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EMDR & the Relational Imperative 2005 RT4117 half title page 7/20/05 3:50 PM Page 1 EMDR AND THE RELATIONAL IMPERATIVE RT4117_Prelims.fm Page ii Monday, July 18, 2005 12:41 PM RT4117 title page 7/21/05 8:44 AM Page 1 EMDR AND THE RELATIONAL IMPERATIVE The Therapeutic Relationship in EMDR Treatment Mark Dworkin Foreword by Francine Shapiro New York London RT4117_Discl.fm Page 1 Monday, August 1, 2005 12:56 PM Published in 2005 by Published in Great Britain by Routledge Routledge Taylor & Francis Group Taylor & Francis Group 270 Madison Avenue 2 Park Square New York, NY 10016 Milton Park, Abingdon Oxon OX14 4RN © 2005 by Taylor & Francis Group, LLC Routledge is an imprint of Taylor & Francis Group Printed in the United States of America on acid-free paper 10987654321 International Standard Book Number-10: 0-415-95028-7 (Hardcover) International Standard Book Number-13: 978-0-415-95028-2 (Hardcover) Library of Congress Card Number 2005004356 No part of this book may be reprinted, reproduced, transmitted, or utilized in any form by any electronic, mechanical, or other means, now known or hereafter invented, including photocopying, microfilming, and recording, or in any information storage or retrieval system, without written permission from the publishers. Trademark Notice: Product or corporate names may be trademarks or registered trademarks, and are used only for identification and explanation without intent to infringe. Library of Congress Cataloging-in-Publication Data Dworkin, Mark, 1950- EMDR and the relational imperative : the therapeutic relationship in EMDR treatment / Mark Dworkin. p. cm. Includes bibliographical references and index. ISBN 0-415-95028-7 (hardbound) 1. Eye movement desensitization and reprocessing. 2. Psychotherapist and patient. 3. Psychic trauma--Treatment. 4. Post-traumatic stress disorder--Treatment. I. Title. RC489.E98D94 2005 616.85'210651--dc22 2005004356 Visit the Taylor & Francis Web site at http://www.taylorandfrancis.com Taylor & Francis Group and the Routledge Web site at is the Academic Division of T&F Informa plc. http://www.routledge-ny.com To the loving memory of my mother Annette Dworkin for teaching me the values of caring for my fellow humans; and To the loving memory of my father Harry Dworkin for teaching me to live as a man in this world. The carpenter has a hammer, the surgeon has a scalpel, the clini- cian has the self. The clinician’s professional experience, theoreti- cal knowledge, clinical skills, and personal history will shape the therapeutic self, and, in turn, affect the process of therapy. —Hayes and Gelso (2001) Contents Foreword ix Preface xv Acknowledgments xxi Chapter 1 The Relational Imperative in EMDR 1 Chapter 2 The Therapeutic Relationship and Its Underlying Neurobiology 13 Chapter 3 Using EMDR Relationally in Daily Clinical Practice 27 Chapter 4 Phase 1: Client History Taking and Treatment Planning (Trauma Case Conceptualization) 47 Chapter 5 Phase 2: Client Preparation (Testing Affect Tolerance and Body Awareness) 65 Chapter 6 Phase 3: Assessment (Trauma Activation Sequence) 83 Chapter 7 Phase 4: Desensitization (Active Trauma Processing) 105 Chapter 8 Countertransference, Transference and the Intersubjective 125 Chapter 9 The Relational Interweave and Other Active Therapeutic Strategies 165 vii viii • Contents Chapter 10 Phase 5 Through Phase 8: Installation (Linking to the Adaptive Perspective), the Body Scan (Intensive Body Awareness), Closure (Debriefing), and Reevaluation 191 Appendix A Trauma, PTSD, and Complex PTSD 215 Appendix B The EMDR International Association, and the Definition of EMDR 221 Appendix C Myths and Realities About EMDR 227 Appendix D EMDR Clinical Applications for Diverse Clinical Populations. © EMDR Institute, Inc. 233 Appendix E Confusion Regarding Research on EMDR 237 Appendix F Trauma Case Conceptualization Questionnaire 239 Appendix G Clinician Self-Awareness Questionnaire 247 Appendix H International Treatment Guidelines and EMDR Research 253 Appendix I EMDR Clinician Resources: The Humanitarian Assistance Program 267 Glossary 271 References 275 Notes 285 Index 287c Foreword Too many books are written from an “either/or” position. A major strength of this work is that the author is a sensitive, intelligent clinician who is an integrationist in the best sense of the word. Trained in psycho- analysis, gestalt, group, Ericksonian, family, and cognitive–behavioral therapies, Mr. Dworkin has incorporated EMDR into his sense of what is essential for effective psychotherapy. His insights into the importance of the therapeutic relationship are enhanced by 30 years of successful clinical practice with affiliations as diverse as the Mount Sinai School of Medicine and the Bronx VA Medical Center. In the 14 years since he learned EMDR, he has been able to answer for himself the following questions: “How important are empirically supported therapeutic procedures?” and “How important is the relationship?” The answers, we both agree, are that both are crucial. In short, neither can function to the best benefit of the client without the other. In this text, Dworkin draws on his extensive clinical experience, the wisdom gleaned from the burgeoning field of neurobiology, and his understanding of the adaptive information processing model (Shapiro, 2001, 2002), which guides EMDR, to provide clinicians practicing any form of psychotherapy with a more thorough appreciation of the pro- cesses of clinical change and the dynamics of effective therapeutic relation- ships. He underscores and makes practical that which has been shown in extensive research: The importance of the therapeutic relationship cannot be dismissed from the realm of clinical practice (Norcross, 2002; Caston- guay & Beutler, in press). Why indeed would one “separate the dancer from the dance” (Shapiro, 1994)? In addition, Dworkin illustrates how a thorough understanding and application of EMDR methodology is an important factor in substantial therapeutic change. ix x • Foreword Clearly, psychotherapy should, whenever possible, be guided by solid research. Consequently, both the American Psychiatric Association (2004) and the Department of Veterans Affairs/Department of Defense (2004) practice guidelines now place EMDR in the highest category of effective- ness for the treatment of PTSD. As indicated in an extensive meta-analysis of the EMDR research literature (Maxfield & Hyer, 2002), fidelity of treat- ment predicts magnitude of treatment effects. The robust contribution of the therapeutic relationship to treatment outcome is likewise well estab- lished (Norcross, 2002; Castonguay & Beutler, in press). Moreover, an APA division of psychotherapy task force reviewed the extant research base and identified four relational elements that are demonstrably effective — the alliance, cohesion in group therapy, empathy, and goal consensus — and seven therapist relational elements that are probably effective — positive regard, congruence, feedback, repairing alliance ruptures, self-disclosure, management of countertransference, and quality (but not quantity) of relational interpretations (Norcross, Beutler, & Levant, 2005). Clearly, a thorough understanding and application of EMDR methodology, along with a sensitive and individualized use of the therapeutic relationship, will make for the best EMDR treatment and produce the greatest therapeutic effects. Indeed, it should seem self-evident that any therapeutic effect must be the result of an interaction of client, clinician, and method. In this volume, Dworkin demonstrates the practical application of these tenets. An important contribution of this book is its emphasis on EMDR as a client-centered therapy that attends not only to symptom reduction but also to personal growth. Throughout the volume, Dworkin emphasizes the therapist–client relationship as an integral part of the healing dynamic. The importance of this aspect of psychotherapy cannot be overstated, given what I consider to be the inappropriate dismissal by some (see Nor- cross et al., 2005) of this relationship as mere “noise” akin to the placebo affect and the equally inappropriate dismissal of methods as somehow unimportant as long as the therapist is loving and well intentioned. For most practicing clinicians daily presented with the intense suffering of those people coming to them for aid, neither of these positions is tenable. The human relationship is a sacred bond that joins the therapist and sufferer in a journey that may take them to the pits of Hell and back. The therapist may be the only one whom the patient trusts in his or her life. And it is the therapist’s honest feedback, integrity, and presence as both model and mirror on which the patient must rely. When this foundation has been laid, then the use of empirically supported treatments can assist the patient to attain the most robust levels of personal health. As a field, we have been remiss in failing to honor this important foundation and Foreword • xi equally lacking in our development of measures that chart the attainment of mental health, as opposed to the simple reduction of overt suffering. One hopes that a common treatment goal would be one of comprehensive personal growth, such as can best be attained by viewing the entire clinical picture. This text offers detailed case examples and transcripts to lead the reader through both complete and more circumscribed treatments, attained by the practical application of the principles of relational psychol- ogy, as well as by creative uses of EMDR. Clinicians at all levels of experi- ence will find something to
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