Integrative Approaches to EMDR: Empathy, the Intersubjective, and the Cognitive Interweave

Integrative Approaches to EMDR: Empathy, the Intersubjective, and the Cognitive Interweave Mark Dworkin East Meadow, New York EMDR represents an integrative model of psychotherapy at the theoretical level. During its 16-year history, it has created quite a controversy in academic psychology. Missing from these debates have been additional therapeutic elements that are necessary to propel productive thinking into ways of making greater use of the model. These elements empathy, the intersubjective, and usage of the cognitive interweave in conjunction with transference and countertransference issues are explored. This addition constitutes an assimilative approach to an ever-evolving model of resolving posttraumatic stress disorder. As new treatment modalities are developed, clinicians from many different disciplines and orientations become aware of their existence. In so doing, these clinicians offer many differing viewpoints and critiques, most in a positive and respectful vein, some in less than respectful tones. Such has been the birthing of eye movement desensitization and reprocessing (EMDR) over the past 16 years. Though presented as synclectic (meaning borrowing from many different traditions) by its originator, Francine Shapiro, Ph.D., most of the attention it has received in the literature has been from the cognitive behavioral academic psychologists. Some authors have contributed productively to EMDR s development by research into its effectiveness for posttraumatic stress disorder (PTSD; Carlson, Chemtob, Rusnak, Hedlund, & Muraoka, 1998; Marcus, Marquis, & Sakai, 1997; Rothbaum, 1997; Scheck, Schaeffer, & Gillette, 1998; Shapiro 1989a, 1989b, 1991, 1995, 1996, 1997, 1998, 1999; Van Etten & Taylor, 1998; D. Wilson, Silver, Covi, & Foster, 1996; S. Wilson, Becker, & Tinker, 1995, 1997). Some have dismissed it as just another form of behavioral desensi- Mark Dworkin, independent practice, East Meadow, New York. Correspondence concerning this article should be sent to Mark Dworkin, 251 Mercury Street, East Meadow, New York 11554. 171 Journal of Psychotherapy Integration Copyright 2003 by the Educational Publishing Foundation 2003, Vol. 13, No. 2, 171 187 1053-0479/03/$12.00 DOI: 10.1037/1053-0479.13.2.171

172 Dworkin tization with the eye movements (or other forms of bilateral stimulation, e.g., alternating tones or alternate hand tapping), and some have reached conclusions that this method is not useful or effective (Devilly & Spence, 1999; Foa & Meadows, 1997; Jenson, 1994; Lohr, Tolin, & Kleinknecht, 1996; McNally, 1999). Through all of this controversy, Division 12 of the American Psychological Association has rated EMDR as probably efficacious for civilian populations (Chambless et al., 1998), as recently as autumn 2000, and the International Society for Traumatic Stress Studies gave EMDR an A/B rating. (Foa, Keene, & Friedman, 2000). Clearly, the mental health community is coming to terms with this paradigm shift. Missing from these discussions and debates have been key, critical issues integrating specific ideas and commonly held curative factors in psychotherapy, dealing with elements of the therapeutic relationship. The role of empathy, dealing with the intersubjective, and the uses of the cognitive interweave (a discovery of EMDR) in conjunction with transferential and countertransferential material are three examples that this article explores. The cognitive interweave is an active procedure used during an EMDR session when the productive phase of desensitization is blocked. The clinician, with knowledge of the client s history and characteristics, uses this information to enable the client to shift into a more adult mode, releasing him or her from the dysfunctional way of experiencing his or her problems. As this article demonstrates, an additional source of information that may enable the client to shift, using the cognitive interweave, may be found in the transferential reactions of the client and the countertransferential reactions of the clinician. The purpose of this article is to open a discussion on these salient issues in an integrative manner, to promote productive and courteous dialogue, and not to put a branding iron approach on an ever-evolving psychotherapy. The time is right for mental health professionals to end the bitter feuding that has characterized some of the discourse surrounding EMDR (Rosen, McNally, Lilienfeld, 1999) and to continue to develop and improve on new technologies that synthesize useful ideas for the betterment of the mental health field. This is not a methodology that mesmerizes but one that remains open to criticism and debate from both within and without the EMDR community. The goal should be to bring together those factors that promote growth and healing for our clients. The controversy that has surrounded EMDR should continue, but only with the respectful tones of its proponents, its innovators, and its detractors. It is clearly an unfinished work; its originator, Francine Shapiro, Ph.D, has always said that the theory would be modified as research into its efficacy, its component analyses, and its neurobiology progressed. But just as surely as it is a work in progress, it is also an example of a theoretical integration.

Integrative Approaches to EMDR 173 Stricker and Gold (1996, pp. 47 50) elaborated on three different types of psychotherapy integration models. The first, technical eclecticism, does not rely on new theoretical models but rather designs treatment plans tailored to individual need on the basis of already existing technologies. The second, the common factors approach, relies on those curative factors that are the underpinnings of all psychotherapies, attempting to identify specific effective ingredients in any group of therapies. The third form of integration is theoretical integration, which offers different perspectives at the level of theory and practice. EMDR became an example of this last form of psychotherapy integration when it moved from eye movement desensitization, a simple behavioral form of desensitizing anxiety, to a more integrative model of accelerated information processing. Francine Shapiro, EMDR s originator, stated, One principle that is crucial to EMDR practice...and which is suggested by the consistent application of the procedure is that there is a system inherent in all of us that is physiologically geared to process information to a state of mental health. This adaptive resolution means that negative emotions are relieved and that learning takes place, is appropriately integrated, and is available for future use. The system may become unbalanced due to a trauma or through stress engendered during a developmental period, but once it is appropriately activated and maintained in a dynamic state by means of EMDR, it transmutes information to a state of therapeutically appropriate resolution. (Shapiro, 1995, p. 13) Borrowing concepts from psychoanalytic thinking, EMDR states that most current-day pathologies are the result of old, painful memories. These state-dependent memories have not yet been able to be metabolized by the brain s synthesizing abilities. Shapiro (1995) stated, The continued influence of these early experiences is due in large part to the fact that present day stimuli elicit the negative affects and beliefs embodied in these memories and cause the client to continue acting in a way consistent with these earlier events. (p. 14). Shapiro went on to note that there is a lack of appropriate assimilation in the present and that the client has not been able to learn from the experiences of the past. Although research continues to be directed at the reasons why EMDR is so effective, no conclusive data have been demonstrated to date. EXPLAINING EMDR EMDR is a complex, eight-phase methodology that integrates elements of cognitive behavioral, psychodynamic, hypnotic, and family systems elements within its structure. The eight phases, described by Shapiro (1995, p. 67 68), are client history taking, client preparation, assessment,

174 Dworkin desensitization, installation, body scan, closure, and reevaluation. Client history taking evaluates the client s presenting problem, assesses client coping styles and abilities, and endeavors to trace back to the past history earlier trauma that may have contributed to the intensity of the presentday reactions. In this phase, the clinician evaluates a client s readiness to begin desensitizing his or her traumas; only after this evaluation is made does the clinician move on to the second phase. In the client preparation phase, the client is assisted in understanding the explanations of how EMDR can help, a safe place exercise (which is described in greater detail later in this article) is performed, a stress management technique is taught, and safety and control factors are preformed. In this phase, the client tries different forms of bilateral stimulation to determine which one feels most productive. Although the eye movements are what EMDR is most known for, alternating sounds and/or tapping may also be used. In the third phase, assessment, a memory is chosen to work with, the picture of the worst part is picked, and then the negative cognition the person currently holds is elicited, as is the desired belief. Then the desired belief is measured on a scale from 1 to 7, with 1 being completely untrue and 7 being completely true. This is called the Validity of Cognition Scale (VOC) and was developed by Shapiro (1995). After getting the VOC, the clinician asks the client to link the picture with the negative cognition to elicit the painful emotions that are held in a blocked or frozen state. The degree of severity is ascertained according to Wolpe s (1991) Subjective Units of Distress Scale, from 0 to 10, with 0 being no distress and 10 being the most distress. Finally, the clinician asks where these state-dependent feelings are held in the body, and the next stage immediately begins. This fourth stage is what EMDR is most associated with, desensitization, with caricatures of clinicians waving their fingers in front of the client s eyes. In actuality, the client starts with all elements of the assessment phase in his or her consciousness, and sets of at least 24 alternating eye movements, tones, or taps are administered. The clinician breaks periodically to check in with the client to observe what he or she is experiencing. Once the memory is desensitized down to a 0, the next phase begins. This phase, installation, deals with installing the desired belief the client wanted (this belief was elicited during the assessment phase). Holding the picture of the trauma with the new belief and instituting bilateral stimulation until the VOC score is a 7, the clinician facilitates the desired belief to be installed. The next phase is the body scan; here the clinician instructs the client to hold the target memory of the trauma and the positive cognition and scan his or her body for any residual tension. If any occurs, more bilateral stimulation is applied until the tension subsides completely.

Integrative Approaches to EMDR 175 The seventh phase is one of closure, There are differing techniques used to close down a session depending on whether the trauma has been completely reprocessed. The final phase, reevaluation, starts at the beginning of the next session to evaluate the client s progress during the week. The Cognitive Interweave The cognitive interweave is an active intervention used when bilateral stimulation alone does not shift the client s brain into a more functional way of processing dysfunctionally stored information. There may be many causes for processing to get stuck for instance, perhaps the person has a blocking belief that interferes with his or her brain s ability to keep information moving toward resolution. Shapiro (1995) stated that the term interweave refers to the fact this strategy calls for the clinician to offer statements that therapeutically weave together the appropriate neural networks and associations (p. 244). Verbally, she has stated that the word cognitive refers only to the fact that this is a verbal process. Furthermore she considers interweaves to fall into three categories: responsibility, safety, and choice. Shapiro (1995) cited four instances when the client will need clinicianassisted processing: looping, insufficient information, lack of generalization, and time pressures. It is crucial that one know one s client s strengths and accomplishment as well as timing and targeting. In my opinion, it is crucial that the clinician know when a countertransferential event has occurred. It may also be conceivable that the clinician could notice a transferential reaction without becoming triggered. The same comments about using the interweave still apply. This understanding is based on the belief that transferential reactions interfere with processing the material and at the same time inform the clinician about a deeper level of struggle going on in the client. By using an interweave when the processing is stuck, the clinician empowers the client to accept a more adult or adaptive perspective. This idea is based on the notion that when the trauma occurred, it got locked into the brain in state-dependent form, with the level of affects and thoughts of that time period of the client s life. The client comes in to treatment, first because he or she is in emotional pain and because of information gained later in life, which informs him or her that change is possible to a more adaptive (adult) perspective. So the clinician is optimally identifying with the adult part of the client s personality while remaining empathic to the different child parts of the client s personality. Understanding the transference can see the activation of a child part. Here is a short example: Let s say someone is looping around the issue

176 Dworkin of releasing his or her grief over the death of a 16-year-old dog, which had seen him or her through many hard times and loved him or her through everything. And let s say that the client s blocking belief is, I m betraying Toto if I let go and grieve. Let s imagine that the client s transference to us had to do with a critical parent s demand to do something a certain way, and this gets projected onto us. Perhaps we have a belief that to grieve means to release one s pain as quickly as possible. This timetable of ours may not fit with the client s timetable. Perhaps the client reads our belief correctly as our demand that he or she break down and cry now. Compassionate as we are, let s say we start to get a little irritated with the client s looping. Perhaps he or she has read our unconscious response correctly and is caught between cooperating and resisting, both because it is not the right time for the client and perhaps also because he or she intuited our unconscious demand as similar to demands made on him or her earlier in life. Were this to be the case, the client might shut down or loop. (Many other possibilities could occur; these are just two examples). Knowing the client s history will help us. Standard EMDR methodology in Phase 1 requires that the clinician get a solid history know whom he or she is dealing with. On the basis of some rapid internal processing, we realize that we are unconsciously repeating the parent s ways. What if we knew that there were other times in our client s life in which the client was given as much time as he or she needed to do something in his or her own way successfully. What if we use choice as the interweave of choice, in a questioning way, and say something like, And what would you experience if you took all the time you needed to deal with your grief in your own way? Perhaps we see a glimmer of hope and understanding in the client s eyes. Perhaps he or she recognizes the possibility of the present being different from the past. That small moment is the exact time to say, Go with that, and chances are enhanced that the client will link the more functional neural network with the dysfunctionally stored information. The train is once more going down the tracks. Definition of Countertransference To deal with countertransferential reactions, we must first define the term. According to Kernberg (1985, pp. 50 52), the term countertransference can be classified in a classical manner or a totalistic one. Classically, countertransference is defined as the therapist s irrational reaction to the transference of the client. I define it so for the following reasons: (a) This more narrowly constructed definition allows me to be more precise about the phenomena I am describing, and (b) there are other issues involved in dealing with therapist irrational issues when it is not in response to a

Integrative Approaches to EMDR 177 transferential issue. I am aware that there are legitimate differences of opinion about what constitutes a countertransferential reaction. These are very subtle differences. It also may not be easy to tell whether the therapist s reaction is or is not related to the client s transference, but it is crucial to try to cull out the differences. By processing this reaction, in the moment, quickly and internally, the clinician could arrive at a decision as to whether his or her reaction is countertransferential, and, if it is, then a more accurate and empathic response could be given in the form of an interweave. It is very common that our journey into the client s private world has triggered something in the client toward us. It is also quite possible that what gets triggered in us may be a clue to a deeper issue the client is struggling with. RELATIONAL ASPECTS OF EMDR In each phase, relational issues are present. It is therefore all the more puzzling that elements of the therapeutic relationship have received so little attention. In fact, in Dr. Shapiro s 1995 textbook, Eye Movement Desensitization and Reprocessing, Basic Principles, Protocols and Procedures, mention of the even most basic characteristics of the therapeutic relationship are most noticeably absent. In attempting to integrate these aspects, I am keeping in concert with Stricker and Gold s (1996) definition of an assimilation model of integration in which the theoretical structureof EMDR is maintained and other approaches are added to it. There are specific characteristics of the relationship that can readily be agreed on. A client calls an EMDR therapist to make an appointment. This person is full of pain and expectation (both positive and negative). The relational aspects start here. The therapist listens to the voice and is affected, perhaps developing some beginning empathy or perhaps even being triggered (read, transference or countertransference) by what is said or by the tone in the voice. The client accepts a time to come in for the initial consultation. The client hears the words and tone of the therapist. The client is affected, perhaps with hope, perhaps with anxiety; perhaps he or she is now triggered by the process and content of the phone call. Now both therapist and client begin to have fantasies about what this meeting may bring. Now they meet; the client talks, and the therapist listens and asks questions. The relational field has begun to become a fluid interpersonal and intersubjective experience. These characteristics are givens in any form of treatment. There are many levels to these communications. There are many opportunities to create a working relationship, and many opportunities for misunderstanding. The Rogerian concepts of unconditional positive regard, congruence,

178 Dworkin and empathy have been hallmarks of necessary preconditions to healing. Central also to the discussion of the relationship is the process of projection. This process is present in the transferential/countertransferential matrices. Projection occurs when a distressing state of being is ascribed to another party, often times on the basis of old, painful interactions that have never been resolved. The person has a distressing or traumatic event or set of events that hurt. His or her wishes, hopes, and fears about receiving treatment are there from the beginning, and the therapist responds to these elements. When the client perceives the therapist as empathically caring, a working alliance and a positive transference develop. However, when the therapist misses an important element of communication, responds from a position of defensiveness or ignorance, or embodies aspects of old, unresolved memories, a negative transference develops. This explanation of differing types of transferential experiences is a too linear explanation of a nonlinear dynamical and chaotic system of interactions, embedding both positive and negative aspects. These interactions continue throughout treatment, in every moment of every session. There may be many times when the therapist may be triggered by the client s presentation, and vice versa. This may seem to be an overly simplistic beginning. Any first year social work student could present the aforementioned. The issue now becomes more complex. Let s say that during this set of interactions the client not only projects onto the therapist, but now, because of the enormity of the client s pain, the process of projective identification occurs, in which he or she begins to respond to his or her projections onto the therapist as though the therapist had the attributes projected on to him or her and was actually responsible for triggering the client s pain. Who is the client now really responding to? If triggered, it may be not only the therapist but also the person the therapist embodies. Now take this a step further. Let s suppose that the therapist may be triggered by the way the client is now presenting (the classical position of countertransference) and begins to respond in a reciprocal way, unaware that therapeutic attunement has now been disrupted. When this occurs, it may be said that a transformation occurs. This conceptualization comes from contemporary interpersonal theory. If the therapist is triggered, what old, painful memory or set of memories has been neurally stimulated in the therapist? If this becomes the case, then whom is the therapist relating to? It is possible that he or she may also really be relating to the mother, father, teacher, brother, or sister who has been stimulated in him or her because of old, unfinished painful interactions. What has the client said or done to elicit this response? Is the client aware that he or she has elicited this response? Does the client feel terrified, or gratified, or unaware? Many times even skilled and experienced therapists will review a session that did not go the way they imagined and experience discomfort for vague and undefined reasons. These processes

Integrative Approaches to EMDR 179 may start to occur as early as the client history taking phase in EMDR, in spite of or because of the care, nurturing, and concern that the clinician shows to the client. Then comes the client preparation phase, in which the explanation of EMDR is given. How does the clinician present this approach? How does the client receive it? EMDR represents an important shift in what has been the usual and customary way the public thinks of psychotherapy, whether it is psychodynamic, cognitive behavioral, hypnotherapeutic, or family therapy. There are many opportunities for anxiety and misunderstanding here. Careful attunement to how this information is received will be instrumental in assessing whether the client will become a willing partner or a wary or avoidant participant. The need of the EMDR therapist to take a client through a safe place experience during the preparation phase has equally important implications for maximizing cooperation. The purpose of safe place, a complex, eight-stage process, is to teach the client how to move from states of calm to states of negative arousal and then back to calm. The therapist asks the client to bring up an image of a place where he or she feels completely safe and comfortable. In itself, this request may have its dilemmas. When the client demonstrates this ability, the clinician then reflects the descriptions back to the client, using client language and soft, hypnotic tones. Then the clinician uses a form of bilateral stimulation (eye movements, audio tones, or alternate tapping) to enhance this feeling state. Then the client is asked to bring up an experience that is mildly distressing. When that is achieved, the client is instructed to shift back into his or her safe place. Although this experience is a functional diagnostic way for the client to demonstrate an ability to tolerate distress and to self-soothe, it can also be seen as strange and unusual. There needs to be careful attention by the clinician to observe subtle reactions that may indicate distress or confusion on the client s part. Next come the assessment and desensitization phases. The term processing in this article refers to the matrix of associations, conscious and unconscious, that the client experiences during a set of eye movements. Processing may be associated with other concepts, such as free association or mindfulness. A very complex, many-leveled relationship has been constructed. We are in a relational mode whether we remain quiet during processing (which is the suggested mode as long as the information is moving toward resolution by only the use of bilateral stimulation administered by the clinician) or whether intervention using the cognitive interweave is called for. The clinician is facilitating the brain s ability to resolve trauma in a relational mode. There are many unforeseen variations that may occur; clinicians have had the experience of using the standard protocol and interspersing nurturing words like good, or you re doing fine

180 Dworkin and finding something not quite right. They may sometimes discover that those were the exact same words the client s teacher/uncle/father/sister used when abusing the client. Conversely, the opportunity for making a good enough interweave can be used successfully, on the basis of the understanding of the client s history and what is occuring in the moment, transferentially, during the desensitization phase. Suppose it was traumatic for the client to disagree with his or her mother. Let s suppose the client is working on a memory of being emotionally abused by his or her mother during a disagreement over curfew. What would happen if, during a moment of processing, something from the therapist signalled disagreement? Furthermore, let s suppose that the therapist accurately picks this up and uses the cognitive interweave of safety to facilitate the brain s continued healing. Perhaps the therapist might intervene by saying in a questioning tone, And what would your experience be if you felt safe disagreeing with me? Perhaps a sparkle may come to the eyes of the client, indicating the possibility of the present being different from the past (thus linking a functional neural network to dysfunctional material). It can be argued that because the clinician has studied the subtler nuances of the relational field and knows the client s history, he or she is now empowered to use transferential material to fashion a productive cognitive interweave. Empathy To study these subtler nuances and use them productively, one needs to develop a set of preconditions that will facilitate the work. These preconditions can be found in the works of Carl Rogers (1980). Specifically, he pointed to three aspects of the therapeutic relationship that he considered to be crucial. They are unconditional positive regard, congruence, and empathy. The third, most crucial aspect is empathy. What exactly are the qualities of empathy? Rogers (1980) has stated that to be empathic with another human being requires entering the private perceptual world of the other ; becoming sensitive, moment to moment, to the changing felt meanings which flow through this other person. It means temporarily living in the other s life, without making judgments, and sensing the meanings which the client may only be dimly aware of (p. 142) My position is that empathic abilities are developed over time and that even in the most mature, well-trained clinician a caution must be given. Because of the nature of the intersubjective, an empathic stance is still a minefield fraught with difficulties. Rogers (1980) stated that to be with another in this way means laying aside not only your own views and values, but in some sense laying aside

Integrative Approaches to EMDR 181 yourself (p. 143). Here I take issue with him. I do not believe that can humanly be done. We take ourselves where we go, and to believe that we can lay ourselves aside is to me a fiction. This is where knowledge of transference and countertransference becomes crucial. When one enters into the world of the other, the potential for being triggered by the other becomes exponential. The Intersubjective This leads us to the study of the intersubjective, that seeks to comprehend psychological phenomenon not as products of isolated intrapsychic mechanisms, but as forming at the interface of reciprocally interacting worlds of experience (Stolorow & Atwood, 1996, pp. 181 182). This view interfaces with some of the aforementioned dilemmas of empathy. If the clinician enters into the client s world and the client enters the clinician s (knowingly or unknowingly), this interface is ripe with potential for both to be triggered. This view of the relationship is quite different than a traditional analytic perspective of the transference and countertransference phenomenon, primarily because the position of analytic neutrality is a myth. On the basis of field theory and psychoanalysis, Stolorow and Atwood, in their 1997 article, Deconstructing the Myth of the Neutral Analyst: An Alternative From Intersubjective Systems Theory, debunked the idea that a clinician can remain neutral. In their writings on empathy, they argued, it is rooted in the belief that places the emphasis on the role of emotional responsiveness in facilitating the development of a sense of self (p. 434). They disagreed with the idea that the clinician can remain objective to the client s subjectivity, especially in the face of the client s subjective response to the clinician. From the beginning, starting with the initial phone call, a multidimensional, nonlinear system of reciprocal mutual influence (Stolorow & Atwood, 1997, p. 431) develops and grows. Transference and countertransference are continually occurring and continually shifting in the fluid field of the intersubjective. From this point on, only negative transference is referred to in illuminating the connection between the intersubjective and the cognitive interweave. The reason for this limited view is because the cognitive interweave is used only when the processing becomes stuck, which is an indication only of the negative when it is interfaced with transferential reactions. To be clear, we are examining a specifically negative reaction toward the therapist that is based mostly on old painful memories that become triggered but not identified as such. A colleague stated that EMDR helped her to cycle in and out of transference and countertransference more quickly. This is a good point that needs one suggestion: that we add the word reaction after transference and counter-

182 Dworkin transference. Because this phenomenon is continually happening, it is not possible to ever completely cycle in and out. However, when there is a reaction (meaning when this phenomenon becomes prominent in the work) it becomes necessary to deal with it. The question now becomes how to deal with this phenomenon. I suggest that EMDR already has a superior answer embedded within the cognitive interweave. The Cognitive Interweave Versus Empathic Reflection and Analytic Interpretation This intervention moves the process further along by linking one neural network of the client s (which is more functional) with the dysfunctionally stored material. This does not make Rogers (1980) or psychoanalytic thinking wrong, it just appears that in the accelerated information processing model, the interweave may be more facilitating to healing. (This opinion is solely based on clinical observation. Research is needed to prove this theory). Rogers believed that the clinician needs to interpret and reflect the client s innermost emotional state for healing to proceed; psychoanalysis, in most schools of thought, believes that transference distortions need to be dealt with by interpretations for the work to proceed. Stolorow and Atwood (1997) had a different remedy, called empathic introspective inquiry. They stated that such an inquiry seeks to illuminate the principles unconsciously organizing the client s experience, the principles unconsciously organizing the clinician s experience, and the oscillating field between the two of them (p. 441). Contemporary interpersonal theory states that it is commonplace for the clinician and client to become involved in an intricate dance in which they become enmeshed in each other s reactions and must realize that this phenomenon is occurring and both must work their way out of it. Rather than viewing this dilemma as springing from developmental delays, contemporary interpersonal psychoanalysts view it as intrinsic to the interpersonal field, in which the self-system of both therapist and client are constructed to minimize the possibility for the experience of anxiety.in both the latter two instances the clinician is still unnecessarily involved in analyzing with his or her client the clinical phenomenon that is occurring and, in doing so, inhibiting the brain s own potential for healing. This final point is in agreement with Dr. Shapiro s (1995) position that it is the client s brain that does the healing and that interpretation of any kind may inhibit this process. Doing so has the potential to take the client out of his or her process as he or she listens to the wisdom of the clinician. The only time to become more active in EMDR is when the processing appears stuck and the clinician needs to enable the healing to proceed by linking a positive neural network with a dysfunctional one. However, I

Integrative Approaches to EMDR 183 must also agree with Stolorow and Atwood about the system of reciprocal mutual influence. This causes me to have a different slant on the ongoing phenomenon in the clinician/client dyad. The potential for becoming triggered both on the client s and the on clinician s side becomes exponential. Loosely speaking, this creates the ground for ego state work as well (Watkins & Watkins, 1997). When triggered, which part of ourselves is responding, and which part of the client are we responding to? We could draw this process out to the point that, very rightly so, there are more than two people in the room, or many parts of the two people operating simultaneously. Then, from there, if we continue to be unaware, the part of the client that we have responded to when triggered will be triggered again. That part or another part of the client may respond unaware, triggering still another part of ourselves, unaware. How many people (read, ego states ) do we have in the room now? This process could keep going to the point of futility. Even as little a verbal response as Go with that can have many dimensions to it. This is a common verbalization made by the EMDR clinician just prior to beginning another set of eye movements. Consider when it is said and how it is received. Has the clinician accurately perceived the client s communication? Does the client experience the clinician as cutting him or her off verbally? (We do sometimes.) What reactions does the client have to this seemingly innocuous verbalization? Even if we tell our client that we might do this (cut them off to go back quickly to the processing) to empower the processing, what might the client s reaction be, in the moment? The intersubjective field is fluid. That means that a client may be in agreement with us about the possibility of cutting him or her off to keep the processing going when we initially instruct him or her. However, what state of mind could the client be in when we actually do this? What was the clinician reacting to when he or she spoke those words? I suggest that if, in Roger s (1980) terms, we enter into the private life of our client, our responses must be subjective, as Stolorow and Atwood have described. Being subjective holds too much potential for responding in a reactive mode and precipitating a corresponding reactive mode in the client. What if we are triggered when we reply, Go with that, and out of awareness we said those words to cut off something painful in ourselves. Then I imagine that we would be triggering off something in our client. Here is where self-knowledge is extremely important. Rogers (1980) stated that the clinician must be well integrated to deal with the vicissitudes of the client s inner life. Even the well-integrated clinician may still be triggered. Now, though, the opportunity to deal with this triggering is enhanced. Paul Wachtel (1977), in his book Psychoanalysis and Behavioral Therapy, suggested that our countertransferential reaction could be used to inform us of what the client may be experiencing on more subtle levels. He stated that if one is

184 Dworkin continually questioning one s own motives and actions, and checking as well to see how what is surmised from within the session compares to what goes on outside, there is also much opportunity to correct and verify one s view and considerably enhance one s understanding of the patient and his (her) difficulties. (p. 141) The following is an elaborated clinical example from my practice: George, a 32-year-old dentist, is referred to me for communication problems with his fiancée. Because of adult children of alcoholics issues in his background, he has blocked off all the pain of his traumatic memories by becoming emotionally controlling, using strong intellectual defenses. He seems to be willing to engage in treatment so that he can have a better relationship but doubts that there are any real issues left to deal with; he believes that he has solved them. I, on the other hand, had rather controlling parents and felt smothered by them. I reacted with anger and acted out during my adolescence. Because I ve had plenty of therapy, I know that I m beyond those problems. However, when George presents himself and his issues, I get triggered; I am not initially aware of this. When I suggest EMDR to George he gets triggered, but he is not aware of this. We go through the first two phases and reach the phases of assessment and desensitization. He chooses what seems to be a painful memory; we work on it. The next session, he comes in and says in a faltering way, with something getting stuck in his throat, I ve got to be honest with you, I didn t get much out of the last session. Maybe it was a poor choice of memories, or maybe things are no longer bothering me. I realized that the phrase I ve got to be honest, said with these nonverbal cues, was loaded with multiple transferential meanings. Now, if this were an analytic session, I would self-reflect and inquire into what might be getting stirred up in him from how I might be reacting to him. We would then go through a detailed inquiry, in which I may or may not share some of what I experienced but would certainly be introspective. Now, Stolorow and Atwood or Wachtel (before he was EMDR trained) wouldn t be suggesting EMDR (unless they had their own awakenings), but I use the example this way to illustrate how this psychological field may operate. What I did in my EMDR session with George was to reflect silently on what might have transpired between us and reflect on my participation, which he might have been reacting to, but instead of the detailed inquiry, I thought that we may have been stuck around the issue of control, he needing to block his feelings, and I needing to push my (EMDR) agenda. I wondered aloud about a slight alteration of the protocol, and I thought to myself about using the cognitive interweave of safety in a questioning way. I chose safety because I believed that the issue of control was a defense against unconsciously felt danger. I asked him if it would be OK with him to experiment with being

Integrative Approaches to EMDR 185 completely honest with me while feeling safe and believing that no criticism would come to him. He thought he could experiment with that, and we did a set of bilateral stimulation. He began laughing heartily. His next set of associations had to do with how he needed to be dishonest with his father whenever he felt pushed into a corner. I then said, Go with that, and out came many painful recollections and tears, relating to the pain he had been defending against. DISCUSSION Paradigm shifts create anxiety and opportunity. The anxiety may be created because of the discomfort felt by those who believe that their ways of doing treatment may be eclipsed or thrown out. There has been much discussion about the methodology of EMDR; some of it has been respectfully couched, whereas others have violated their integrity, denigrating the originator and practioners of the model. Dr. Rosen and colleagues (1999) did a disservice to the rational advancement of new ideas when, in the publication Skeptic, they compared EMDR to Mesmerism, showing a picture of a human body with the head of an ass (p. 69) moving its fingers across the eyes of a woman (p. 67). Preliminary neuroimaging studies show changes in cerebral blood flow, which seem to indicate that EMDR has a positive effect on the brain s ability to process old information in new ways. In a recent study, using single photon emission computerized tomography, Levin et al. (1999) performed scans to determine the mediating neuroanatomy of traumatic emotions and the effects of three EMDR treatment sessions on the brain. Scans were performed prior to EMDR and after treatment. The results showed the following: after three EMDR treatment sessions, the anterior cingulate gyrus evidenced increased activation, as did the left prefrontal cortex. These areas, the anterior cingulate and the orbital frontal cortex, may help in modulating the fight/flight reflexes. The activation of the prefrontal cortex may indicate the assignment of meaning to the emotions associated with traumatic via the elaboration of cognitive strategies (Levin et al., 1999, p. 168). Further research is now occurring among neurophysiological researchers as to which brain structures are affected and in what ways. Future research will clarify these issues more precisely. We can learn from those who came before us and use what is useful, discarding what is not. In this article I have endeavored to identify useful elements of Rogerian empathy without buying into the notions that (a) we can set ourselves aside and (b) we need to reflect our empathic interpretation of the client s feeling states back to him or her. I have also identified elements from psychoanalysis that continue to stand the test of time;

186 Dworkin namely that (a) in therapeutic relationship there are elements that are not obvious to our consciousness alone, and (b) by increasing our awareness of the fluid and ever changing nature of the intersubjective, we may be able to craft cognitive interweaves to more effectively promote healing from trauma. In identifying these elements, I have not bought into the notions of having to explore the transference or make interpretations about it. The cognitive interweave, a standard part of EMDR, appears to yield superior results because it keeps the client in his or her process rather than having to be taken into his or her head to listen to the wisdom of the clinician. However, the cognitive interweave is woven into the fabric of the therapeutic relationship. Integrating various and useful parts of differing therapies appears to be the wisest course of action in moving the progress of psychotherapy forward. This position appears to be in sync with Stricker and Gold s (1996) assimilative model of psychotherapy integration in that a single theoretical structure (EMDR) is maintained, but techniques from several other approaches are incorporated within that structure (p. 51). These issues are simply jumping-off places for others, when stimulated, to comment and critique and do research, so that we may continue to approximate more effective methods, which will probably be combinations of many threads from many traditions. I have developed a transference/ coutertransference questionnaire, which is in the process of being field tested presently. I welcome any constructive comments from those who use it. I also welcome the same from those who read this article and have differing opinions, stated in respectful tones. REFERENCES Carlson, J. G., Chemtob, C. M., Rusnak, K., Hedlund, N. L., & Muraoka, M. Y. (1998). Eye movement desensitization and reprocessing for combat-related posttraumatic stress disorder. Journal of Traumatic Stress, 11, 3 24. Chambless, D. L., Baker, M. J., Baucom, D. H., Beutier, L. E., Calhoun, K. S., Crits- Christoph, P., et al. (1998). Update on empirically validated therapies. Clinical Psychologist, 51, 3 16. Devilly, G. J., & Spence, S. H. (1999). The relative efficacy and treatment distress of EMDR and a cognitive-behavioral trauma treatment protocol in the amelioration of posttraumatic stress disorder. Journal of Anxiety Disorders, 13, 131 157. Devilly, G. J., Spence, S. H., & Rapee, R. M. (1998). Statistical and reliable change with eye movement desensitization and reprocessing: Treating a trauma within a veteran population. Behavior Therapy, 29, 435 455. Foa, E. B., Keane, T., & Friedman, M. (Eds.). (2000). ISTSS guidelines for PTSD. New York: Guilford Press. Foa, E. B., & Meadows, E. A. (1997). Psychological treatments for posttraumatic stress disorder: A critical review. Annual Review of Psychology, 48, 449 480. Jenson, J. A. (1994). An investigation of eye movement desensitization and reprocessing (EMD/R) as a treatment for posttraumatic stress disorder (PTSD) symptoms of Vietnam combat veterans. Behavior Therapy, 23, 311 325. Kernberg, O. (1985). Borderline conditions and pathological narcissism. New York: Aronson.

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