As much as I’ve loved Eye Movement Desensitization and Reprocessing (EMDR) therapy and revolved my clinical practice around it, it has always felt like it has had one major short-coming; it has primarily been practiced as an individual therapy (Capps, 2006; Linder, 2020; Linder et al., 2021; Linder et al., 2022; Marich, 2011; Parnell, 2010; Shapiro, 2017). Although EMDR group and couple protocols have taken off in recent years, and Shapiro and colleagues published the edited booked about using EMDR relationally in 2007, EMDR is still largely practiced and taught by most EMDR trainers, consultants, and therapists in individual formats, i.e., only therapist and client.
As a trained systemic therapist who views relationships as the most robust predictor of well-being, longevity, and health (Johnson, 2019; Herman, 2015; Perry, 2009), I wondered if individual EMDR therapy, as it was currently practiced, taught, and researched for the most part, may be unnecessarily limiting its potential for change. I suspected that EMDR could benefit from including more of the client’s relational system, as only therapist and client isolated in the therapy room felt confining to me. Because humans are social and bonding creatures, the more relational the healing process, the better, right? Many elements of trauma are rooted in disconnection on a neurobiological and polyvagal level (Porges, 2021). A good partner can often help regulate a traumatized person significantly better than the therapist from the strength of secure attachment developed from years of safety and trust, instead of a therapist who’s generally helping for only days, weeks, or months.
However, there is a reason why EMDR is primarily an individual therapy; trauma work is fundamentally unpredictable (Marich, 2011), and EMDR is complicated enough in the context of individual therapy, without including the client’s relational system present in the therapy (Marich, 2011; Parnell, 2010, Shapiro, 2018). Because it is always possible that EMDR is harmful for clients (Marich, 2011), my conviction was that making EMDR more relational and adaptable to the context of couple therapy is particularly complex.
In my earlier days learning therapy, I felt similarly attracted to developing competence in emotionally focused therapy (EFT) as my relational model. The reason people pursue therapy is almost always rooted in disruptions in attachment and the quality of one’s relationships. The quality of relationships is the quality of our lives. EFT and EMDR can both be considered treatments for attachment trauma (Johnson, 2002; Shapiro, 2017).
My dissertation topic, the targeted investigation of EMDR and EFT trained, licensed clinicians’ perspectives is vital because it could offer a nuanced window into how EMDR and EFT can be integrated in couple therapy. My study, completed in 2019-2020, was conducted using Thematic Analysis (TA) because of its focus on commonalities across participants’ responses and its inherent flexibility and compatibility with both induction and deduction (Braun & Clarke, 2006). These advantages enabled me to pose specific questions related to integrating both therapies, while simultaneously allowing the data from participant interviews to largely influence the study.
Even after my study, integrating EFT and EMDR in couple therapy is poorly understood and limited by case examples and lack of research (with only two unpublished dissertations before my own). Also, because the current literature has been primarily case examples, it has insufficiently attended to the conceptual similarities and discrepancies in the theoretical bases of both EMDR and EFT.
In the spirit of transparency, a central difficultly I grappled with is my bias for relational therapy. We unavoidably exist in relationship from our first to our last breath. I have had a strong conviction that combining EMDR and EFT may not only be useful, but perhaps necessary in certain clinical situations to promote the desired outcome—transformative and second order change for clients and their relational systems. As a clinician, I can believe this, but as a researcher, I needed to distance myself from this conviction. This was additionally challenging because I have been programmed in MFT graduate programs (my PsyD is in Couple and Family Therapy) to think relationally, focus on what is happening between people, and privilege relational paradigms. During my dissertation, my chair, Alba Nino, and I had worked closely together to ensure that my pro-relational bias did not compromise the integrity of the study. For example, in the study, one participant stated, “if I’m doing an EMDR sequence and we’re working in a memory with their six-year-old self, and I ask them to imagine their adult self is in the room, it’s actually an enactment with two parts of self. Then perhaps I want you to imagine being a six-year-old; can you imagine what it might’ve been like if that adult was there to just hold her and just to see her?”
Other EMDR and trauma-informed therapists and researchers are also focusing more on attachment. We know that one of the most important factors determining whether two people develop PTSD from the same exact traumatic event is social support (Herman, 2015; Perry, 2009). The essence of trauma is often a sense of aloneness and isolation, or betrayal by important attachment figures. EMDRIA, the EMDR Institute, and the Humanitarian Assistance Program (HAP) realized this recently and thus added the fourth cognition category emphasizing connection and attachment. For the same reason, aside from the Flash Technique, Phil Manfield (2010) is known for bringing “dyadic resourcing” to the EMDR community, supplying the client with a potent relational resource to help heal their trauma.
One of the co-founders of EMDR therapy, Deany Laliotis, had realized, too, that the future of EMDR may be more individualized based on relational factors. With EMDR founder Francine Shapiro, Laliotis co-wrote previous versions of the widely-used EMDRIA-approved EMDR training manual. In a 2018 video from her website, Laliotis outlined how she envisions the future of EMDR will unfold. She posited that the field of EMDR is gradually moving from the standard protocol that emphasizes method and procedure in the context of individual psychotherapy into the realm of what she calls “integrated relational therapy.” Laliotis also asserted that this paradigm shift starts with treating the individual as infinitely unique, instead of as a mere object of a protocol, as clients’ processes rarely fit the linear map. For example, she suggests that EMDR therapists are and will be “going beyond” a “quick fix,” which refers to the general resolution of a memory and is the contemporary aim of EMDR therapy.
Going beyond a “quick fix,” Laliotis (2018) stated, consists of seeing clients and their struggles uniquely, with fresh eyes, as part of a wider, intricate tapestry of relationships, intersectionality, and experiences in an ever-changing and increasingly complex world. “Fixing” individual symptomology, the original objective of EMDR therapy, is only part of the client (and their social network’s) story, she clarified. “Staying out of the way,” as EMDR clinicians are traditionally trained to do in EMDRIA-approved trainings, may not be enough because, as therapists, we are always inevitably part of the process. Here, Laliotis was stressing how important clients’ relationships with EMDR therapists are; after all, we as EMDR therapists are clients’ surrogate attachment figures.
Wesselmann and Potter (2009) modified the standard EMDR protocol, removing the Validity of Cognition scale, for clients with attachment trauma because it can impede activating the memory network and thus processing the trauma by keeping clients in their minds instead of their bodies. In 2008, Parnell published a book dedicated to EMDR resources and many of them have an attachment focus. In 2013, Parnell published Attachment-focused EMDR, which mirrored Laliotis’ ideas. While Parnell (2013) emphasized how the attachment focus is vital to healing, she focused primarily on therapist and client, not integrating the client’s partner(s), family, or community directly into EMDR treatment. Parnell (2013) compared this subjective attunement or affective resonance to playing a musical instrument as you feel the instrument resonate from the inside. This involves clinicians using their own bodies as tools to feel and sense what is happening for clients. This is linked to our mirror neurons, helping us sense what clients are feeling by sensing our own body. It is tuning into our shared subjectivity with clients, the part of us that may know something without knowing how or why we know it. Undoubtedly, prominent EMDR clinicians are increasingly heeding the importance of relationships and attachments to trauma treatment.
It is tuning into our shared subjectivity with clients, the part of us that may know something without knowing how or why we know it.
Table 1: Overview of Integrating EFT Across the 8 Phases of Standard Protocol EMDR
Phase
Client History
Interventions
Help each partner identify salient past experiences such as emotional neglect, abandonment, betrayal, or attachment injuries that may have laid a foundation for a trauma-based responses
- Explore past experiences from prior relationships as potential targets to reprocess with EMDR, only in their relevance to the present issues in the EFT negative cycle with their Significant others
- Assess appropriateness for EMDR treatment and contraindications (e.g., history of dissociative symptoms) using EMDR readiness worksheet (see Shapiro, 2017)
- Assess history of betrayal and attachment injuries
-Implement the 3-pronged approach: identify current triggers rooted in experiences from the past (e.g., past trauma within or outside of current relationship); present (i.e., any sensory stimuli linked to the moment the infidelity was learned about), and future (i.e., experiences that maintain attachment resilience)
Preparation & Stabilization
- Promote capacity for mutual affect regulation and access to coping resources, e.g. attunement and active listening skills, guided imagery, relaxation skills training, mindfulness skills training
- Prepare couple to process targets based on current triggers (i.e. symbols [messages or images] that represent past trauma), past events (more recent events related to past trauma)
- Inform partners that past trauma can sensitize them both to cues/triggers in their current attachment
- Prepare partners to empathically listen and silently support each other when they reprocess past trauma. Clinician should determine if it’s better to have one partner observe the a reprocessing partner, or if it’s better to separate them for a 1-3 individual EMDR sessions, see Linder et al. 2022 from our guidance around this
- Identify current physiological and behavioral symptoms stemming from trauma affecting the relationship in the present
- Employ more attachment-based resource, such as dyadic resourcing (Manfield, 2020), to increase each partner’s sense of internal psychological control so that they can effectively receive EMDR concurrently with the EFT work.
- Resource development: identify salient positive and/or recovery experiences, strengths, abilities, comforting, non-conflict images, animals, symbols of resilience, a time each partner felt particularly loved, safe, competent, etc. Protective, nurturing, or wise figures (Manfield, 2010; Parnell, 2008). These figures can be real or imagined. In many ways imagining is easier, because it allows the client to pedestalized and project positive qualities, see Parnell, 2008
- Floatback to the earliest linked memory (i.e. recalls the memory of the first time they felt deeply betrayed; Linder et al., 2021; 2022) Note: with attachment injuries and relational trauma, clients may have more success with non-relational resourcing.
- Install a calm/safe state for the couple
- Use RDI for the couple as a resource they can turn to that combats the negative cycle
- Develop a dyadic resource to combat the negative cycle as a team
Target assessment
- Access primary targets (e.g., most disturbing memory linked to their current relationship distress, images of past trauma).
- Assess Subjective Units of Distress ratings (SUD) used in this and throughout the other phases to assess clients’ emotional states and responses and prevent flooding or dissociation (Shapiro, 2017)
- Describe most distressing image (based on the past trauma memories with the highest SUD ratings) accompanied by a negative self-cognition
- Identify desired positive cognition and assess link between emotions and body sensations
- Measure validity of cognition (VoC; see Shapiro, 2017) to appraise the experienced subjective level of believability of the positive cognition.
- VoC is ideally assessed periodically throughout the later phases as well to ensure adequate trauma processing.
Desensitization
- Reprocess current relational triggers and their respective float-backs (e.g., partner’s phone ringing)
- Increase VoC, reduce associated affect (i.e., hurt, sadness, fear)
- If there were an affair, utilize the Recent Events Protocol (Shapiro, 2017); otherwise use standard protocol in individual or conjoint sessions
- Implement cognitive interweave: may involve witnessing partner’s support (i.e. hand-holding,, hugging, hand on lap)
Installation
- Strengthen association between traumatic image and positive cognition
- Standard installation protocol (i.e., connecting the traumatic image to the positive cognition)
Body Scan
Mindfully scan the body to identify and process any lasting sensations of emotional debris linked to the target image (i.e., tension in the chest).
Closure
- Verify client’s psychological stability after treatment (i.e., partners will not experience trauma symptoms as persistently)
- Verify couple’s capacity to self-soothe (i.e., partners will be able to discuss infidelity without active conflict)
- Use self-soothing, resourcing, and related techniques if needed
- Create templates for positive emotional relatedness with partner (i.e. how would you and your partner be relating if you both were ready to end treatment?
- Review expectations for treatment and assess if met
- If was a conjoint session: discuss the observing partner’s reaction after preparing them to be as supportive and intentional in their response as possible
Reassessment
- Appraise treatment effect with both partners and its effect on the negative cycle
- Confirm comprehensive reprocessing of relational issues
- Explore what has transpired since closure session
- Return to relational issues memory/image, verify that reduction in associated distress is maintained by reduced a VoC, and a clear body scan.
- Gauge SUD to ensure minimal disturbance
- Reinforce treatment gains with Future Templates
Note. Adapted from Eye movement desensitization and reprocessing (EMDR) training manual from the EMDR Institute (2021).
Key take-aways and similarities
I believe the future of EMDR is more relational and my study, among other work in the field, seems to support this. Although in EMDR the indicators of client progress are referred to as “phases” and in EFT they are “steps,” both therapies begin with building rapport and history-taking (step one of EFT and phase one of EMDR). Attentive history-taking is crucial to the effectiveness of either therapy. Thus, in both, the therapist searches for very similar information; the source of the emotional wounds and traumatic events, most of which are attachment-based, so their dysfunction in the present can be appropriately accessed and then healed.
The attachment need for partners to “feel seen” by each other in EFT appears to correspond to client’s adaptive information processing (AIP) working properly in EMDR, guiding partnered EMDR clients naturally from believing the EMDR negative cognition as truth in a given target memory, to realizing their positive cognition is actually the truth (which is essentially phase five of EMDR, installation) with the loving support of their partner. Likewise, being “trauma-informed” in EMDR is similar, in essence, to being “attachment-based” in EFT.
One common self-soothing technique in phase two of EMDR is called “calm/safe state.” In calm/safe state, the clinician helps the client identify an imaginary place where the client can experience any moment in their own mind, by deepening a felt sense of it using all five senses. Then, the clinician helps the client learn to use an imaginary place to cultivate a calm/safe state and its accompanying positive sensations (of calm and safety) by purposely thinking of something that mildly bothers them, and then returning to the feelings of calm and safety from mentally eliciting their calm/safe state in their mind. Other self-soothing strategies involved intentionally relaxing body parts with visualizations, breathing techniques for relaxation, and activating and strengthening the client’s strengths or qualities they want to reinforce, such as happiness or equanimity in what is called “resource development” in EMDR nomenclature. In EFT, the goal is similar, though the partners learn to use each other for soothing, instead of themselves individually (like in EMDR), which may be more natural. Whether it’s self, or other soothing, the outcome is the same. Humans need both: to be able to self-sooth and turn to each other for soothing.
A swiss cheese metaphor may apply here: both EFT (a relational therapy at its core despite an individual version of EFT developing in recent years) and EMDR (a primarily relational therapy that’s been developing relationally) have their inherent gaps or limitations, but together in unison, they may fill in each other’s holes, paving the way for a superior, fortified, and more resilient variant of both. Possibly a way of thinking about integrative work versus only working from one therapeutic model is that the risk and possible rewards are higher; like investing in risky start-up companies, the investor is more likely to triple their money, but significant losses are possible, none of which aren’t recoverable, fortunately with a skilled clinician. Integrating EMDR into EFT couple therapy can be a powerhouse of effectiveness: trauma is isolation and connection is healing.
Social Justice
The study did not focus on participants’ or clients’ contextual realities such as nationality, language, race, ethnicity, ability, gender identity, sexual orientation, size, or height among others. During the interviews, topics such as how the clients’ social locations were related to their experiences of trauma or their couple dynamics were not mentioned. Insufficient attention to social location continues to be a major issue in marriage and family therapy and mental health. Not all couples and clients are equal. Clients’ social locations have an enormous impact on their access to healthcare (e.g., ability to pay for treatment, transportation, availability of qualified providers) and overall therapy outcome (Linder et al., 2019). The fact that no participant spoke of these issues strengthens already marginalizing dominant discourses, and reflects major blind spots among participants and the field. We as researchers also should have also more proactively solicited this contextual information about clients from participants as well. Future studies on the integration of EFT and EMDR should specifically inquire about the influence of contextual factors in clients’ realities and trauma histories, and the therapeutic process. Demographic characteristics of therapists’ clients can also be included as part of the data collected.
Jason N. Linder, PsyD, LMFT, is an AAMFT Professional Member holding the Clinical Fellow designation and an EMDR-certified licensed bilingual (Spanish-speaking) therapist, approved EMDR consultant, and EMDR-HAP accredited training facilitator who specializes in attachment/relationship, trauma, addiction-related (such as motivational interviewing), and mindfulness therapies. He is passionate about diversity and social justice, and remains committed to serving underserved, multi-stressed, and disenfranchised communities, not only with his therapy, but also in his teaching, training, supervision, consultation, and forensic work. Dr. Linder also enjoys working with clients who are therapists, creators, entrepreneurs, and people who stutter.
This article was first published in the Jan/Feb 2023 issue of The Therapist, a publication of the California Association of Marriage and Family Therapists (CAMFT).
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Capps, F. (2006). Combining eye movement desensitization and reprocessing with gestalt techniques in couples counseling. The Family Journal, 14(1), 49-58. https://doi.org/10.1177/1066480705282055
Herman, J. (2015). Trauma and recovery: The aftermath of violence—from domestic abuse to political terror. (3rd ed). Hachette UK.
Johnson, S. M. (2002). Emotionally focused couple therapy with trauma survivors: Strengthening attachment bonds. Guilford Press.
Johnson, S. M. (2019). Attachment theory in practice: EFT with individuals, couples, and families. The Guilford Press. https://doi.org/10.1111/j.1752-0606.1985.tb00624.x.
Laliotis, D. (2018). EMDR therapy. The Center for Excellence in EMDR Therapy. https://emdrtherapy.com/
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Linder, J. N., Niño, A., Negash, S., & Espinoza, S. (2022). Thematic analysis of therapists’ experiences integrating EMDR and EFT in couple therapy: Conditions and risks of integration. International Journal of Systemic Therapy, doi: 10.1080/2692398X.2022.2090205
Linder, J. N., Walsdorf, A. A., & Carlson, M. W. (2019). Mindfulness interventions for latinx immigrant couples: Contextual and cultural considerations. Journal of Couple & Relationship Therapy, 19(3), 189-211.
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