June 12, 2017 at 7:46 PM
One of the striking features of eye movement desensitization and reprocessing (EMDR), as well as progressive counting (PC), is that the therapy action seems to occur entirely inside the client’s mind. This has led some people to proclaim that, for these methods, the therapy relationship is superfluous.
Early on in PC’s development, I conducted brief post-session interviews to learn more about the client’s experience. What struck me in one case (that I wrote up) was how important the therapy relationship seemed to be, despite limited interaction during PC. This was a client I considered to be “securely attached” and high functioning.
Lina did mention memory details on a few occasions, but usually commented only minimally in between sets. Even so, when I asked her for any comments following the session, she said, “The fact that you are going through those things with someone [the therapist] gives you the security to go through it.” (Greenwald, 2008, p. 90)
This brought to mind the Lend a Hand study (Coan, Schaefer, & Davidson, 2006). Researchers recruited sixteen happily married, heterosexual couples to explore how hand-holding might impact tolerance of pain. Researchers placed shock electrodes on the ankle of each woman before leading her to the fMRI chamber. While being scanned, a signal would intermittently cue the participant when a mild shock might be coming. Each woman underwent this experience: while holding her husband's hand; while holding the hand of a stranger; and without hand-holding. Results overwhelmingly showed that the hand-holding helped them regulate levels of emotional distress. This held true both in self-reported distress and in fMRI images of activity in brain regions that register danger. Though any hand-holding provided some comfort, the benefit was far greater when the hand belonged to the husband. Furthermore, women reporting the highest levels of marital satisfaction experienced the strongest positive effects.
So when Mom kisses a boo-boo to make it better, that’s not just a trick. It really does make it better! Similarly, when a therapist holds a client’s hand – even if only metaphorically via empathic presence – that helps the client to tolerate emotional pain. And when the therapy relationship is strong, that helps the most.
The good news is that therapists are already on the right track in this regard. Though terminology may differ, nearly all modalities emphasize rapport, empathy, and therapeutic alliance (Norcross, 2010). This is arguably at least as important for internal-action methods such as EMDR as for any other treatment modality (Dworkin, 2005).
Research has found that those with secure attachment status tend to be more responsive to trauma treatment (Muller & Rosenkranz, 2009; Stalker, Gebotys, & Harper, 2005). This is perhaps in part because securely attached people have better affect tolerance, but perhaps also because they are able to form stronger relationships with their therapists, and thus benefit more from the support of a therapist. If we create strong relationships with our clients, our support will be all the more useful when we ask them to work through pain to get to healing.
Dworkin, M. (2005). EMDR and the relational imperative: The therapeutic relationship in EMDR. NY: Routledge.
Coan, J. A., Schaefer, H. S., & Davidson, R. J. (2006). Lending a hand: Social regulation of the neural response to threat. Psychological Science, 17, 1032-1039.
Greenwald, R. (2008). Progressive counting for trauma resolution: Three case studies. Traumatology, 14, 83-92.
Muller, R. T., & Rosenkranz, S. E. (2009). Attachment and treatment response among adults in inpatient treatment for posttraumatic stress disorder. Psychotherapy: Theory, Research, Practice, Training, 46, 82-96.
Norcross, J. C. (2010). The therapeutic relationship. In B. L. Duncan, S. D. Miller, B. E. Wampold, & M. A. Hubble (Eds.), The heart and soul of change: Delivering what works in therapy, 2nd edition, pp. 113-141.
Stalker, C. A., Gebotys, R., & Harper K. (2005). Insecure attachment as a predictor of outcome following inpatient trauma treatment for women survivors of childhood abuse. Bulletin of the Menninger Clinic, 69, 137-156.
Note: Thanks to Rebecca Chapman, PsyD, for her assistance in writing this.