Integrating Relational Psychoanalysis and EMDR

Embodied Experience and Clinical Practice

Hemda Arad

• Publisher: Routledge
• Year: 2017
• eBook ISBN: 9781351660549
• Topic: Psychology
• Subtopic: Mental Health in Psychology
• Index: Psychology

Integrating Relational Psychoanalysis and EMDR: Embodied Experience and Clinical Practice provides contemporary theoretical and clinical links between Relational Psychoanalysis, attachment theory, neuroscience, and Eye Movement Desensitization and Reprocessing, all of which bring both the patient's and analyst's embodied experience into the forefront of clinical thinking and practice. The author grounds an in-depth view on the ways psychoanalysis and EMDR can be effectively integrated to complement each other through a presentation of fundamental concepts and an abundance of insightful and moving clinical vignettes.

Hemda Arad outlines the theoretical and clinical concepts that allow the integration of Relational Psychoanalysis with EMDR's unique contributions, specifically appreciating the neurological and embodied experience in an individual's development in relation to the classic talking cure's approach to dealing with "big T" trauma and with "small t" everyday attachment-related trauma. Arad describes a view of a modified EMDR approach capable of reaching many patients, beyond the trauma work for which it originally became known, in order to lend its more embodied approach to the advancement of the relational endeavor. Vivid clinical illustrations, chosen to elucidate theoretical concepts, make the complex theoretical ideas more accessible. The clinical portions illustrate a range of ways that EMDR and relational work, which may at first seem incompatible, may be integrated to help therapists navigate the two methods.

Integrating Relational Psychoanalysis and EMDR: Embodied Experience and Clinical Practice will appeal to psychoanalysts, psychoanalytic psychotherapists and psychodynamic therapists who wish to learn about the relational tradition in theory and practice or are seeking a way to integrate their work with other versatile approaches such as EMDR, as well as advanced students studying across these areas and EMDR clinicians who would like to broaden the scope of their skills.

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Part 1

Literature and theory

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Chapter 1

EMDR—History, method, protocol, and modifications for integration with relational psychoanalysis

ךכ לכ היה רצ

חרכומ זא יתייה

ףועלו םייפנכ שורפל

ובש םוקמ לא

ובנ רה ומכ ילוא

ףוקש םיאור קוחר םיאור

םימ לע לותש ץעכ םדא ןב

שקבמ שרוש

םיימשה לומ הנסכ םדא ןב

שא תרעוב וב

טילבטור בקעי —

So sad and narrow it was

I had to

spread my wings and fly

to a place perhaps like

Mount Nebo

from which to see far, to see transparently

A human, like a sapling planted over water,

seeks a root

A human, like the burning bush against the skies,

within a fire burns

— Yaakov Rotblit

At times, patients find themselves in dire straits. In wanting to help, we, their companions on the path of seeing more clearly, look and listen through what they tell us, while trying all the tools in our toolbox. At other times, we may feel as if our patients’ pain and sense of urgency to reduce their pain is mirrored in our mired responses to their wish. We may feel frustrated and helpless. Remembering peoples’ basic needs and acquiring a bird’s-eye perspective may then help us seek out and look into unexpected places for help, while holding in mind the potential of bridging over the abyss even while standing there with them.

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This chapter describes the history, theoretical underpinning, and pragmatic aspects of Eye Movement Desensitization and Reprocessing (EMDR). Beyond the history of this technique and an overview of the stages and conditions of its use described below, this chapter makes the case that EMDR and psychodynamic psychotherapy are productively integratable. In presenting this option, I hope to expand the understanding of the potential uses of EMDR’s highly structured protocol, one that was originally established to treat trauma cases. I describe the origin of EMDR and some of the current major variations in the use of this therapeutic method. I also delineate here the spectrum of current trends in the thought and practice of EMDR, and emphasize views that appreciate psychodynamics as a valuable part of a whole approach to treatment.

In addition to describing the underlying functions of the brain that are related to the successful introduction of EMDR, and a discussion of how it may be used to intervene in the service of engaging blocked emotions, I present some ideas about additional reasons supporting EMDR’s potential effectiveness, beyond what we know from research. I suggest, based on the literature of infant and adult attachment, that EMDR might provide interactions that are analogous to those essential in mother−infant interactions, as well as to those between intimate partners or partners in therapy, in establishing patterns of interrelatedness, including some patterns that are anxiety provoking and others more organizing. I argue that EMDR may offer the missing link between the emergence of bodily connection in the session, and the use of organizing yet desire-restricting speech.

The journey

Moving into the clinical realm, some decades ago I had already begun to observe the impact of embodiment on psychic life. Until then, talk therapy, especially the psychodynamic, psychoanalytic approach, seemed to demand going the extra distance to listen out fully, taking as long as needed to observe shifts in moods and states of mind. The quiet space created was not unlike the mother−infant environment in which attunement is a key factor in the ebb and flow of the baby’s emotional regulation. However, since adults walk into our offices with complex attachment experiences, very frequently it happens that reaching a point in which attunement is attained can take a relatively long time through talk therapy alone. In contrast, I at first observed the effectiveness of the less verbal and more embodied method of psychodrama, which carries the patient more rapidly into her affected experience. In psychodrama, attention is given to breathing patterns, to sounds, to body contours, to dissociation, to new discoveries that emerge wordlessly along with a narrative to create an embodied experience that closely matches known mimetic repetitive word experiences, yet deconstructs and reconstructs their interpretation. Observing this allowed me to consider how closely these new versions still fit the old paradigmatic existence.

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Further, in the consulting room, I noticed that when a person feels “stuck” in a space without emotion, the option of promoting the patient’s own movement, either through a simple motion that had already been initiated, such as hand clenching, or gross motor movement, as in walking with or without talking, can move the person toward feeling. Invariably, emotions emerge in the patient.¹ It is hard to dissociate in motion. The connection of the feet with a ground surface, the movement away from thought and control, and even breathing bring the patient back to life. Here, encouraging the patient to imagine a situation that preoccupies their mind serves as a mitigating factor. From a psychodynamic perspective, we know that what is close to the surface is not necessarily a defining founding experience, yet it may serve as a screen memory that represents a dynamic form that is experienced over and over again.

In following these movements, I was fascinated by the way, within a short period of time, hours or days, a person could move from a frozen emotion to a full expression of it that was rich in affective detail. I will not discuss here the merits and limitations of psychodrama, except to say that although all efforts are made to integrate the newly founded emotional material and anchor it within a reality check and mentalization of available attachment objects both within and without the group, much was left to be desired in the form of integration of the material in the following days and weeks of affective exposure. It felt to me that the ideal situation would be an affective exposure that was closely followed by a sustainable psychodynamic, indeed psychoanalytic integration, grounded again in the transference-countertransference matrix in which exploration could blossom and affect regulation be enhanced, so as to prevent the reoccurrence of the original trauma of overwhelming exposure with no foreseeable containment.

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In a less dramatic form, the EMDR process targets early remembered experiences that are similar to the new situation at hand (F. Shapiro, 2001). With the embodiment of current images and experiences through EMDR, the mind tracks earlier experiences that feel the same, or that hold the bodily memory of a traumatic experience. Again, attention is given to minimal cues in breathing patterns, eye activity, body posture, and changes in general bodily representation of affective shifts. Here they are contained by the EMDR practitioner with the smallest sound or comment or perhaps with witnessing alone during the bilateral stimulation (BLS; also known as dual attention stimulus [DAS]) segments of the EMDR protocol. At an alternate time, the observation is then shared with the patient when the BLS sequence is at a break, in order to elicit a direction to follow. The patient’s affective responses can vary from minimal to expressive, and the intervention consists in following the change in the emotional or narrative path, assuming that neural pathways are opening up as the signifier² neurologically recognizes the signified.

EMDR operates on the premise that traumatic events often cause a person to develop harmful beliefs and behaviors, and that EMDR processing opens patients to fresh understanding and insights that allow them to cast off these destructive tendencies (Parnell, 1997; F. Shapiro, 2001; R. Shapiro, 2005, 2009). Parnell (1997) has asserted that EMDR can be successful in relief of childhood trauma symptoms ranging from “physical and/or sexual abuse, grief and loss, medical procedure trauma, accidents, or witnessing violence” in work with patients where other forms of therapy have yielded limited results (p. 113). According to Parnell, EMDR processing of trauma takes the patient to a deeper level. But what is this deeper level? Both EMDR and psychodrama engage the mental sphere through their relatively rapid access to emotions through embodied experience. In psychodrama, patients are both setting and observing the scene, as it is played out by others, who take the roles of the original perpetrator and the patient’s self as they are currently stored in the patient’s memory, increasing the chance of approaching the original neural pathways and activating the shared circuitry by proxy. In both EMDR and psychodrama, what follows is the processing of elements of traumatic events and the resultant anxieties, in a process in which a repaired scenario is played out. In EMDR, the emotion is played out with a vision of a desired situation and reaction. In psychodrama, it is the played-out situation that triggers the mind to seek alternatives to an unwanted situation, whether traumatic or developmental.

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Self-defense classes for women frequently use the playing out of a dreaded scenario, often with a male volunteer who takes the part of an attacker to help trigger anxieties based both on self-talk and in working through these anxieties with movement and action. The idea in psychodrama, as in EMDR, is to activate the debilitating anxiety and to allow the mind to consider alternatives that the mind and body together come to find can be activated in a stressful situation. As Sapolsky (2004) pointed out, most of our anxieties have nothing to do with actual fear of survival. However, a situation of actual fear in our past can trigger repeated anxiety that is debilitating and that continues to have severe consequences on our well-being. Stress can enhance emotional memories that are stored in the amygdala (Sapolsky, 2004). What EMDR does is to activate the sympathetic nervous system slightly, so that symptoms of anxiety are activated with some moderation, because the patient knows that they are in a relatively safe environment in which unsafe images can be played out and processed to a level of desensitization at which the sympathetic nervous system is no longer triggered (F. Shapiro, 2001). This process is then mediated as new factors are introduced, as for example in the integration of imagined positive cognition into the original dreaded situation. With the original situation in mind, its playing out, with a newly projected outcome, typically activates the sympathetic nervous system as the parasympathetic nervous system recedes to the background. It is important to mention that the completion of this action will be activated with a calming element only at the point when the entire pathway is cleared in which the parasympathetic nervous system has come to the fore and the sympathetic nervous system has receded into the background.

For example, if the processed material had to do with a recent event, as if a patient is terrified of waiting for her mammogram results because her sister just died of breast cancer, then clearing the reaction to her association with her too being at risk of being diagnosed, treated, and dying of cancer may be in order. In this example, another pathway of anxiety may be activated, that of loss and the fear of being completely alone and without protection as family members pass from this earth, leaving her alive but having to fend for herself. It is important to recognize the full complexity of the anxiety, not only the presenting anxiety. EMDR practitioners are trained to search for what is called the target, the source of the original anxiety that triggers all the others on this path (F. Shapiro, 2001). The process must be flexible, as what may seem to be a bedrock target may be the tip of an anxiety iceberg.

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What I realized with psychodrama first, and then with EMDR, was that even with effective integration of the processed trauma or anxiety-provoking situation, there was much residue to be processed in the days that followed. This is a prime time during which the mind happens upon new realizations regarding other aspects of life. Although these could be processed through another psychodrama or EMDR session, there are problems which, at that stage of the work, are better addressed with an analytic process. For example, psychodrama sessions are usually done in groups, and in intervals where there may be months between sessions, which does not allow for immediate processing. Similarly, EMDR discourages expanded discussion into the presenting issue. Yet both are activating the nervous system, mind, and amygdala through motion, and once these pathways are open psychoanalysis can allow analytic deepening while the attachment element hovers over the deliberation.

Another approach I have used over the years with both adult and child patients is sand play. Observing children as they occupy their hands and engage in quiet play in a sand tray in the presence of a therapist can often bring out similar reactions.

I have often thought that mixing therapy with play in a fashion similar to the way both D. W. Winnicott (1971) and Margaret Mead (2001) describe it, can bring about a real-world experience that defies cerebral rationalization, breaking earlier barriers established to block traumatic awareness in the service of an internal sense of psychological cohesion. It is important to emphasize the centrality of the perceived benevolence in this process. Play can occur only in situations of relative psychological safety when there is an observer or inner activation of observer representation, as when the mother is in close proximity, or the child feels protected when sensing that the therapist is keeping an eye out and has given the patient permission to play or play out (Winnicott, 1971). Similarly, EMDR attempts to explain the reason why a motion or emotion like those triggered by BLS can evoke a psychodynamic response in the mind and body, and how this embodiment can open the door to modification in the response to the traumatic experience. In theorizing about the way EMDR works, one can look back on the psycho-dramatic movement that lies at the base of the actual dramatization of a scenario and see how it primes the patient emotionally. EMDR uses a similar but less dramatic system of movement in which an external motion is applied to the patient to occupy the thinking mind and release the feeling mind-body, essentially allowing the patient to bypass the apparatus set in place to help avoid frightening or sad thoughts.

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In the everyday to and fro, we find ourselves in situations that spontaneously call upon procedural knowledge to help us in potentially stressful situations. Consider an example from outside the consulting room that is mildly stressful.

When playing table tennis competitively, confronted by a capable opponent, the space to think strategically disappears into a motion that feels slowed down tremendously; the racket becomes an extension of my hand, the world disappears, and all I can hear is the syncopated skip of the ball and my own breathing. No thinking interferes, yet I am more alive than in any other engaged conversation. I become my breathing, my movement, my thoughtless aliveness. How did that happen? More importantly, how might I recreate this synchronized, satisfying sensation in other realms of my life?

Having traditional psychodynamic and cognitive training, and although grateful for words in exploring and analyzing states of mind, sentiments, and behaviors, I can also feel the limitation of words. I have noticed that more embodied approaches, such as psychodrama and sand play, offer quick ways to help a reserved patient get to emotions, a movement that then allows some verbal processing. However, what I found was missing for me was the continued observation and processing of all that unfolded from the emotional experience. Early on, I felt that combining a psycho-dramatic approach to embodiment should be interfaced with a psychoanalytic approach in which intense emotions can be transferred to the analyst and explored via verbal exploration of visceral and emotional experiences. But at that time, about two decades ago, mixing any method with the psychoanalytical could often be regarded as only an externalization of the transference experience, rather than a way of opening up emotional viability in order for the transference to flourish in the analytic realm.

We know that without affective engagement there is no transformative and lasting therapeut...

Table of contents

• Cover Page
• Praise
• Integrating Relational Psychoanalysis and Emdr
• Relational Perspectives Book Series
• Title
• Copyright
• Dedication
• Contents
• Preface
• Acknowledgments
• Permissions
• Introduction
• Part I Literature and Theory
• Part II Case Studies Using Both Relational Psychoanalysis and Emdr
• Index