Attachment and Intersubectivity
Attachment and Intersubectivity in EMDR Psychotherapy
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The attachment literature, beginning with Bowlby’s three volumes starting in 1960, has seen an explosion of convergence between infant researchers, developmental neuroscientists, attachment theorists, and intersubjective psychoanalysts Cassidy and Shaver, (1999 ), Wallen (2007) ; Schore 1994, 2003a, 2003b, Siegel (1999), Lyons-Ruth (1998, 2000, 2002, 2005, 2006) Stern (2004), Bromberg (1998), (2008). Interestingly, Bowlby was criticized by members of the British Psychoanalytic Society for challenging Freud.
Clinicians start to evaluate attachment patterns that the client has developed with significant people in their lives during phase one of EMDR, but there is there is little mention of evaluating the initial intersubjective attachment process, or how the clinician notices how the person relates to them initially, or how they relate, respond and are affected by these interactions. This discussion continues to be is missing from EMDR evaluation and treatment. Wallen (2007) states that the attachment relationship in psychotherapy is how the client is most likely to be healed. Norcross (2002) shows the research on the specific relational (attachment) issues central to the healing process. As Dr. Shapiro wrote, “Why indeed would one separate the dancer from the dance?” (Dworkin 2005). With EMDR’s obsessional preoccupation with research, there is none regarding the efficacy of EMDR wit complex PTSD. Yet most of the clinical problems that confront the practicing EMDR clinician deal with just this issue. HAP trainees face even more daunting problems with these attachment disorders.
Most vexing to the practicing clinician are the attachment disordered clients are those who present with disorganized attachment disorders. This population has been documented in the professional lierature (Barasch 1991; Lyons-Ruth 2001, 2002, 2005; Liotti 1991; Chu 1992; etc).
Intersubjective problems are an outgrowth of attachment disorders. Intersubjectivity starts at birth. Schore (1994, 2003a, 2003b) has written extensively on the development of affect tolerance developed through right orbitofrontal to right orbitofrontal attachment of the mother infant dyad. This learning is procedural and non conscious by definition since it happens before the development of language. Infant researchers, neurobiological researchers, and intersubjectivists agree. (Lyons-Ruth 2005, Wallen 2007, Stern 2004;). AIP as a conceptualization is inherently dyadic from birth. There would not be any secure attachments or adaptive information processing if there was not the presence of a loving caretaker.
There is a wealth of neurobiological research that informs us that client and clinician are connected and attached (put all citations in here). Both have different appraisal mechanisms (Siegel 1999) based upon different life experiences, and differing adaptive and dysfunctional memory networks. When the clinician attunes to the client he/she is affected by client’s verbal and non verbal presentations (Wallen 2007, Badenoch 2008, Gallese 2005). Multiple memory networks are activated. These activations have significant impact on the application of EMDR procedures. So why has the EMDR community not embraced this balance when the research demonstrates this importance?
Procedural representations are at the most fundamental levels of relating, and are rule based on “how to” (or “how we”) do things, i.e. how to joke around, how to even say hello. I hug most of my childhood buddies whom I’ve known for more than forty years, but I shake hands with my friend Ben (I’ve known him 50 years). He does not love me less, and probably more. However his implied relational knowing (Lyons-Ruth 1998) is that friends shake hands, so we shake hands. That is our shared implied relational knowing developed over time.
This non conscious process procedural form of interpersonal learning has been termed, “implied relational knowing” Karlin Ruth-Lyons (1998); “mental models” (Siegel 1999), “the brain learns from the past and then directly influences the present and shapes future actions (Ibid 72). Early procedural forms of learning become the earliest implicit memory networks in relating. Clients whose traumatic experiences began early in childhood often grow up with conflicting mental models, or implicitly dysfunctional memory networks such as “Daddy (mommy) hates me, daddy (mommy) loves me.”
In any form of trauma treatment these conflicting mental models, along with the differing implied relational knowing of client and clinician create intersubjective difficulties that go by different names; rupture and repair to the therapeutic alliance (Bordin 1976, 1989), misattunement and reattunement; “now moments” and moments of meeting.” (Stern 2004); dissociative attunement (Hoppenwasser 2008), and the old standby’s, transference and countertransference, (Freud (1912 etc) and projective identification and enactments (Baker 1997). Though there are differences in these terms, they all deal with relatedness.
To elaborate the intersubjective and attachment in the EMDR approach to psychotherapy, is to state that every communication (explicit and implicit) has degrees of relatedness. The interaction of the adaptive and dysfunctional memory networks of clinician and client as they co-participate in the 8 phases of EMDR hold implications for changes in EMDR Basic Trainings.
Intersubjectivity (which arose out of different schools of relational psychoanalysis) can be defined as the study of how my subjectivity interacts with your subjectivity. Rather than the mistakes of former theoriticians who posit subject to object interactions (Freud the analyst remains the blank screen; Janet, the hypnotherapist gives “moral guidance” Shapiro the clinician remains attuned) intersubjectivity is based upon an egalitarian approach that wonders, “how does my subjectivity affect your subjectivity and visa versa”). In information processing terms it can be said that intersubjectivity is the study of how my memory networks interact with your memory networks. While the history of relational psychoanalysis can be traced back to the writings of Sandor Ferenczi and Otto Rank, the roots of intersubjectivity can be said to have been started by Robert Stolorow and George Atwood in the 1980′s. They debunk the “myth of isolated minds” in their 1992 book Contexts of Being and state that “Emotional experience… is always regulated and constituted within an intersubjective context.” (p 13). Research into the mirror neuron system expands the neurobiological position of the intersubjective in AIP.
“Intersubjective consciousness” defined by Stern (2004) is the co-creation in the phenomenology of consciousness “where there is matching or great overlap in this phenomenon of each partner” (Stern 2004). This form of consciousness is intermingled and separate at the same time, or how the client’s memory networks are living in the clinician’s mind/brain, and how the clinician’s memory networks are living in the client’s mind/brain simultaneously, with multiple states activated (parallel information processing) in each party causing differing degrees of relatedness and attunement; or somatic activations (transference, countertransference, projective identification, enactments, misattunements and reattunements, now moments and moments of meeting, or combinations of all of the above either in parallel or sequential processing).
“Intersubjectivity is thus more than a match or communication of explicit cognitions. The intersubjective field, co-constructed by two individuals includes not just two minds, but two bodies (Schore 1994, 2003a, b, 2007). At the psychobiological core of the intersubjective field is the attachment bond of emotional communication and interactive regulation. Implicit unconscious intersubjective communications are interactively regulated and dysregulated and psychobiological somatic processes mediate shared conscious and unconscious emotional states, not just mental contents.”
When a patient begins EMDR treatment, the EMDR clinician makes a good enough evaluation of the client’s presenting complaints, with attending symptoms, attitudes, beliefs perceptions, affects and sensations etc., and works to define the feeder memories that are the experiential contributors to the traumas that have led to dysfunctional information processing. There are exceptions to defining feeder memories too quickly, and this is when the clinician evaluates the client as too traumatized and dissociated, and a more thorough history taking needs to be put off until the client has learned more preparation strategies to stabilize themselves. Again the emphasis is on procedure, with vague recommendations about having a “strong enough therapeutic relationship”; but again, issues of attachment are not included in developing this “strong enough therapeutic relationship (whatever that may mean).”
Contrast EMDR training with the newer model of Structural Dissociation which explains the necessity and methods of “Overcomng the Phobias of Attachment and Attachtment Loss” (van der Hart 2006) as part of the first phase of trauma treatment, (Janet ) in stabilizing the client for trauma work.
The issue of needing greater preparation time has been written about before by EMDR clinicians (Paulson 1995; Twombly 2000; Gelinas 2003), but not specifically about how this time needs to be spent strengthening relatedness, working out misattunements, and creating stronger shared therapeutic implied relational knowing.
Allison, a 25 year old client began EMDR psychotherapy with me two months before the first draft of this paper. She had been in treatment for more than ten years, but none of her former clinicians screened her for a dissociative disorder, even though they diagnosed her with “Borderline Personality Disorder.” She easily met criterion for complex PTSD having suffered from continuous physical and emotional abuse since infancy. During Phase One History Taking, she complained that I was not starting “EMDR” (meaning phases 3-8) quickly enough. “All you want is my money, and I don’t have any.” Soon after she started making excuses about why she couldn’t pay me in a timely manner (we had discussed this problem prior to her first appointment and had come to, what I thought was an equitable arraingement.) When I gently (or so I thought) reminded her of our agreement she collapsed into tears. Now I felt like a thief. I searched myself for my contribution to this dilemma and found that I had dissociated my irritability. In admitting that I did have a reaction to her acting out she reconnected to me acknolwledging that she had her part in this misattunement as well. This led us to be able to have a stronger sense of relatedness, and a therapeutic implied relational knowing, (Lyons-Ruth 1998) based upon our multiple shared experiences. As our attachment relationship developed more adaptive memory networks that each of us developed she became closer to safely starting EMDR Reprocessing phases.
AIP and Intersubjectivity
How does intersubjectivity relate to AIP? The research on the mirror neuron system; Rizzolatti ans Sinigaglia 2006; Gallese 2005); Schore’s right brain to right brain connectivity (1994, 2003a, 2003b); (Siegel 1999; to see that we are connected brain to brain, or in AIP terms, client memory networks are in relation to clinician memory networks. Perhaps they are in attunement and resonating together as the resonance circuits of their social brains are in sync with each other (Siegel 2007). In this case productive work begins, continues into preparing for EMDR reprocessing; it may continue through reprocessing, installation, body scan, and closure, and begin again in re-evaluation. In this case client and clinician may mentalize or reflect on what is transpiring. This is part of what is implicit in Shapiro’s concept of dual awareness.. Mentalization is a…”mental activity that enables the individual to understand him/herself and others in terms of subjective states and mental processes” (Fonagy 2009). However, insecurity (or insecure relatedness, (state dependent memory networks) inhibit the brain’s capacity to mentalize (Fonagy 2002).
The implied relational knowing of clients who suffer from chronic relational trauma is the expectation of harm from others (traumatic transference). It is assumed that the implied relational knowing of the EMDR clinician will be of being of service to traumatized clients, unless “countertransference interferes” with the procedures of EMDR. Healing traumatic memories is relational and procedural. It takes two brains in attunement with each other to procedurally release the pain and dysfunction of frozen trauma. However, because of differences in implied relational knowing, misattunements are bound to occur and need to be addressed as soon as possible.. These misattunements could derail the healing process, or enhance it, in large part based upon the clinician’s ability to somatically use this knowledge to glean what may be an implicit message from the client. The clinician needs to continually observe their own processes and contributions. This is a physical process through the mirror neuron system, the resonance circuitry and the social brain, that embodies the simulated interpretations of the other’s intentions. These “embodied interpretations” of other’s motives are a more modern way of thinking about transference and countransference. However, these processes are not linear and are continually shifting. Paying attention to these processes while applying the procedures, protocols and principles of EMDR can assist chronic relationally traumatized patients to heal and lead productive lives.
This implicit relational knowing of patient and therapist are different, and intersect to create an intersubjective “field” that includes different “sensing” of each person. As this “field” between the two becomes more complex with repeated encounters of attunement, misattunement, rupture, and repair (or now moments and moments of meeting in intersubjective terms) it gives rise to new possibilities for more secure and adaptive forms of interacting. When there have been enough “moments of meeting” a stable enough implied relational knowing forms (and a secure enough attachment to the therapist). This does not solve trauma, nor does it change older less functional procedural knowing, but it gives the patient and therapist a “platform, or scaffold” to work from. When the two persons re-attune to each other, members of The Boston Change Process Study Group, – (BCPSG-) argue that “such moments of meeting shift the relational anticipations of each partner and allow for new forms of agency and shared experience to be expressed and elaborated.” (p. 282) Lyons-Ruth, a member of the BCPSG, argues that these moments of intersubjective meeting constitute a pivotal part of the change process. My position is that new implied relational knowing between patient and EMDR therapist, is a necessary compliment to all the procedural modifications developed for dissociative patients. These successful experiences are the foundation for moving into active EMDR trauma processing phases because they create a secure enough attachment in the present between them to move into the active part of trauma work, (phases 3-8).
The work of neuroscientists, on the mirror neuron system ((Rizzolatti, Sinigaglia, Gallese, Fogasy, Fadiga, and Iacoboni) adds to the neurobiological findings necessary to expand AIP and EMDR psychotherapy; Fonagy’s work on mentalization; current fMRI research on complementary systems of inferential processes with mirror neuron research (de Lange et al 2008 and others); Schore’s work on affect regulation;(1994, 2003a,b, 2007), the attachment theorists and Siegel’s interpersonal neurobiology (1999, 2006, 2007) all enhance a discussion of the intersubjective in AIP.
The Neurobiology of the Social Brain, Intersubjectivity, and EMDR
As early as 20 years ago (Iacoboni 2008) a new class of premotor neurons named mirror neurons were discovered. Research has confirmed mirror neurons in humans , (Gallese et al 2005, Rizzolatti et al 2006, Fogassi 2006) which contribute to empathy (Rizzolatti et. al. 2006, Damasio 2003) and therefore attunement and resonance. The purpose of this paper is to explore the need to include the EMDR clinician’s subjectivity as part of EMDR methodology.
Motor neurons fire right after mirror neurons at the perception of the intention of the other (action observation and action intention). Mirror neurons are located in the frontal, and parietal cortices, and in the visual and auditory centers. They are connected to the resonance circuitry of the medial prefrontal cortex, the anterior cingulated cortex, the super temporal cortex and the insular cortex with projections into the limbic area. Though mirror neurons fire when they experience an “intentional attunement” (Gallese et. al. 2005), what “intention” they attune to could be an activation of dysfunctional memory networks based on past experience which may not be what is “actually” meant (Hoppenwasser 2008). This interpretation could be a resonant and embodied affective experience which may be an accurate representation of the other, or a misattuned limbic reaction based upon the activation of dysfunctional memory networks, or what may be called a transferential activation. (ibid p.83). To add to this neurobiological complexity, not all mirror neurons are alike, or equal. A class of mirror neurons, named “super mirror neurons” may help in the process of distinguishing self from other. This class of mirror neurons may be responsible, in part, for reflection and mentalization.
van der Hart et al., state that “Reflection on our thoughts, feelings, and other mental actions allows us to infer intentions and motivations behind our own and other people’s behaviors. This reflection is an aspect of mentalization (Fonagy et al. 2002). Mentalization may help predict the actions of others more accurately (Janet 1938; Llinas 2001). There is current neuroscience research debate upon which systems, or circuits; motor simulation systems (including super mirror neurons) or inferential circuits with no motor properties (Brass et. al 2007; Gallese 2005; Iacoboni 2008) are responsible for this complex understanding of the “other.” However, whichever theory predominates the evidence shows that client’s and clinician’s cognitions, beliefs, affects, sensations, and perceptions (a two person viewpoint of AIP) are intrinsically related to each other, adaptively, dysfunctionally, or both. The application of EMDR procedures may be influenced by the clinician’s memory networks; adaptive memory networks may assist in accepting these procedural applications (continual attunement), or dysfunctional memory networks of the clinician may induce confusion or fear in the traumatized client.
An example of this neurobiological intersubjective process in EMDR psychotherapy could be seen during the Assessment Phase. When the clinician asks for a positive cognition the client may be able to comply if their arousal is within their “window of tolerance” (Twombly 2000). However, since dysfunctional memory networks have already been stimulated both by the procedural steps and by whatever reactions the client has to the activation of dysfunctional memory networks; the client’s conscious and non conscious activations of dysfunctional memory networks in relation to the clinician, and activation of less adaptive implied relational knowing (Daddy hurts me; daddy loves me, as in the case of disorganized attachment problems which were stimulated and activated by the male clinician, either just through the procedural steps, or, and or, the activation of the clinician’s implicit dysfunctional memory networks (perhaps the traumatic memory the client chooses to work on activates the clinician’s dysfunctional memory networks, but he is not consciously aware of this happening. Maybe this is not such an easy example. In this case when the clinician asks for the positive cognition, which is the “hoped for” belief after reprocessing is over, the client’s defensive memory networks may propel him to state a positive cognition and a VOC of 7 because they have separated from the painful and dysfuctionally activated memory networks. The clinician may be attuned to this problem and may re-educate the client; or the clinician maybe triggered and his tone in explaining the positive cognition and VOC may be confusing to the client who may pick up the double level message, even though the clinician only intended to educate. In other cases the clinician may simply avoid the PC and VOC entirely, thinking that it will change any way so why get into these thorny problems. This decision may be based upon previously failed experiences during the PSO, which may also activate earlier dysfunctionally stored memories of failure. Perhaps client and clinician may avoid the PC and VOC and have a positive experience; but the PC and VOC are needed to instill hope that at the end of processing there will be resolution, closure and increased self esteem and functionality. Without this hope the client’s abilities to reprocess old trauma may be compromised.
Focusing on the properties of mirror neurons shows that they are all not alike. Iacoboni (20008) describes a class of “super mirror neurons” located in the orbital frontal cortex, the anterior cingulated, and the presupplimental cortex. An experiment was performed where two sets of participants were asked to either think about college professors, typically associated with intelligence and everything that came to mind; the other group was asked to think of “soccer hooligans” those fans who are unruly and destructive, typically associated with stupid behavior, and write down everything that came to mind.
Then both groups were asked a series of general knowledge questions. The group that associated to college professors (intelligence) outperformed the group that associated to “soccer hooligans.” Iacoboni concluded that thinking about intelligence makes you smarter, while thinking about stupidity makes you dumber. Perhaps there is a role for mirror neurons in thinking about the hoped for cognition. It would then hypothetically take the activation of super mirror neurons in action execution to be able to perform an inhibitory action, in the face of “stupidity” of traumatic images and negative cognitions associated with these images, and in a reflective manner grasp the possibility of a better future and more positive belief in ones’ self.
However, what happens in the history taking phase of EMDR when a patient with complex PTSD starts to talk about their history? Other models of trauma treatment state that the clinician must first overcome the phobias of attachment and attachment loss before moving into active trauma treatment (van der Hart et. al 2006). Structural Dissociation elaborates the need forspecific issues to be dealt with during the first phase of the Consensual Model of Trauma Treatment ( ), stabilization and symptom reduction. In 2003 Denise Gelinas wrote a beautiful paper integrating ideas from other therapies that do have more elaborated preparation phases with combination with the power of phases 3-6 in EMDR Reprocessing. Where are the references to her paper in the EMDR literature?
In EMDR treatment in the preparation phase the client may have a dysfunctional reaction to the clinician. Perhaps the clinician was just demonstrating eye movements, with the patient’s permission. The clinician told the client what he intended to do, but when he raised his hand to demonstrate, at that moment the client’s mirror neurons, activating his insula which hyperactivates his amygdala, interprets this action intention as a sign of danger. Mentalization is temporarily lost. His dysfunctional memory networks implicitly remember his father raising his hand before striking him and he is activated into a traumatic transference and dissociates. This is a neurobiological example of transference in a dissociative patient. Conversely what happens when the male client demonstrates diagonal eye movements with an attractive female client and his erotized countertransference blocks his awareness that he is moving his hand diagonally downwards towards his genitals? What about Safe/Calm Place? What if the client cannot find a safe place but can do a yoga pose? That seems simple enough; but what if practicing this procedure doesn’t hold outside of the session.
What dysfunctional memory networks become activated in the client? What memory networks are activated in the clinician? How does the clinician deal with possible dysfunctional memory activations in himself? What if the client says that he doesn’t care if he has a safe place or not? What if he wants to start reprocessing trauma? What memory networks are stimulated in the clinician. Failure? Rejection? Submission? Rebelliousness against the “EMDR Police?” What if the clinician’s practice is low and he becomes afraid of losing his client and has deprivation memory networks activated. Then subservient memory networks may become activated as well. The client may sense that he has the upper hand (possibly some sadistic or aggressor memory networks may have become temporarily activated until he finds himself in the reprocessing phases, unprepared for the level of dysfunctional activations to follow. How might that affect the clinician with a low practice? Now he may be faced with dealing with a client in the grip of vehement emotions, way outside of his window of tolerance (Twombly 2000), unable to contain himself because of his demand to start reprocessing before procedural and relatedness elements were firmly in place. What memory networks are activated then in both participants? When this event occurs there are EMDR procedures to assist the client in the Desensitization phase.
Facilitating blocked processing (overaccessing or underaccessing a target memory) or the cognitive interweave are the procedures; how does the clinician respond to those procedural variables when he’s also hyperaroused? EMDR training does nothing to prepare the clinician for these possibilities.
Is the EMDR community implying that if one just follows the methodology that all will be well? What if the client needs to stop, but forgets the stop signal because of being so hyperaroused, and regresses to reflexive action tendencies (van der Hart et. al 2006) with low mental levels and low levels of mental efficiency. What if other memory networks become activated that had been so emancipated that it is as though a new person (alter, ego state, EP etc) appears. What if the clinician is not prepared or trained in dealing with dissociative disordered clients. This can be an incredibly scary experience which has been termed vicarious traumatization, or secondary traumatization (Perlman and Saakvitnee 1995; Figley 1995)
These events may not happen, and there are admittedly many safeguards built into EMDR approach to psychotherapy. However, not taking into account the synergy of procedure and relatedness, or the loss of relatedness can have negative consequences. Training EMDR participants without a full understanding of their conscious and nonconscious participation in this process is unwise at best; foolhardy at worst.
There are so many variables that only a few more will be listed by phase. During the Assessment phase the client may become confused between the two “nows,” or as previously discussed, may not understand or remember that the positive cognition is what is hoped for, and not what they believe now. How might the clinician’s experience be communicated to the client? How might the client react? Even though this part of EMDR was explained in the preparation phase the client was not activated by a traumatic memory, and different and possibly more adaptive memory networks were activated in the client during the preparation phase when they were not activated into dysfunctional memory networks. In the preparation phase they may have signaled understanding. In the Assessment phase when an actual traumatic memory is assessed for reprocessing other memory networks may be activated dealing with the need to defend against the pain of trauma (these memory networks might be called emotional personalities in Structural Dissociation).
During the Desensitization phase a patient may be underaccessing the target memory, causing blocking and blanking, but the EMDR clinician has his dysfunctional memory networks activated and instead of facilitating blocked processing, or using a cognitive interweave he goes blank as well.
Transference and Countertransference in EMDR
Shapiro has clearly stated that attunement is continuously a necessary part of EMDR treatment throughout the eight phases (Shapiro 2007), and transference/countertranceference issues must be taken into consideration and postively dealt with (present situation activating past dysfunctional memory networks.). What others label pathology, I view as implicit messages about how past memory networks are intruding on the present as a “heads up” to the clinician that they may not be aware of. Without strategies to identify, decode and inform the client, the clinician will engage in an “enactment,” which is their countransference “acting out” of their implicitly activated dysfunctional memory networks, activated by the client’s dysfunctional memory networks. In other words, they didn’t get the message, and the “dance of dysfunctional memory networks” will continue until the clinician can engage in a decoding process, and find a “moment of meeting” to repair the rupture of attunement that has occurred. Hoffman’s 1983 paper “The Patient as Interpreter of the Analyst’s Experience” and Hoppenweiser’s paper “Being in Rhythym: Dissociative Attunement in the Therapeutic Process (2008) both discuss, from different vantage points this intersubjective experience.
As the clinician applies the procedures for EMDR, whether it’s during history taking, preparation, assessment desensitization etc, what comes up for the clinician NOW?, in terms of possible dysfunctional activated memory networks and what strategies can be developed to expand Shapiro’s “unified field theory.” The question to ask is “what adaptive and dysfunctional memory networks of the clinician are interacting intersubjectively, explicitly or implicitly with his/her client’s memory networks NOW? Here we have the beginnings of the frame, or template for exploring the synergistic interactions of the spontaneity of procedure and relatedness as client and clinician engage in AIP/EMDR.
To further complicate matters, what we refer to as transference or countertransference may occur in very many subtle ways. So that unless one can make immediate distinctions between embodied attunement and somatic activations, numbing, etc. they may become confused and not understand what is happening to their client, or them. The term for what may be going on is projective identification. Clinicians have the experience of going blank even when they have mastered all the procedures in the 8 phases. They do – personal observation of many years of being an Approved Consultant to EMDR clinicians training for Certification, and personal experience during the Desensitization phase.
Schore discusses projective identification as a subsymbolic transmission of affect. He states, “Neuroscientists describe “early emotional learning occurring in the right hemisphere unbeknownst to the left; learning and associated emotional responding may later be completely unaccessible to the language centers of the brain…From this realm that stores split off parts of the self (or in our language dissociated memory networks devoid of language, or dissociated ego states) also come projections that are directed outward into the therapist…Defensive projective identification, an early forming right brain survival mechanism for coping with interactively generated overwhelming traumatic stress, is activated in response to subjectively perceived social stimuli that potentially trigger imminent dysregulation. I suggest that at the moment of the projection, the patient’s disorganizing right brain (fragmented self) switches from a rapidly accelerating, intensely dysregulated, hyperactive distress state into a hypoactive dissociated state” (ibid p 75).
The EMDR clinician who goes blank may have had a rapidly accelerated intensely hyperactive distress state, switch into a hypoactive dissociated state (negative somatoform dissociation, Nijenhaus 2004); his failure networks activated or may be countransferentially receiving a message from his patient to “go away” because of the early traumatic dysregulated memory networks that become activated into the clinician. Lowenstein (1993) discussed this phenomenon calling it a “dissociative field.” (Lowenstein 19923. However, if the clinician can contain his experience of the patient while this process is occurring during Desensitization he can use his somatic awareness as a tool to create an “intersubjective or relational interweave.” (Dworkin 2005).
These somatic activations may happen in other phases of EMDR as well. During the Closure Phase (Phase Seven) of a successful, but incomplete EMDR processing session, Deborah, an EMDR therapist, experienced her patient, Jim, as being too hyperaroused to safely drive his car. He had come to EMDR treatment because he had been too submissive and dependent in his relationships with women and had experienced a recent rejection involving finding his girlfriend cheating on him with his best friend, also a woman. He had a history of dysfunctional memory networks of being enmeshed by an anxious mother who used him emotionally to compensate for her husband’s neglect. Jim suffered from a disorganized attachment pattern, characterized by his mother telling him since as a little boy he was told how “fragile” he was, and being taken into her bed when his father was “out of town on sales calls.” At other times he was cruelly rejected by both parents when he had been awoken by a nightmare of monsters, and told to stay in his room in the dark. Jim had dissociated these old memories and was working on reprocessing this recent love rejection.
During this incomplete EMDR session Deborah’s mirror neurons saw and heard something in Jim’s demeanor and voice that she interpreted as his being too hyperaroused to drive. Her auditory mirror neurons were activating her embodied dysfunctional pain memories, dissociaitively, of her mother’s painful experiences when she caught her husband cheating on her with another man. She extended the patient’s session because she “did not want to have Jim leave her office until it was safe for him to drive. Jim had come to a plateau and was ready and capable of stopping for the day. Deborah didn’t want Jim to leave the session in this hyperaroused state. Deborah had temporarily lost her ability to mentalize and reflect on Jim’s progress, and experienced him as being “too vulnerable and fragile.” Jim’s visual mirror neurons interpreted Deborah’s embodied worry which activated dissociated memory networks of his mother’s “concern” over his “fragility.” This implicit interpretation activated submissive and fearful memory networks and he experienced an anxiety inducing “now moment” transferentially.
Deborah, unable to productively reflect on her somatic activations (which were her dysfunctional memory networks of her mother’s painful rejection) used Safe Place, Lightstream, the spiral technique, and many R/D/I procedures to “safely close down the session.” Until that moment, Jim had been happy with his progress, and was content to stop for the day. His dissociated “fragility” and disorganized attachment memory networks to an anxious woman became triggered activated fearful memory networks holding dysfunctional beliefs that he was really not “OK” when he thought he was (as had been the case when his mother used him nightly for her own self soothing). His subservient embodied simulation of Deborah’s dissociated memory networks were activated, and he once again put a woman’s painful feelings ahead of his own needs. As a result he was late for an important appointment costing him a date with a new woman who rejected him, which retriggered his defectiveness memory networks, as he was successfully reprocessing rejection traumas.
During Re-evaluation phase (phase eight) Jim reported that he had a difficult week. He was in a mildly agitated state because of last week’s closure phase and subsequent rejection. He entered the treatment room and began speaking in a tone that Deborah’s auditory mirror neurons “embodied” as criticism and rejection of her; This could have manifested as a countertransferential overcompensated caretaker memory networks in Deborah. However during that week she had a consultation with me and we used her somatic activations to floatback her “present day trigger” (her countertransferential reaction) to her dysfunctional memory networks holding her mother’s pain of being rejected by her husband. She reprocessed these dysfunctional memories in consultation and was able to remain fully present when Jim arrived for his next EMDR session.She was able to sensitively ask Jim if they had had a misattunement during the end of their last session; Jim’s dysfunctional memories of not recognizing when he was in danger, originally began to prompt him transferentially to be protective of Deborah, as he had with his mother. Her activation and interpretation of it signaled to him that he is in some kind of danger because she acted so “concerned.” This caused a fearful transferential reaction in him. However, his mirror neurons now responded to Deborah’s reattunement. She stated that she had a sense that something might have interfered with her evaluation during closure that he was actually fine to leave. She stated that she regretted keeping him past the treatment hour, causing him to miss his appointment with thios new woman, incorrectly stating to Jim that they had better work on strengthening his resources. This moment of meeting caused Jim to reflect on his inner knowledge that he was indeed fine to leave the last session and he thanked Deborah for her validation of his adaptive state. Deborah then suggested that they reprocess what had occurred at the end of the last session and the beginning of this one (another example of an intersubjective interweave). Jim’s associations now went back to his mother’s emotional abuse of Jim during the two differing episodes; one when he had been brought into his mother’s bed for being too “fragile” and the other dysfunctionally cruel memory networks of rejection when as a little boy he had been told to leave his parent’s bedroom when he had entered in an actually fragile state having suffered from a nightmare.
Discussion
These thoughts come as a result of interactions i had over the years in the EMDR community, but became more crystallized starting in Sea Ranch in January, as a result of some challenging interactions I had with Dr. Shapiro during HAP trainer’s training. Each trainer in training must present AIP in a specific area of therapy. I should add that i have been competently teaching this conceptualization for more than a decade, so what is to follow is not the result of a lack of a fund of knowledge. I had chosen to integrate AIP with intersubjectivity and dissociation, subjects I am very familiar with. When it was my turn to present to Dr. Shapiro and the trainer’s group, my negative arousal went beyond my threshold of containment and I fumbled with my description. My visual and auditory mirror neurons reflected Dr. Shapiro’s negative arousal and my posture began shrinking into more and more of a defensive pose. My dysfunctional memory networks; mirror neurons, and inferential processes were activated; I remained attuned to the dance of the intersubjective processes going on inside of me, and between myself, Dr. Shapiro and the rest of the class. My rejection and failure and dysfunctional memory networks were activated. I “interpreted” her facial gestures and “irritable” tone as her displeasure. Her mirror and motor activations implicitly conveyed to me that that her dysfunctional memory networks were activated as well.
These processes continued explicitly, with her criticisms of my presentation, and implicitly through her nonverbal displays of displeasure. There came a point midway into my presentation when I withdrew from this “malevolent transformation” (Sullivan 1950), and I contained my somatic activations, through compartmentalization (Dworkin 2005). Having compartmentalized my negative memory activations I activated my adaptive memory networks ((Dr Shapiro and I are friends, and we respect each other). As I reflected on the process that was going on explicitly and implicitly inside of each one of us and between us, I changed the rules of the game, so to speak. I began a “process analysis” of our interactions using the principles of AIP illustrating how my initial fumbling represented the behavioral parts of my dysfunctional memory networks, which activated her dysfunctional networks and so on, back and forth illustrating the intersubjective. In doing so I was back on firm ground. Though many dysfunctional networks had been activated, my reflective action tendencies (van der Hart et. Al 2006) or adaptive memory networks had not diminished sufficiently. I began to become more comfortable with my position and continued this process analysis My colleagues noticed that my posture changed. My back straightened and I began to sit upright.
As my adaptive information processing abilities became enhanced I observed Dr. Shapiro appearing to be more in sync with what I had been saying. My visual and auditory mirror neurons activated my motor neurons into an embodied simulation of mental state resonance with her (and possibly the group). My abilities to imagine (or mentalize) a positive outcome (“and when you see that picture in your mind, what would you like to believe about yourself now?”) became enhanced. Our resonance circuits were attuned to each other and we “moved along” (Sander 1998) to the end of my presentation well. After my presentation ended Dr. Shapiro asked me to write an article for our journal on AIP and the intersubjective.
On the ride from Sea Ranch to San Francisco, George Abbott and Carol Crow marveled that I had been like the phoenix arising from the ashes. They let me know that they felt great compassion for me as I fumbled, and were cringing as their mirror neurons and associated neural structures activated their dysfunctional memory networks of shame and humiliation (or in mirror neuron terms, empathy) (Rizzolatti et al. 2006). Then as I shifted the dialogue they experienced relief for me, and excitement that I could have the resilience to have regrouped and re-conceptualized my thinking in AIP terms.
So what is the point of this story as it relates to the everyday experience of the EMDR clinician as they sit with their traumatized clients? We are hard wired to connect to one another, and in relating, we are affected by our clients shifting activated memory networks. Our memory networks; embodied attunement, somatic activations, and whether they activate the resonance circuits of our social brains (Siegel 2007) is the heart and soul of this paper. Maintaining or regaining our adaptive memory networks to enable us to continue attuned connections which is the intersubjective part of applying EMDR procedure.
In EMDR, the focus is from the adaptive memory networks of the clinician meeting “dysfunctional memory networks of the traumatized client. Implicit in this conceptualization is that it is the “healthy clinician” who will be treating the “sick client.” While it is hopeful and preferable to think that the action tendencies and mental levels of the clinician are higher than those of the client, and that the clinician is competent in EMDR psychotherapy, there is still a false “subject to object” premise that many past psychotherapy experts such as Freud, Janet, Shapiro, and others have espoused. Great problems exist in subject to object treatment approaches. Specific to AIP/EMDR The “unified field theory” needs to be expanded to include the interaction of the client and clinician memory networks in a bidirectional non linear process. The focus in AIP/EMDR would have to combine procedure, relatedness and intersubjectivity synergistically in all eight phases, and in every moment of treatment. EMDR psychotherapy would have to also shift to a bidirectional, non linear therapeutic encounter. Training in “The EMDR Approach To Psychotherapy” Parts One and Two would have to be altered substantially. There would have to be an adjustment to including the memory networks of the clinician in interaction with the memory networks of the clinician. This may not be that big of a problem. During the didactic portions of the trainings participants would have to be reminded of this synergistic effect continuously; while the practicums could be altered on day one to list presenting problems EMDR participants face as clinicians as the Present Day Referent, and then they could attempt to find earlier memories connected that theme. On days two and three they could reprocess these memories. This could then be a launching point for them to start their own EMDR therapy as a condition of training.
Greater problems would exist in HAP trainings because of the nature of the client populations in mental health clinics, and heavy caseloads carried by these clinicians. Alterations into teaching strategies are outside the realm of this paper, but it does seem ridiculous to train them similarly when they face so many different challenges.
Research into this synergy of procedure, relatedness and intersubjective would become more complex. Component analyses would be a nightmare. It is somewhat of an oxymoron to state that we could accurately research “procedural relatedness.” Though I have attempted to develop “scripts for rating relatedness procedures such as Compartmentalization and Intersubjective/Relational Interweaves. There is a wealth of research on aspects of the therapeutic relationship (Norcross 2002), but it goes to the heart of what is problematic in EMDR. If it can’t be researched, it does not become a central part of AIP/EMDR teaching, so generations of EMDR clinicians will be bombarded in 3 day weekend Part One and Two workshops about the “principles, protocols and procedures” (Shapiro 2001) of EMDR. Most of the participants who finish Part Two and request my consultation for certification cannot even name the 8 phases of EMDR, no less describe the procedural elements that go into each phase.
Yes, it is written and taught that “clinical decision making” rests with the EMDR therapist, but who is to say that attaining a license as a mental health clinician assures competence. Where is the research for this assumption? The Part One and Part Two Manuals continue to be refined yearly causing micro fractures in the cohesive understandings of EMDR procedures, and it hurts the relatedness of the EMDR community. Approved Consultants understand that clinicians trained in EMDR in 1990,1995, 2000, 2008, and 2009, and in between have differing understandings of procedural variables. The 1990 clinician will ask, “Why don’t I return to target after every set?” The 1995 clinician will ask “What is a Trauma Sequence Plan? The 2000 clinician will ask, “Why don’t we take a SUDS at the end of a treatment session? When and how do I try to get a “Touchstone event?” The 2006 clinician will ask “Do I floatback the Present Day Referent during history taking? Or do I wait until the Desensitization Phase?”
Intersubjectivity posits that we exist in other’s conscious and non conscious spaces mentally. The research in neurobiology seems to indicate that this is so. Through the process of embodied simulation, or inferential processes, we experience, and are influenced by explicit and implicit processes of our clients and ourselves, and we have continuous feedback loops physically during any of the phases of EMDR and any of the processes in EMDR treatment. The research of the neurobiology of the social brain, the resonance circuitry and the mirror neuron system needs to be included in any discussion of Shapiro’s “unified field theory.” Trying to teach the EMDR Approach To Psychotherapy in Two weekends, even with five hours of “consultation” in between Part One and Part Two, and then 5 hours of consultation after Part Two is a laudable step in the right direction. However it remains insufficient in being able to learn the principles, procedures and protocols of EMDR, no less understand and deal with ones’ own subjectivity in the process..
Neurobiological discoveries have made advances in our understandings of attachment and intersubjectivity, and have demonstrated that when clinician and client are in communication in treatment they are hard wired to each other, meaning that representations of the patient exist in the brain of the therapist and visa versa. The indication for a change in EMDR is that procedure and relatedness are synergistic. If EMDR truly is written on rubber, as was said so often by Dr Shapiro, then the research demands that we make changes in the theory and practice of AIP/EMDR.
Relatedness is not only an issue between client and clinician, it is one between organization to organization. In Europe EMDRE has made connections with other trauma organizations. In the USA there is no such connection. I handed EMDRIA a golden opportunity in 2008. After a year of hard fought service to EMDR against the unfair treatment by certain members of ISTSS who controlled the Revised Guidelines For Treatments For PTSD, there was a meeting in London at the EMDRE/ISTSS conferences. There was organizational interaction with plans to further greater understandings and cooperation. This could have led to joint projects, presentations at each other’s annual meetings; interactions with a 2600 member organization responsible for The Revised Edition of Effective Treatments for PTSD. How many of ISTSS members are on the faculty of graduate schools of Psychology, Social Work, and Medical Schools? How many of those faculty members could have been persuaded to have their doctoral students encouraged to research needed aspects of EMDR? Certainly there are known opponents who would try to block such a relatedness position, but this is not true organization to organization. Certainly there are members in ISTSS who are sympathetic to EMDR. Dr. Bessel van der Kolk is only one of many. The EMDRIA Board, and the Executive Director of EMDRIA wrote to me when I queried, and acknowledged that no attempt was made after this seminal moment in 2008. Is the moment lost? The momentum has been lost, and a prominent member of the ISTSS community has been alienated by EMDRIA.
The deafness of the EMDR community is stunning and baffling. My adaptive abilities are informing me that it is time to make a substantive change. There has been no attempt at integrating the synergy of procedure and intersubjective in EMDR basic trainings; books and journal articles written by the EMDR community, nor in any EMDRIA workshops other than the ones I give. The overdeveloped preponderance on procedures for various types of problems with no attempt to integrate the intersubjective has caused me to re-think my position in the EMDR world. For years I have resisted developing a variant of EMDR; I now think I have to, hence the title of this paper, “Relational EMDR.” This modification may be acceptable, or it may not; if it is not acceptable to the EMDR community at large I will be very much like the little boy in The Little Prince, who at the beginning of his story drew a snake who had eaten a mouse, but when he showed the adults his picture all they could see was a hat. So he had to leave and travel to other worlds.
