t matter and don’t listen to me”). And his negative cognition, “I am unimportant,” is actually a defense against a similar implicit relational knowing of Gary’s. Clinician needs to be taught, right from the beginning of basic training in EMDR, that these occurrences are possible, not absolute, and a moment of meeting that is well fitted to the situation is required. This moment of meeting re-engaged Gary in a problem-solving attempt.

“Now Moments” and “Moments of Meeting” during the Preparation Phase

It is important to remember that there is a difference between a state shift, as evident in phases one and two, and a trait shift that occurs as a result of successful reprocessing during phase four. Activations of dysfunctional memory networks can re-occur and the client and clinician are vulnerable to these activations. Gary continued to act subserviently while trying to develop a “Safe Place” unsuccessfully. The clinician, remembering Gary’s difficulties in developing an appropriate negative cognition in the history taking phase, initially experienced compassion towards Gary since he was “obviously” is trying. However, as Gary continued to be unable to experience safety, regardless of the clinician’s creative efforts to give Gary different choices, the clinician again experienced himself becoming frustrated; his frustration was evident in his tone of voice, facial features, etc. Gary’s mirror neurons accurately reflected the clinician’s frustration, but his embodied experience was again an appraisal of his being at fault, and failing again. He experienced an embodiment of anxiety related to failure memory networks, but he did not want admit this reaction for fear of “hurting the alliance.” The clinician had demonstrated kindness and flexibility, and Gary feared that he would anger the clinician with his inability. While he continued to try to comply with the instructions he withdrew into a dysfunctional belief of “I’m incompetent.” This withdrawal was not acknowledged by the clinician, who had a somatic reaction of going numb. This numbing was based upon an activation of his dysfunctional memory network of being helpless (which was actually Gary’s problem with developing safety. If the clinician was able to use this somatic reaction appropriately, it might have given him a clue to Gary’s difficulties.)

When the clinician’s mirror neuron activation causes him to have an embodied experience of activated dysfunctional memory networks, the work functions of treatment do not progress. The clinician needs to learn to compartmentalize (Dworkin 2005) this activation, and then deal with this “now moment” with a “moment of meeting.” In Gary’s case, the clinician was able to finally attune to the Gary’s difficulties.

“Now Moments” and “Moments of Meeting” during the Desensitization Phase

These “now moments” can be observed during the desensitization phase of EMDR clinical practice when the client reports that “nothing” has occurred after two consecutive sets of EM’s. While many “instructive” procedures facilitate blocked processing, the clinician needs to pay careful attention to the verbal or non-verbal intersubjective experiences that may be occurring when reprocessing trauma becomes blocked. The adaptive and dysfunctional memory networks of both client and clinician, both with mirror neuron activations and somatic reactions (whether somatic activations, or somatic numbing), can guide the clinician in making these clinical judgments.

Robert was a 36 year old, single, social worker, who contacted this author for EMDR reprocessing. He had been traumatized by a harsh romantic breakup and believed that he was defective because of this rejection. Other treatment methods were not useful in helping him resolve his dysfunctional failure and rejection memory networks, and he decided that he would “try” EMDR. His implicit relational knowing was that older men show kindness and compassion. He reported a good relationship with his father; a fair relationship with his mother (“she’s a bit too emotional for my taste, just like most women”), and he had a strong social support network. The author and the client made a good beginning alliance; during history-taking, Robert said that there were few childhood “issues”; he scored low on his DES-T and completed all procedures of the Preparation phase. While the author’s dysfunctional subservient memory networks were activated he did not pay attention to his somatic reactions informing him that there were more childhood issues than he was aware of. It seemed as though Robert and the author had achieved mental state resonance, and he had the requisite coping abilities to begin the active phases of EMDR.

He reprocessed some childhood issues of rejection during athletic competitions with little distress. During one of these reprocessing sessions he began to remember a dissociated memory of being a little child and finding out that his mother, who was not present to watch him play Little League, had an extramarital affair with his father’s best friend. After finishing his childhood athletic competition traumas, the trauma of seeing his father in pain was next.

P – “I see my father crying and I go over to comfort him.”

NC – “I am a failure.”

PC – “I did the best I could.”

VoC – 3

E – Sadness and guilt

SUDS – 8

Body – Heartache and pain in his stomach

At the end of two sets of EMs he said that no new information had come up for him. Longer sets, direction changes, instructions for under-accessing a target memory, and cognitive interweaves such as “If this had happened to your best friend as a little boy, what would you tell him?” were used. No “standard instruction” seemed to fit. A “now moment.” Occurred and this author had an experience of not being able to think clearly. This is an intersubjective example of a now moment that is non verbal (as many of them are). The author quickly reflected on this dilemma and wondered if his mirror neuron system was sensing non-conscious dysfunctional memory networks from Robert that may have been activating dysfunctional unprocessed memories of the clinician’s when he felt helpless and could not figure out what to do.

The author first compartmentalized his anxiety in not being able to think clearly, and then decided to share his inner experience of clouded thinking as a “moment of meeting.” (The author’s implicit relational knowing was that he is safe to reveal his process). When informed of this experience, Robert exclaimed, “That’s it! That’s what I experienced. I had forgotten all about it. I couldn’t think clearly and I blanked out.” The author suggested that this intersubjective moment of what had just happened be reprocessed, and another dissociated memory network of Robert’s became activated. He remembered an experience of being six years old, in his first school play, and forgetting his lines. His mother, who was in the audience, began to cry, activating shame in Robert and causing him to urinate in his pants, increasing his feelings of humiliation to unbearable levels. He experienced an elongated period of intense emotional releases with dual attention and verbal support from this author, whose adaptive memory networks of compassion were activated. After this period of release Robert recognized that he had been choosing women to date who would be critical of him. In a non conscious manner, he realized that his identification with his father’s pain propelled him to continually repeat this pattern. This author did not make any suggestions that would make Robert think this way. Once this intersubjective block was discovered and reprocessed Robert was able to adaptively reprocess his dysfunctional memory networks which related to a merged sense of himself with his father. It took three 90-minute sessions to reprocess the rest of his past problems with women, the romantic breakup that had sent Robert into therapy, his present day referents (dating women with similar characteristics to his mother), and his future template of finding a more appropriate partner, whom he eventually married. This author receives holiday greeting cards every year; Robert is married and has two children. Again, the purpose of this paper is not to discard any part of AIP; it is to elaborate it so that it now is seen and taught as a two person model, informing the work of EMDR psychotherapy.

“Now Moments” and “Moments of Meeting” during Incomplete Closure

During an incomplete closure, a now moment occurred. While debriefing the client who had been in EMDR psychotherapy for seven months, client and clinician were discussing how she had experienced positive affect for the first time about a person who had rejected her. Her trauma remained unfinished, and the clinician’s dysfunctional memory network activation of feeling rejected caused him to make the mistake of suggesting that the client list a number of positive attributes and experiences the client had with this person. The clinician’s conscious judgment was that the client had begun to tolerate positive affect, and thought that he was supporting this progression. He was unaware of his dissociated anger network. His suggestion was met with intense negative affect by the client. She had an activation of her rejection networks and correctly experienced this suggestion as a dismissal of her remaining pain. (Activated by her auditory mirror neuron interpretation of the clinician’s non conscious intent to have finish and “get over it!” This was his problem that he later worked out by using the Clinician Self Awareness Questionnaire (Dworkin 2005, 2009). It was also experienced as an order which was not the clinician’s conscious intent. But as the clinician reflected on his dysfunctional memory activations of being angry, he recognized that his covert impatience towards the client was an activation of how he had experienced the client’s complaining about how long this process took. This awareness opened up his awareness regarding his mother’s impatience towards him.

The clinician recognized that he had made an error and discussed this error at the beginning of the next session, during re-evaluation . He further said that he had wanted the client to make as much progress as possible in the shortest time, but that he could recognize that while his conscious intent was to move the process along, that he was pushing the client, and that he had an activation that he had worked on. He then reported to the client that he was pushing her in a direction that made her feel too vulnerable, and “commanded” like her parents had done to her as a child.

The client felt moved by the clinician’s sharing. The intersubjective field was reshaped with more dual awareness and safety. They were able, after the re-evaluation phase, to revisit that “now moment” and “moment of meeting” as a place to start reprocessing her rejection traumas. In a short time she was able to release the pain of her implicit subservience and recognize that she had a right to say no. (This example is a variant of what this author has previously written about, and is called the relational interweave (Dworkin, 2005).

The client’s mirror neurons had become activated because of the implicit intentionality of the clinician’s demand to get better more quickly. Her embodied simulation of this implicit intention was the activation of both painful submission to authority and her rageful refusal to ever submit again. As she reprocessed these activations during the next session, she was able to also recognize that she had been repeating this pattern with a man who loved her (but also had his own issues to work out). Her functionality improved significantly and she was able, calmly an assertively, to confront her present partner and request (strongly and assertively) that he self-reflect on his issues. She reported that he received her request in a very different manner and decided to seek his own EMDR treatment. In essence, her mirror neuron activation began an intersubjective process that included adaptive and dysfunctional memory networks of both parties interacting in a manner that when recognized promoted a great deal of healing. This example demonstrates that the clinician’s memory networks are always interacting with the client’s; hence, EMDR protocols and procedures cannot be set apart from the non-linear, bi-directional interactions of client and clinician.

Discussion

In every phase of EMDR, instructions are given to the clinician regarding how to perform EMDR procedures based upon the AIP model. While useful, such instructions do not include the possibility that the clinician’s dysfunctional memory networks may be interacting with the dysfunctional memory networks of the client’s. As demonstrated in the case examples during phases 1, 2, 4, and 7, the clinician has adaptive and dysfunctional memory networks that interact with the client’s memory networks. The procedural elements of developing a negative cognition, or Safe/Calm Place; accessing and stimulating dysfunctionally stored information; containing and stabilizing dysfunctional information; facilitating blocked processing; and closing down incomplete sessions have intersubjective risks and opportunities for creating a stronger therapeutic alliance so that the client may feel safe enough to reprocess deeper and more painful dysfunctional memories (Safran et al 2002). Addressing blocks to preparing clients, facilitating adaptive information processing, and closing down incomplete sessions is more complex than just following these instructions. A fuller instruction might be added to include, “and just notice mindfully how your attunement is affected, both adaptively and dysfunctionally by your memory network activations and interactions as well as your client’s.”

Awareness of the clinician’s dysfunctional memory network activations, in intersubjective interaction with the client’s memory networks; the ability to recognize what to do once noticed, enhance EMDR practice. But without their inclusion in the AIP model too many unacknowledged problems arise.

Instructional behaviors are necessary but not sufficient. They give the clinician a “roadmap” to follow with all the tasks required of him and his client. For instance, during intense emotional releases in the desensitization phase, “The client relies on the clinician to provide emotional stability and a sense of safety during the abreaction” (Shapiro, 2001, p. 174 Clinicians whose memory networks become dysfunctionally activated during intense emotional releases may have beliefs that they are “harming” the client by continuing bilateral stimulation, when the client seems to be adaptively remaining in dual attention but has not reached the next plateau of adaptive information processing. This may be a function of a dysfunctional memory network of the clinician, and not just the result of other training the clinician has experienced with different orientations.

In a different situation, a clinician who may have been “harmed” but unaware of that memory network activation may continue reprocessing with their client way past their client’s tolerance. The clinician may have “learned” that it was safer to harm than be harmed, but this information may not be available to the clinician’s self awareness. The client’s subservient memory network may continue allowing reprocessing to continue in spite of being taught the stop signal in phase two. Then the clinician’s sadistic memory network activations, as an overcompensation to have being harmed may be activated. In this case the clinician may continue harming the client until the client dissociates.

The reader may interpret the clinician’s dysfunctional memory networks as “countertransference” that needs to be dealt with so that the clinician does not interfere with the client’s reprocessing. The intersubjective matrix is far more complex. Current instructional guidance aids critical thinking, but ignores the possibility that part of the blocks in reprocessing may be caused by implicit non-linear interactions between both parties. The clinician is intrinsically part of the process whether he verbalizes anything or not. Both are in nonlinear continuous intersubjective feedback loops (intersubjective consciousness Stern, 2004, p. 243).

Instructions to clinicians to be mindful of their somatic reactions as well enlarges the focus of attention for both client and clinician memory network activations. The example of the author becoming unable to think straight while reprocessing a memory with Robert illustrates this point. When dysfunctional memory networks of the clinician are activated, intersubjective strategies are needed to continue productive reprocessing. This elaboration starts with broadening the theoretical underpinnings of EMDR by making explicit the intersubjective nature of AIP.

The Clinician Self Awareness Questionnaire (Dworkin, 2005; Dworkin 2009) is a tool clinicians find useful to those ends. However, nothing takes the place of competent EMDR psychotherapy for the clinician when he sees dysfunctional memory network activations repeating, and implicitly interrupting, the work.

Self-reflection implies that the clinician is capable of maintaining dual awareness. This process may be validating for the EMDR clinician. When the clinician finds moments when dual awareness diminishes, he should immediately use a compartmentalization strategy to regain his self-reflective abilities. If it were not for the adaptive memory networks of the clinician in concert with the application of EMDR procedures, many dysfunctional memory networks of the client would not be reprocessed. When the clinician observes patterns of dysfunctional memory network activation that block reprocessing (in consultation with a colleague), he would be well advised to reprocess these memory networks that block mental state resonance.

 

Detailed intersubjective strategies that this author has briefly described are outside the architecture of this paper. These strategies, if not implemented with effectively, will be blocks to adaptive information processing. These dysfunctional activations of the clinician can be used productively. The processes of compartmentalization and self-reflection, using AIP as its theoretical basis, are one strategy. They are the beginning of a series of processes that have implications for furthering the practice of EMDR psychotherapy. Using these “dysfunctional memory network activations” productively to continue adaptive information processing is a superior way of viewing them as just “pathology that needs to be reprocessed by the clinician so that he can get back to practicing EMDR being “optimally interactive.” (Shapiro 2007a p 76). The implication is that these activations have no merit. It is useful for all EMDR clinicians to continue to work on reprocessing their dysfunctional memory networks, but using them productively to create “moments of meeting” makes them more than “interruptions” that pathologize the EMDR clinician. Another limitation of this paper is its lack of recognition that unprocessed memories all have dissociative elements, or dissociative disorders. While much has been written on this subject (Forgash and Copley eds 2008) it has been in ego state language. If AIP is the theoretical underpinning to EMDR, dissociation, in all of its forms should be elaborated in the same language.

Recommendations

These strategies, along with this elaborated conceptualization of AIP, have implications for training EMDR clinicians. It is this author’s opinion that it is well past time to restructure the formats of EMDR Basic Training. The current course of two three-day workshops, with no real accountability, is problematic. Further suggestions for detailed improvements are also outside the realm of this paper and will have to wait. For now, the most important change that can be made within the same structure is to teach AIP as the non-linear, bi-directional interactions of client and clinician memory networks and to teach clinicians how to recognize “now moments” and create “moments of meeting.” It is also crucial to have EMDR clinicians understand how AIP is the theoretical basis for EMDR, and for them to understand and demonstrate this understanding by the end of the Basic Part One and Part Two Trainings. Too few “fully trained” EMDR clinicians continue their education and become “Therapists Certified in EMDR” by the EMDR International Association.

Standards for training new EMDR clinicians in the United States are the responsibilities of the EMDR International Association. Slight modifications of explaining AIP might include giving explicit explanations that the formation of memory networks, from infancy, is dyadic, and therefore communal in its origins. It would be useful to have a stronger emphasis that AIP includes the encoding of the dyadic experiences that form the basis for further relating; The attachment literature and research has demonstrated this over and over again. The images, attitudes, perceptions, emotions, sensations, cognitions, and beliefs that comprise memory networks include implicit relational knowing (Lyons-Ruth 1998). They are the sum total of adaptive (autobiographical intersubjective) experiences, and dysfunctional (implicitly encoded intersubjective) experiences become dysfunctional memory networks. Either adaptive or dysfunctional memory networks may become activated in the present due to the process of association, which will then activate memory networks in “the other” (clinician); this can easily be taught in the standard way in the training. Examples could be included in the client clinician matrix during each phase. The trainer, through intersubjective example during question and answer, could demonstrate that every human being has a combination of adaptive and dysfunctional memory networks.

The manual could include a section that encourages the participant to write one or two adaptive and dysfunctional memories networks that still affect his current day functioning (this would not need to shared). Another part of the manual could have the participant write down an example of an adaptive or dysfunctional memory network activation he experiences during each part of the training. This intersubjective elaboration, which seems to elude many EMDR clinicians, may become tangible and affectively encoded in the participant’s brain (thanks to George Abbott, Ph.D., HAP Trainer, for this idea).

During each phase of EMDR, adaptive memory networks of both client and clinician set the stage for mental state resonance (Siegel 1999). When dysfunctional memory networks of the client affect the dysfunctional memory networks of the clinician, mental state resonance is breached, and learning (which is the function of adaptive information processing (Shapiro 2001) becomes inhibited. Then the suggestion could be given that the clinician and client together search for what caused the misattunement; this could enhance the clinician’s understanding that the success of EMDR depends on both a collaborative working alliance and the attention to mindfulness of both parties. Fidelity to the protocols and procedures yields the most robust results (Maxfield & Hyer, 2002), and the participant should be mindful of the effect on the psychotherapy process should he modify them. These recommendations are meant to augment, not replace, what has been researched to be useful.

During the practicum experience, the clinician could be encouraged to think about a client he (SUDS, 5) has experienced some dysfunctional memory network activation with, and then use this memory activation as the present day referent, developing a targeting sequence plan from that point. This experiential learning would enhance the participant’s sense of what he may need to reflect about not only during the training but also back in his office.

This author urges EMDRIA to incorporate, as a condition of completing basic EMDR training, the expectation that each participant complete a number of sessions as a client, outside of the practicum.    

Mirror neuron research shows that humans respond with intentional attunement and embodied simulation to affect charged actions of the significant other. Unfortunately, while attachment, developmental neurobiology, intersubjectivity and mirror neuron research are part of AIP, they are not detailed in AIP. It’s time that the EMDR world wakes up during its second generation to include what is already an intrinsic part of many therapies are interacting in bi-directional, non-linear ways. This elaboration of AIP is simply taking what Dr. Shapiro implied (personal communication 2009); however, the implications of this explicit elaboration will have far-reaching effects on the practice and training of EMDR for future generations.

Hopefully this paper will accelerate the conversation of their rightful place in treatment and training.

    

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This article proposes that eye movement desensitization and reprocessing (EMDR) would be strengthened by being conceptualized as a two-person therapy; that is, a therapy that employs dialogue between clinician and client about the resonance, attunement, and intention of their relationship. Current research on the mirror neuron system provides a hypothetical neurological underpinning to this proposal. Detailed clinical examples illustrate rupture (Now Moments) and subsequent repair (Moments of Meeting) of the therapeutic relationship in the Eight Phases of EMDR. The high potential for relationship rupture during EMDR therapy is discussed. Suggestions are made for improving EMDR practice, training, and consultation by attending to the intersubjective experience between client and clinician, especially when working with clients who have experienced repeated and pervasive disappointments in love and work.

• EMDR procedures foster a state of balanced or dual attention between internally accessed information and external bilateral stimulation. In this state, the client experiences simultaneously the distressing memory and the present context. The combination of EMDR procedures and bilateral stimulation results in decreasing the vividness of disturbing memory images and related affect, facilitating access to more adaptive information and forging new associations within and between memory networks. These memory networks that contained the perspectives, affects, and sensations of the disturbing event(s) are no longer segmented in a frozen state; learning occurs which allows them to connect with adaptive information networks. Earlier memories which are encoded maladaptively increase vulnerability to pathology including anxiety, depression, PTSD, and physical symptoms of stress and may interfere with healthy development of an individual’s sense of self worth, safety, ability to assume appropriate responsibility for self or other, or limits one’s sense of control or choices.

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What can parents do if their child may be bullying?

Bullying should not be written off as a ‘phase’ that children go through, because it is not an acceptable or healthy pattern.

Not all bullies come from abuse backgrounds. There are some parents who may overtly or covertly encourage bullying. An example was the mother who wrote on her daughter’s social network page stating something negative about another girl. This kind of behavior encourages children to be bullies. It cannot be tolerated.

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EMDR-and-the-Relational-Imperative, by Mark Dworkin, LCSW

I am pleased to announce that Routledge Publishing, a division of Taylor and Francis, has just set me 6 copies of my book, translated into Italian. The publisher is Raffaello Cortina Editore.

The name of my book in Italian is:

La relazione terapeutica nel trattamento EMDR

A Relational View of Intermittent Bilateral Stimulation

One of the most frequently asked questions my students and consultees ask is how I determine when to start and stop bilateral stimulation (BLS). Starting at the beginning the desensitization phase is when we start. My client and I have already determined the type of BLS in the Preparation phase. Right after asking where my client feels sensations in their body (the end of the Assessment phase) is the correct time to begin.

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This is a commentary on EMDR based on my observations from clinical practice that adds the relational perspective to Francine Shapiro’s standard methodology. During the last 19 years I have conducted thousands of EMDR sessions. The patterns of response I have seen in my clients and the latest discoveries in the neurosciences, which support my conviction in the relational imperative, have prompted me to write this commentary.

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This essay is for the practicing EMDR clinician who might benefit from a veteran’s point of view regarding Adaptive Information Processing (AIP), and the proper application of the procedures of EMDR. The views expressed might be agreed with by some, the ideas written in this essay are mine alone and do not necessarily reflect any organization I am affiliated with.

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(Editor’s Note)

This issue is very close to my heart and soul. It is why I chose it to be the first in a series of articles on EMDR as a two person methodology.

The issue of self disclosure in EMDR has not yet been explored.

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