Relational EMDR: The Synergy of Procedure, Therapeutic Attachment, and Intersubjectivity – Implications For An Expanded Conceptualization Of Adaptive Information Processing and EMDR Psychotherapy
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Abstract: Conversations regarding the future of AIP and EMDR need to be continued, leading to modifications in concept, practice, and training methods and qualifications for enrollment in training. It should be noted that “trauma” in information processing terms is defined as any event that becomes encoded in the brain of the client in an implicit, dysfunctional manner, leading the client to feel and act dysfunctionally in life whenever any part of that dysfunctional memory network is activated. In the training of EMDR psychotherapists, the overemphasis on procedure to facilitate change in EMDR psychotherapy misses the opportunity to make it a richer experience by explicitly including the synergy of the ongoing therapeutic attachment and intersubjective experiences that occurs between client and clinician in every moment of EMDR treatment. Without these additions EMDR will continue to suffer the incorrect belief in many quarters that EMDR is just a compendium of techniques.The purpose of this paper is to discuss implications for expansion in AIP conceptualization, suggest that ongoing attachment and intersubjective experience in EMDR psychotherapy is intrinsic, and that changes in training methods are necessary.
It has been suggested that this “relational” or “psychodynamic” approach to AIP/EMDR is one of several different models. The synergy of procedure, attachment and intersubjectivity described in this paper has always been an intrinsic part of the methodology. When one breathes and oxygen is transferred from the lungs to the bloodstream there is no disagreement of the complex interactions that occur. There cannot be one without the other in order an animal to breathe, whether the animal is a lion, eagle, or human being. They are all part and parcel of the process. Problems arise in the case of asthma, in humans, and then specific steps need to be taken to restore the smooth flow of functioning to this intrinsic process, but in general, one cannot separate out the functions of inhalation into the lungs and the intrinsic transfer of oxygen into the blood. So it is when client and clinician work together. Separating one from the other is an artificial and incorrect. Mirror neuron research has demonstrated this phenomenon conclusively. (Gallese 2005, 2008, 2009; Rizzolatti, G. & Sinigaglia, C. (2006); Cozolino 2002, 2006; Damasio 2003; Siegel 2007; Iacoboni 2008).
Dr. Shapiro partially acknowledges the importance of attachment and intersubjectivity when she writes: “the ability to be attuned and sensitive to the client’s needs and non verbal cues, offer unconditional regard, and model positive relational values is contingent upon the therapist’s ability to be present, attentive, and optimally interactive. A variety of specialized techniques and questionnaires have been devised to assist therapists in identifying their own problem areas and memories that benefit from processing (Dworkin 2005)” (Shapiro 2007).
However there have not been attempts to integrate the synergy of procedure, attachment and intersubjectivity into the conceptualization of AIP (2001, 2006, 2007, 2008), EMDR Basic EMDR Trainings, books or journal articles, or workshops (with the exception of Dworkin 2003, 2005, 2006, 2007, 2008, and 2009).
AIP Conceptualization – Broadening The Model
In 2001 Shapiro states “there is a distinct balance between neurological systems that takes information and processes it to an adaptive conclusion”; in 2006 she states that this information processing system is adaptive and intrinsic and forged by millions of years of evolution,” and in 2008, Solomon and Shapiro states, “…the AIP model posits the existence of an information processing system, that assimilates new experiences into already existing memory networks.” Here is an alternate conception. Without contradicting the previous statements this author suggests that the “unified field theory” of AIP (Shapiro 2006) be expanded to include the bidirectional, non linear, multiple activations of adaptive and dysfunctional memory networks in both client and clinician, and that the verbal and implicit (implicit=subsymbolic) messages that each sends to the other also be included. While it is acknowledged that humans may be born with an intrinsic, physical and adaptive information processing system, from the time of the birth cry an infant’s information processing system is dependent on the interaction of the caretaker/infant relationship.
Human beings are open systems capable of influence and change; yet the model on which AIP/EMDR seems to indicate that the conceptualization of AIP is a closed model. The only acknowledgement to problems in adaptive information processing happen when there is less than an optimal relationship (this does not hold true for traumas of natural and human made disasters. Stating that there is an intrinsic system in various neurobiological systems that processes information to an adaptive resolution (Shapiro 2001) seems to violates the basic tenant that human beings are inherently neurobiologically interdependent. However, I do not believe that this is her intent. In “EMDR, Adaptive Information Processing, and Case Conceptualization” (Shapiro 2007) she remarks that “a child may fall off a bicycle, and cry, but with appropriate comforting and nurturing the fear passes, and she learns what is necessary for a more successful ride in the future.” and, “… the child’s earliest interactions …forge the very sense of self through which the rest of the world is interpreted.”
In these statements Dr. Shapiro explicitly acknowledges that the information processing abilities of the child are intrinsically tied to the mature and adaptive information processing abilities of the older capable other (in this case the mother. In describing transmutation of memory within AIP she and Dr. Roger Solomon write that, “The EMDR protocol involves accessing the dysfunctionally stored information, stimulating the innate processing system…thereby allowing the characteristics of memory to change as it transmutes to an adaptive resolution.” (Solomon and Shapiro 2008). Here there is no attempt to spell out the clinician’s adaptive and dysfunctional memory networks, which are intrinsic in interaction with the client’s adaptive and dysfunctional memory networks in accessing the client’s dysfunctionally stored information, in relation to the differing problems encountered with the traumatized client’s attachment and intersubjective responses.
Dr. Shapiro emphasizes “the need to be attuned and sensitive to the client’s needs and non verbal cues, offer unconditional regard, and model positive relational values is contingent upon the therapist’s ability to stay present, attentive, and optimally interactive” (ibid 76). So why is that not enough? The current approach to EMDR psychotherapy is limited from a number of angles.
First, it is a variant of a “subject to object approach,” similar to the days of Freud and Janet, and many of the current day CBT approaches. In a subject to object approach the focus of exploration and intervention is on the traumatized client from the attuned clinician, who is relatively free of problems. The exception occurs when countertransference occurs; then it is the job of the clinician to resolve this problem which “interferes” with the procedures necessary to effect reprocessing of traumatic memories (EMDRIA 2007). The concept that countertransference “interferes” is partially incorrect. Dr. Shapiro in her 2007 article is neutral on countertransference stating that, “…countertransference occurs when the therapist’s personal and unprocessed memories are stimulated.” (ibid p 76). This statement is correct, but again incomplete.
Is countertransference the pathology that gets in the way of reprocessing traumatic memories? Perhaps, but perhaps it is also the clinician’s signal to himself that his dysfunctional memory networks have been stimulated. Why has this happened? I suggest that it is possible, from an intersubjective position (your subjectivity and my subjectivity); that it is the client’s dysfunctional memory networks interacting with the clinician’s dysfunctional memory networks. This would be the process of projective identification and enactment. The difference between transference and projective identification is more easily described and experienced than productively dealt with. In transference a client may tell me that all I care about is his money. In projective identification I start to experience myself as the thief.
Schore has suggested (2003b) that the subsymbolic transfer of affect happens because the client does not have the verbal awareness or abilities to say what he is experiencing. This may happen in any of the eight phases of EMDR psychotherapy. In this case his “dysfunctional memory networks” are all he has to communicate with. He doesn’t know this, but it’s the best he has. So maybe this transmission of affect could be seen as an adaptive attempt to reach the clinician through the clinician’s “countertransference.” In this case countertransference would not be something that interferes with whatever intersubjective process was happening, but was an intrinsic and adaptive way of being reached. The question then starts to become more speculative. How does the client dissociatively “know” what “dysfunctional memory networks” to activate in the clinician? Hoppenwasser (2008) theory of “dissociative attunement,” may provide an answer, or at least a direction to move towards. She posits that the traumatized client picks up subsymbolic signals from the clinician and then dissociatively transmits (almost through code, like a telegraph machine, for those of us old enough to remember what that is) these messages to the dissociated parts of the clinician, and then receives a dissociative response from the clinician’s countertransference. In truth, the concept of countertransference is problematic because it implies a unidirectional experience from client to clinician. Even the concept of projection/counterprojection is still inaccurate, in this author’s opinion because it implies linear communications first from the client, and then from the clinician. It is only when the therapist recognizes his subjectivity in a dysfunctional process of enactments that patient and clinician can be freed to make a relational repair of the rupture that occurred between them.
The second problem with Shapiro’s approach to countertransference is that what remains implicit is how the “application of procedure” is viewed as attunement to the client’s traumas, missing the point that this application is a function of the EMDR clinician’s memory networks, adaptive and dysfunctional, and how these memory networks are transmitted to the client in every single moment of treatment, and not just in what we are calling countertransference (or projective identification).
Here is an easy example, The client walks in; the clinician asks what the client wishes to works out; or why have they decided to seek treatment, etc., and the client says “Why the hell should you care?” Now perhaps the traumatized client was “just” becoming defensive because of fearfulness that he might reveal something shameful. But, “Would it be alright with you to if you consider the possibility that you, the clinician, saw something on the client’s face; heard something in the client’s tone of voice; or even experienced something in their presentation that you couldn’t put your finger on, but it activated dysfunctional memory networks in you that are dissociated from your consciousness, and in a non conscious manner you conveyed some sort of negative appraisal and arousal (Siegel 1999) to the client, who then responds to your “benign” question with an activation of their dysfunctional memory networks leading up to a hostile behavioral response? I am not saying that this is so, but it could happen.
If you would consider this possibility would you then be willing to consider that every moment of every session you have with every client may be loaded with activations of functional or dysfunctional memory networks that become transmitted from the client to the clinician, back to the who receives the message(s), becomes activated with adaptive or dysfunctional memory networks, and then responds etc. Human communication gets a little more complicated doesn’t it? And this is not just “psychoanalytic.” This is neurobiology, starting with infancy (Schore 1994, 2003a, 2003b; Siegel 1999; Lyons-Ruth 2005, 2006; Bromberg 2006).
As it is presented, the AIP Model does not spell out the intrinsic connections regarding the connectivity of procedure, and the relatedness embedded in the procedure. One cannot sever procedure from the memory networks applying and receiving the procedure. This would be akin to severing the inhalation of breath from the transfer of oxygen in the lungs to the bloodstream. The 20 years of research on the mirror neuron system (Rizzolatti and Sinigaglia 2006; Gallese 2005; Iacoboni 2008); the resonance circuitry of the social brain (Siegel 2007; Cozolino 2006); the interpretation of intentional attunement, whether it is from motor simulation (Iacoboni 2008), or inferential processes (Brass et. al 2008) should be sufficient proofs that mother and infant; (Schore 1994; Siegel 1999) client and clinician (Cozolino 2006; Badenoch 2008); lover and beloved etc. are neurobiologically connected.
The most egregious error is that this process is missing from EMDR trainings, and gives EMDR trainees the message that one needs to be in attunement; make a “therapeutic relationship” (whatever that means to the clinician); apply procedure with fidelity, and healing will occur; and if it doesn’t happen spontaneously, then facilitating blocked processing, which includes the cognitive interweave will ensure that an adaptive link from the clinician’s adaptive memory networks will link into the client’s pathologically blocked memory networks and reprocessing will recommence productively, ending in the client’s adaptive information processing being restored.
The most basic understandings of transference and countertransference are missing from the trainings, no less the correct emphasis on the ongoing “subject to subject,” interactive process, intrinsic in the procedures of EMDR. This gap in training is problematic as the clinician’s explicit and implicit affects, sensations, perceptions, activations of dysfunctional memory networks, subsymbolic transmissions of dysfunctional affectivity to the client of his/her dissociated memory networks are not even mentioned, no less appropriately taught how to be dealt with.
Many EMDR trainees have not bought into the methodology of EMDR because it appears to them to be a mechanistic approach that robs both clinician and client of their humanness (personal communications with many EMDR trainees). Again, this is not Dr. Shapiro’s intention; it is an artifact, in my humble opinion, of the insanity of this “evidence based” craze that the health care world has embraced. While it has its utility, research must be balanced by the academic scholarship of the practicing clinician. It is this author’s hope that this paper will help balance a research only attempt at developing more and more useful approaches to psychological healing of traumatized human beings.
This could be done with some didactic attention, both during the morning lectures, and using the practicum’s as a vehicle to cement this teaching.
During the morning lectures in Part One of the basic training, participants could be taught about the issues of attunement and resonance, and the problems and solutions of rupture and relational repair. Then in the afternoon of each day of training, during the EMDR practicum, the participants could use the “countertransferential” issues on their targeting sequence plan to think about the most difficult client that vexes them, and this could be the “Present Day Referent.” The “Targeting Sequence Plan” (Part One EMDR Training Day One) could be used with this issue serving as the “Presenting Problem,” so that the participant could begin to have an experiential awareness of their witting or unwitting participation in this bidirectional, non linear, intersubjective process. This would be the finest form of learning by doing. By participants be directed to choose a client they are having countertransferential reactions to, and they could not only learn about their participation, either by directly tracing back their role in the intersubjective problem, or by the process of a “floatback” (Browning and Zangwill ) which has been taken from Watkins and Watkins “affect bridge” (Watkins and Watkins 1997); or by performing an “affect scan” also taken from Watkins and Watkins “somatic bridge.” they might be able to make some headway using an expanded AIP/EMDR conceptualization.
The aforementioned argument is not intended to change fidelity to EMDR methodology, but rather to supplement and expand it, thus making EMDR a fully integrated two person psychotherapy, similar to the ways that Sandor Ferenzi, Otto Rank and others in the early psychoanalytic community began the task of moving Freud’s initial conceptualizations of instinctual drive, and psychoanalytic treatment from a one person model of psychoanalysis with countertransference being an impediment only (Freud 1915). Fidelity to EMDR methodology IS important, but “fidelity” must be expanded as AIP needs to be expanded to include all adaptive and dysfunctional memory networks transmitted back and forth, in a bilateral, non directional manner between client and clinician.
When EMDR processes go smoothly Siegel aptly names it “mental state resonance.” (Siegel 1999); when there is a rupture of the therapeutic alliance the relational repair needs to be made, and as quickly as possible (Stern 2004). Presently an incomplete version of fidelity to methodological correctness is taught as the research of Maxfield and Hyer (2002) is based only on fidelity to EMDR procedures without a full understanding of EMDR as a fully integrated two person process. Their meta-research that seems to indicate that fidelity to EMDR methodology will bring the most robust results. According to these authors, just staying faithful to the methodology is what is prescribed seems to “prove this theory” because it is a research based approach. However there are additional problems between what is examined in the research, and what is examined in the clinical settings of the practicing clinician. AIP is not incorrect, it’s just incomplete. A case history using a more inclusive approach staying faithful to Dr. Shapiro’s AIP/EMDR conceptualizations will be offered.
Randi The Wronged Woman
Randi is a 44 year old, Catholic, professional woman. She has been divorced for seven years due to her husband’s infidelity. This caused her to become severely depressed. She works as a manager in a bank, and has two grown children whom she describes as “the reason I go on living.” She had worked with an analytically oriented therapist with partial success but still found herself hypervigilant in her next relationship, always being on guard for any “perceived slights.” The therapist sensing that Randi needed more than “talk therapy” referred her to this author, telling me that she was sure that Randi only needed a few “EMDR” sessions (meaning that the therapist expected me to begin EMDR Reprocessing in my first session with Randi.) She entered EMDR treatment with this expectation and was disappointed that I had to evaluate her and “get to know her a little better.” She seemed to accept my explanation of the need to get an AIP informed history (Phase One), and the need to prepare her (phase two) for the active reprocessing phases of EMDR psychotherapy (phases 3-6) but was convinced that after one or two evaluation sessions we could begin reprocessing traumatic memories. Though my “social brain” (Cozolino 2002, 2006), (which includes the mirror neuron system) informed me dissociatively that she wasn’t ready; my countertransference to her demands were to capitulate and begin reprocessing her traumas. My dysfunctional memory networks overrode my adaptive ones because my fear of rejection (and perceived loss of income), and activated my dysfunctional memory networks to behave subservient to her demands.
While I could slow her down somewhat with explanations she could temporarily accept, she complained that she knew that her childhood issues had been resolved and that she needed to work on the pain of her husband’s infidelity. Her dysfunctional memory networks, as it turned out had to do with another man disappointing her; her father; her husband; and me. Her mirror neuron system evaluated me as another man in a string of men who would betray her. Her behavior was to hypervigilantly demand what she wanted, regardless of my “good intentions.” At a certain point she even said to me, “Stop treating me like I’m some kind of fragile patient. Gloria (her previous therapist) told you that I can take it!” While I evaluated her traumatic childhood memories as being quite active she was insistent on working on what she wanted to work on. I explained EMDR; I administered the Dissociative Experience Scale (Carlson and Putnam 1993? or DES, for short) which was expectedly low; she went through her Safe/Calm place experience (Being at Sunday Mass at the church of her childhood)) with all the steps successfully; she learned the Stop Signal; demonstrated stress management techniques that Gloria had taught her; gave an understanding of the train metaphor; and “seemed” to understand and demonstrate the mindfulness necessary for successful EMDR Reprocessing. Still. An inner voice kept on screaming; “stop, slow down the bridge is out,” but I believed that I was being too cautious, and that perhaps she was right. However she was subsymbolically transmitting her helpless little girl memory networks that were the result of her profound neglect in childhood memory networks” and suggested that we approach her painful rejection slowly. Randi suffered from a dismissive attachment disorder and experienced me as dismissing her once again, rather than accepting what I believed to be my compassionate and attuned caution to her need to rush into reprocessing her betrayal trauma. I accepted her need to focus on what she needed too primarily more so that she could “get what she was paying for” (and not be dismissed), but in doing so my dysfunctional memory networks of wanting to be liked and not rejected caused me to become behaviorally subservient to her “entitled child” behavior, based upon her dissociated dysfunctional memory networks of profound childhood neglect.
I considered this a now moment and my moment of meeting was to explain and give her an informed consent lecture. I was unaware of how my rejection and subservient memory networks were activated. I non consciously avoided my anxiety, and was colluding with Randi to avoid her dismissive patterns of interacting, and my unfinished disorganized attachment disorder (hostile/self referential type). One could also consider this an example of concordant countertransference (Racker 1968). She insisted on starting with the following memory:
The private detective she hired to follow her husband reported to her that she had been correct and gave her pictures he had taken of her husband and his lover in a compromising position.
P – Seeing the photo of them kissing
NC – I can’t stand this.
PC – I can move on.
VoC – 2
Emotions – Shame, humiliation and trembling rage
Body – All over
She insisted on the eye scan at a high speed, and be kept on for long periods of time. Her initial associations were, “Nothing is happening at all.” This went on for 2 sets. At this moment I experienced a pervasive feeling of anxiety and defeat in my chest. I used my containment skills and asked her to notice what was happening in her body.
Nothing was the reply. I had her go back to target and scan the picture for more details, (one of the ways of facilitating blocked reprocessing). I asked her to notice any changes to the “target memory. ” She stated that she did not notice anything different. While in hindsight I should have asked her to either focus on more of the target memory, or less (I was not sure whether she was over or under accessing her memory) I was cowed by her increasing agitation. (In my book, EMDR and the relational imperative, I recommend reprocessing her transference to me, I did not suggest this because I was in a dysfunctional state (countertransference to mother); We began reprocessing the target memory, even though she stated that she had not noticed any differences in that memory. Again she reported that nothing was happening. She was in a somatically dissociated state, and reported that she felt nothing different.
I realized that I had dissociated my analytic training that stressed that any rupture between client and clinician was a function of both persons’ subjectivity. I asked Randi to go inside and ask herself what dysfunctional memory networks that might have been encoded earlier in her life that mirrored what might be happening between us. She then had an intense intrusion of dysfunctional memory networks holding painful memories of her father’s emotional abuse and neglect of her being projected onto me. Even though she could access these dysfunctional memories she stated, “Don’t you understand, I feel humiliated and you are not helping.”
I knew that my failure and rejection memories encoded dysfunctionally had been activated even more strongly. I used a Compartmentalization strategy, a variation of Korn and Leeds Resource and Development Strategy (Dworkin 2005), and empowered my action tendencies to return to a prolonged reflective state (van der Hart et. al 2006) where I could mentalize (Fogay 2002) Randi attacking me without my becoming countertransferentially activated .
The Relational/Intersubjective Interweave
I realized that by “pushing my agenda” of facilitating linkages to her past traumas, which she was not ready to deal with, I was recreating an enactment of dismissing her again, like her parents and ex-husband. I realized that my somatic experience a pervasive of anxiety and defeat in my chest was her role in our enactment of her feelings of defeat. I was dissociatively the embodiment of the dismissive attachments she had as a child, and in her marriage. This enactment prevented us from making any progress until it had been remediated by a “moment of meeting (Stern 2004). A moment of meeting is a spontaneous creation by the clinician aimed releasing both parties of the enactment we were stuck in.
I tuned into my somatic awareness of her dysfunctional memory networks of pervasive experience of anxiety and defeat, listening internally to her statement, “”Don’t you understand, I feel humiliated and you are not helping.” Now that I had compartmentalized my dysfunctional memory networks I was able resonate with her pain. This is the first step in the relational interweave.
Using a “relational interweave” (Dworkin 2005, Dworkin and Errebo 2010), a variant of the cognitive interweave when there is a block between client and clinician because of being trapped in an enactment), I admitted to Randi that though I believed that I may have been attuned to her pain, that something in me didn’t feel right, and therefore she had a point when she shared her anger with me for not understanding her pain and humiliation. I owned this as my problem and I then commented about my experience of her “nothingness” letting her know that I had a sense that the “nothing” she had been experiencing might have to do with the lack of connection she experienced as a child with her father, with her husband, and with me NOW and asked her if she could reflect on my thoughts. She became reflective; tears came to her eyes, and she shrugged her shoulders. That was enough of a response (because it indicated that there was a small opening in her blocked reprocessing) for me to ask her to just notice what the dyadic interaction was like for her in this NOW moment (my adaptive abilities meeting her dysfunctional memory networks).
EM’s (or eye movements – a form of bilateral stimulation, or BLS, which is part of the desensitization phase). This is the second step in the relational interweave.
Randi – began to sob bitterly, first condemning herself for “putting me through hell”
(author’s comment) – While I could have said, “Go with that, as is the instruction when the clinician notices a changes indicating reprocessing, I believed – correctly- that her response was another NOW moment because she had a pattern of being harsh on others, or herself). I realized that another “moment of meeting was necessary. I chose to share my experience, in the moment with Randi.
Me, “Randi, I’m OK with your criticism of me (I was). I think that my part was pushing my agenda to make linkages to your childhood activations. That’s not what YOU needed right now. Am I close to what your experience is?
Randi – (Nodding her head yes) Yes, that fits.
Me – Just notice that” (I started another set of EM’s)
Randi – I never told Frank ( her husband) what a bastard he was, because until this moment, had been frozen into the role of being the “good little girl” who did not deserve to stand up for herself.
Me – “Go with that.” (EM’s)
She continued reprocessing her childhood parental neglect; their fighting; her mother’s fighting with her sister; and her needing to always be the peacemaker.
While this vignette does not capture the whole process of her EMDR treatment, it illustrates our need as EMDR clinicians to stay closely attuned and notice any countertransferential activations, recognizing that our use of our somatic activations could be the identification of the coded message our clients are always trying to reach us with (and not like Dr. Shapiro’s characterization of countertransference as an “interference” that needs to be eliminated so that reprocessing can continue. I suggest that Dr. Shapiro and the EMDR community stop looking at countertransfernce as “pathology that interferes with productive reprocessing (EMDRIA Guideline For Basic Training Curriculum) and realize that these now moments, though difficult, are significant meetings our memory networks that when in mis-attunement cause blocks to adaptive information processing.
Compartmentalizing our somatic activations first, identifying and decoding the implicit messages from the client’s dysfunctional memory networks to our dysfunctional memory networks, and regaining attunement creates the needed “moment of meeting” in the EMDR intervention of a relational interweave that becomes the link to securely reattaching in the positive therapeutic alliance. This process of rupture and relational repair, based upon shared therapeutically implied relational knowing (Lyons-Ruth 1998) creates the potential of newly encoded adaptive information networks being formed. It would be useful for the EMDR community to learn to use these valuable relational moments of mis-attunement productively. Otherwise what is lost is the living breathing experience of treatment, leaving procedures, scripts, protocols, and incomplete underlying principles of AIP to be followed. The application of EMDR will always remain a “technique” as long as the intersubjective interactions between client/clinician memory networks remain outside of the realm of exploration.
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