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Psychoanalytic Psychology
2014, Vol. 31, No. 1, 134 144

2012 American Psychological Association

0736-9735/14/$12.00 DOI: 10.1037/a0030044

AN INTEGRATIVE MODEL IN TRAUMA

TREATMENT:
Utilizing Eye Movement Desensitization and
Reprocessing and a Relational Approach With
Adult Survivors of Sexual Abuse
Shoshana Ringel, PhD
University of Maryland

The aim of this article is to offer an integrative approach in the treatment of

adult survivors of sexual abuse. The treatment orientation is psychodynamic and
intersubjective and will draw on three conceptual models: (a) a developmental
model based on current attachment research, (b) current neuroscience findings
concerning traumatic memory that emphasize sensory, affective, and implicit
knowing in the understanding and treatment of trauma, and (c) eye movement
desensitization and reprocessing as an adjunctive technique to help access
traumatic memories. The author will summarize each theoretical perspective
and will provide a case illustration to demonstrate a treatment approach that
incorporates all three modalities.
Keywords: EMDR (eye movement desensitization and reprocessing), disorganized attachment, implicit communication, dissociated self states
Attachment theory provides a developmental perspective on early relational trauma
between children and caregivers, which typically results in the childs development of
disorganized attachment patterns. Research shows that attachment disorganization is
based on the childs fear of the caregiver or the childs perception as being frightened of
the caregiver. The child faces an impossible dilemma when the caregiver, who is supposed
to love and protect the child, is also the source of fear and threat (Hesse, Main, Abrams,
& Rifkin, 2003; Main & Solomon, 1990).
Early traumatic experiences may not be available to cognitive memory function, which
is not well developed in young children. Neuroscientific data suggest, therefore, that
traumatic events may not be readily accessible through traditional talk therapy methods
such as psychodynamic therapy or cognitive behavioral therapy. Current theories of
cognitive and affective neuroscience assert that early traumatic memories are stored in
This article was published Online First October 1, 2012.
Correspondence concerning this article should be addressed to Shoshana Ringel, PhD, 1915
Greenberry Road, Baltimore, MD 21209. E-mail: sringel@ssw.umaryland.edu

134

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INTEGRATIVE MODEL IN TRAUMA TREATMENT

135

implicit, right-brain pathways that are not always available for verbal expression and
insight, but can be reached through sensory, imaginal, and affective methods (Bucci,
2011a, 2011b; Fosshage, 2011; Schore, 2011; Schore & Schore, 2008). These authors
argue that nonverbal and implicit modes of communication between client and therapist
should be the initial focus of treatment before verbal and reflective modes are utilized.
However, both implicit and insight-oriented, verbal approaches should take place in order
for the trauma to be accessed and integrated. Eye movement desensitization and reprocessing (EMDR) is one among several treatment models that can help process traumatic
memories through systematic and gradual exposure to the original trauma via sensory and
affective pathways, culminating in cognitive shifts in perception and beliefs.
The implicit domain of communication is central in trauma work when verbal and
reflective capacities are not available and therefore, right-brain communication through
facial expression, tone of voice, and other physiological and sensory processes become the
main conduits of dissociated memories. Empathic sensing, attunement, and responsiveness by the therapist are important modes of understanding and relating. However, the
therapists own unresolved traumatic schema may be elicited during the treatment, and
because the therapists subjectivity is an inherent aspect of the intersubjective treatment
process, it is important to be cognizant of these affective responses and to work through
potential enactments that may occur during the treatment (Davies & Frawley, 1994).
Schore emphasizes the important function of right brain-to-right brain implicit and
unconscious communication between patient and therapist and differentiates the surface,
verbal, conscious, analytic, explicit self versus a deeper non verbal, unconscious, holistic,
emotional corporeal implicit self (Schore, 2011, p. 77). Bucci agrees with this formulation, but proposes a theory of greater interaction between what she calls the subsymbolic
and symbolic parts of the mind (Bucci, 2011a). The subsymbolic level includes sensory
and somatic representations that comprise the core self across different affective contexts and constitute an emotional and bodily memory system that is not easily linked to
verbal and cognitive processes. The symbolic level contains nonverbal processes, such as
visual, kinesthetic, and tactile functions (Hershberg, 2011). The subsymbolic level becomes activated during a traumatic event and in the subsequent interaction between
patient and therapist. Both Bucci (2011a, 2011b) and Fosshage (2011) assert that it is
important to integrate the subsymbolic with symbolic interactions in order to give
meaning to and negotiate interactions between patient and therapist. Buccis theory of the
mind is similar to Fosshages notion of organizing patterns of self and of self with others
(Fosshage, 2011). Fosshage asserts that imagistic symbolic thinking, or thinking through
images generated in sensory processes, is the earliest mode of memory and that organizing
relational patterns develop based on experiences of self and others that accumulate
throughout development. Like Bucci, Fosshage argues that therapeutic action is based on
the interplay between affective, sensory, and implicit processes, as well as on explicit
processes of reflection and insight. Therefore, he recommends that both explicit and
implicit processes be utilized during treatment so that sensory and affective processing
would be linked to reflection and cognition.
Therapists own emotional schema, which is based on their subsymbolic schema and
on past relational experiences, becomes activated in response to intersubjective interactions with patients. This may involve the therapists own unresolved traumatic experiences
culminating in their desire to save and protect the patient or may involve their feelings of
anger, fear, guilt, and shame elicited in response to patients traumatic narratives and
demands of or disappointment in the therapist. Enactments are inevitable based on the
interplay of traumatic schemas between patient and therapist and are an important

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RINGEL

opportunity of working through. It is important for the therapist to be aware of their

affective responses elicited during the treatment and to manage those in order to minimize
reactive avoidance, withdrawal, or retaliation that may reconfirm the patients deeply
embedded traumatic schemas.
EMDR has been shown to be effective with the treatment of posttraumatic stress
disorder (PTSD; Follette & Ruzek, 2007). However, its success in treating chronic
dissociative disorders related to complex PTSD is still unclear (Steele & van der Hart,
2009). Nevertheless, its emphasis on accessing sensory and affective traumatic memories
can be utilized as an adjunctive procedure with a relational psychodynamic approach. This
approach focuses on the intersubjective relationship between patient and therapist and on
developing reflective and meaning-making capacities in the patient. The patienttherapist
interactions can help process the relational aftermath of trauma through intersubjective
rupture and repair sequences and enactments. Ruptures and repair may occur, for example,
when the patient feels misunderstood or rejected by the therapist, and the two can then
process the interaction and come to a mutual understanding about the meaning of what had
occurred. Enactments happen when patient and therapist fall into binary roles from the
patients traumatic past, such as the role of victim and perpetrator or victim and abandoning parent (Davies & Frawley, 1994). Patient and therapist may then process the
enactment and recognize how the patients trauma impacted the therapeutic space as well
as other relationships in the patients life. A relational approach can therefore help to
elaborate the intersubjective implications of the trauma.

Introduction to Case Illustration

I wait for Sandy to enter the room. As always, she is timid and hesitant, as if asking
can I come in; are you ready for me; am I welcome? She is apologetic for being too
early or too late and she takes careful steps. Her physical appearance reflects her
shifting self states. Some days she seems very young and fragile, whereas on other
days she looks old and tired. At times, she is timid and fearful, and at other times
imperious and demanding.
Sandy had been sexually abused by her grandfather from ages 3 6, while the family
spent summers and holidays at her grandparents home. She has a memory of trying to tell
her mother of the abuse when she was six and her mothers turning her back on her
without a word and walking away. This betrayal has been as painful as the abuse itself and
has been a pivotal memory that has profoundly affected her subsequent relationships with
others. Memories of the abuse were dissociated until Sandy was married with her own
young children. The memories came back gradually, but when Sandy confronted her
mother and grandfather, they both denied the abuse and called her a liar. In one memory
fragment, Sandy, terrified, is hiding from her grandfather in the closet and he is looking
for her, pretending that they are playing hide and seek. We have skirted the particulars of
the abuse many times before, because Sandy has not felt ready to speak of it directly. She
was aware that in the wake of remembering she has started to experience chronic pain,
fibromyalgia, headaches, and digestive problems, as well as fear and dissociation during
sexual contacts with her husband. Other symptoms that have constricted Sandys life
include reexperiencing the abuse through memories and flashbacks infused with fear and
shame (Stolorow, 2007); social fear, withdrawal, and avoidance; and hyperarousal manifested through anger and rage toward her children. Consequently, as a result of the abuse
her life has been severely diminished.

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Attachment Theory and Trauma

Attachment studies show that attachment disorganization is based on fear, either fear of the
caregiver or the childs perception of the caregiver as fearful. A significant number of these
childrens mothers were found to have unresolved traumatic histories that were transmitted to
the child in verbal and nonverbal ways. The mothers unresolved trauma directly affects the
childs disorganized responses and contributes to a disorganized attachment pattern in the child
(Hesse et al., 2003; Lyons-Ruth, Dutra, Schuder, & Bianchi, 2006; Lyons-Ruth & Jacobvitz,
2009; Main & Solomon, 1990). Parents who themselves suffer from unresolved trauma have
difficulty regulating their affects and modeling affect regulation to their children. They also
find it difficult to accept their childrens affect or to be emotionally responsive to their children.
At times, the parents own PTSD symptoms, including reexperiencing through flashbacks,
avoidance, or hyperarousal, can be frightening to the child. Early sexual abuse involves
overwhelming and intolerable emotions of fear, shame, sadness, and anger that the child learns
to avoid or regulate through dissociation, withdrawal, and acting out. These coping mechanisms may intrude into everyday functioning. Sandys history suggests that her fear of her
abusive grandfather and her sense of her mothers fearfulness contributed to the disorganization and dissociative mechanisms that she developed.
Children with disorganized attachment do not develop consistent attachment strategies
and alternate between ambivalent and avoidant behaviors, as well as dissociative behaviors such as freezing and repetitive rituals. Sandys ambivalence is still apparent in her
deep desire for others approval and love, alternating with her fear and distrust of others
and her withdrawal from social contact. Sandys ambivalence is present between us as
well. At times she tells me how much she needs my love and understanding and wishes
to be hugged, whereas at other times she cancels sessions and avoids me.
The people on whom Sandy relied on for security and nurturing abused and rejected
her. The grandfather whom she admired and idolized, who paid attention to her and
promised her treats, was also the one who manipulated, betrayed, and hurt her. More
confusing still were the memories of arousal and pleasure alternating with unbearable pain
and discomfort that 5-year-old Sandy experienced but did not understand. The shame of
her own forbidden desires and the fear of potential betrayals led Sandy to make the
conscious decision to never again permit sexual intimacy in her life.
Dysregulated, traumatic interactions between the child and the caregiver can result in
disorganized patterns of engagement in which the child learns to utilize dissociative
processes that protect against overwhelming and unacceptable affects such as fear and
anger. Children whose caregivers are misattuned or dysregulated as a consequence of their
own unresolved trauma will rely on strategies of isolation, dissociation, or punitive and
aggressive behaviors to regulate their affect and interactions with others. Beebe and
colleagues (2000) found that secure and mutual interactions between mothers and infants
are characterized by novelty and flexibility, but that insecure dyads are either rigid and
inflexible, showing strong mutual dependence, or are emotionally distant and have a
minimal level of attunement. In these tenuously bonded dyads, infants and mothers appear
unresponsive to one another, as seen with Sandy and her mother.
The cycle of disruption and repair between infant and caregiver, during which the
infant may experience rejection by the caregiver, has significant impact for the infants
subsequent development. Caregivers capacity and willingness to recognize their own
misattuned or hurtful behaviors and acknowledge or adjust them to their childrens needs
are critical in repairing attachment ruptures. For example, the infant may experience the
parent as ignoring their distress and rejecting them, and the caregiver, recognizing the

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childs hurt and disappointment, may then try to repair the rupture by proceeding to sooth
and comfort the child, acknowledging their misattuned behavior. These cycles of disruption and repair are instrumental in developing the childs sense of agency and security.
Ongoing interactions of incremental disruption and repair cycles contribute to the deepening complexity and sophistication of infants regulatory systems and are designed to
regulate arousal and create a pattern of better matching behaviors between infants and
caregivers in terms of gaze and vocalizing (Beebe, 2005).
The traumatic impact of the sexual abuse was exacerbated by Sandys grandfathers
pattern of promises and betrayals (to be elaborated on). Her mothers denial of the abuse
and her withdrawal from Sandy further contributed to the deep sense of abandonment and
rejection that Sandy experienced. She learned to regulate her untenable affects through
avoidance, isolation, and dissociation and later through angry and controlling behaviors
with her own children.

Treatment With Sandy

The work with traumatized patients who have learned to use dissociative processes to
protect against overwhelming affects involves initial stabilization. This is achieved
through a therapeutic relationship based on safety and security, regulation of affect and
titration of psychological arousal (especially during the exposure part of the treatment),
supporting optimal functioning in everyday life, and reducing maladaptive responses to
external and internal stimuli (Steele & van der Hart, 2009). Dissociation can mean
alternate and disconnected identities, or ego dystonic feelings, somatic sensations, and
relational conflicts. Such phenomena are experienced by the patient as not me states. In
her groundbreaking book, Herman outlines a stage model for the treatment of trauma that
includes instilling safety, a working-through period of remembrance and mourning, and
finally reconnecting with others through reconciliation with oneself (Herman, 1992).
Sandy and I spend a long time on establishing safety and trust. About 2 years into the
treatment, Sandy gradually realizes how deeply her life is still affected by the aftermath
of the abuse, but she is afraid and does not know how to enter the horrific terrain of her
childhood experiences. She wants me to offer her reassurance and protection, to tell her
what to do and to accompany her as she plunges into this frightening territory. She does
not feel safe with our spontaneous but uncertain dynamic therapeutic process. We both
feel that we need a reliable structure to depend on, a structured protocol that will guide us
through the horror and pain. I explain to Sandy how EMDR works, and she thinks it is a
good idea. We decide to try. For the next 2 months, on a twice weekly basis, we go
through an EMDR protocol during which we process Sandys memories related to the
abuse, related sensory experiences, affects, and cognitions.
EMDR was developed by Francine Shapiro (Shapiro, 2011; Shapiro & Maxfield,
1998) to help integrate and reduce the distress of traumatic memories and has been utilized
for the treatment of trauma. It was proven to be effective in comparison with other trauma
focused techniques (Bisson & Andrew, 2007; van der Kolk et al., 2007). The EMDR
protocol includes a three-pronged approach to address the etiology of traumatic memories,
the symptoms, and the distorted cognitive templates that develop following traumatic
experiences (Shapiro, 2011). The EMDR therapist uses a directive procedure to help
desensitize the clients traumatic memories through an imaginal exposure technique that
emphasizes sensory, affective, and later cognitive processes. According to Shapiro, these
affects and cognitions are activated through bilateral stimulation, either by providing

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visual stimuli, sound, or alternate tactile tapping. During the desensitization procedure, the
client is encouraged to reexperience aspects of their traumatic past and is then taught to
integrate these experiences into more adaptive cognitive structures. The protocol has been
adapted for adults with complex childhood trauma (Parnell, 1999). During the EMDR
procedure, the patient is asked to select a traumatic memory and an image associated with
it and to apply negative and positive cognitions associated with the memory. Along with
visual, affective, and cognitive focus, the EMDR therapist also prompts the patient to
attend to bodily sensations associated with the trauma.
EMDR includes a structured approach that seemed to offer comfort and security for
Sandy. However, the linear, directive model of EMDR contrasts with the unstructured,
spontaneous, and improvisational nature of our previous work in which Sandy took the
lead. As we progressed, the EMDR protocol gradually changed into a more spontaneous,
creative, and dynamic process where Sandy decided what she wanted to work through and
how, and I readily followed. We agreed on basic ground rules, whereby, for example, she
could stop at any time when the memories became too overwhelming. As discussed
previously, during the EMDR procedure, there is an emphasis on physiological and
affective experiences, and later on cognitive integration, and this is particularly helpful
with trauma patients who, like Sandy, do not always possess the language to describe their
experience. The EMDR process occurred twice weekly for approximately 2 months, when
we resumed our unstructured, dynamic format.
I encourage Sandy to describe to me the memories associated with the abuse and the
images that come to her mind. I ask her to experience her bodily sensations and the
feelings, thoughts, and negative cognitions associated with the memories. Many of her
experiences have no words or visual images, but her body remembers. She haltingly
reports the sense of pressure, the tastes, and her difficulty in breathing under a heavy
weight. She is longing for love and attention from her grandfather and would do anything
to please him, but she is also terrified and feels suffocated and trapped. The feelings of
disappointment and betrayal by her grandfather who she idolized and admired are
confusing and painful. He would promise her treats after she had been nice to him, but
never followed through, especially during the Christmas holidays, when the abuse usually
took place. During the Christmas season, Sandy typically disappears for weeks. When she
returns, she tells me that she had experienced flashbacks and that the only way to comfort
the betrayed and angry little girl part of her is to buy herself expensive gifts that she cannot
afford in order to compensate for this profound disappointment.
Gradually, I become acquainted with Sandys little-girl self state, which is usually in
hiding, fearful and resentful, and which refuses to come out. This little girl does not trust
anyones words and promises. Sandy is aware of the little girl self-state but feels helpless
to manage her when she becomes fearful, angry, or demanding. At those times, the little
girl self state takes over her still fragile adult self that she has worked so hard to develop.
Bromberg suggests that traumatized patients develop a mental structure of separate,
incompatible self states, and he notes that the dilemma for both patient and therapist is that
by developing the capacity for self-reflection and the resolution of internal conflicts,
patients experience a threat to the dismantling of their familiar and protective dissociative
structure that may render them more vulnerable for retraumatization (Bromberg, 1998,
2003). When Sandy feels threatened by our exploration of her dissociated self states, she
disappears for weeks and does not respond to my phone calls. Although this can be
frustratingand at times I am very concerned about herI try to be as flexible as I can
and let her know that I am available, that she is on my mind, and that she can return
whenever she is ready.

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Eventually, as the fear subsides, Sandy is able to draw on our connection and her
deepening trust in me and in our work, and we continue to forge on. I rely on Sandy to
be the facilitator with her younger self state and to let me know whether I am using the
right words and asking the right questions. Her little girl can be playful and lovable at
times, but she is also impulsive and stubborn. Sandy and I learn together how to comfort
and reassure her, how to play with her but also how to set reasonable limits. Sandy
recognizes that, like her mother, she had also abandoned this part of herself and that her
little girl self is still longing for attention and recognition. Although I validate (little)
Sandys outrage, fear, and sense of isolation and betrayal, I also encourage Sandy to listen
and communicate with the little girl part of herself and to invite her in as often as possible.
Her adult self is still fragile and tenuous, but she is starting to learn how to regulate and
comfort her childlike self. I experience loving maternal feelings, for both the adult Sandy
and the child. I know that in order for Sandy to love the child, she needs to feel loved by
me. When she disappears, I worry about her, and her disappearance triggers my own
vulnerability to abandonment. In this enactment, I recognize that my experience mirrors
Sandys memory of her mother.
At first, Sandy does not want to talk about what happened with her grandfather,
because it is too raw and painful, but she comes to recognize how constrained and boxed
in her life has become. She is afraid of people; she is isolated and unable to leave the
house. One day she finally decides that the time has come and that she needs to free herself
from his dark power, which has imprisoned her all of these years. I ask her to describe the
part of herself that she would like to enter. She describes a box, both safe and confining,
and how fearful it is to leave it, though staying there leaves her isolated and withdrawn.
She then envisions a wall she dares not look beyond. An old monster leers at her and
threatens to control and overpower her. He is in every stranger she meets and therefore she
cannot trust anyone. At this point, another self state emergesa powerful and angry
Sandy whose voice is loud and imposing, who confronts her grandfather, cursing and
enraged. Suddenly, he has lost his power, and he no longer matters. Tears, saliva, and
blood flow from Sandys nose and mouth, we are both startled as Sandy cries out, You
see what he has done to me, you see? Sandy seems much lighter as she leaves my office.
I, on the other hand, feel quite overwhelmed by Sandys unexpected physiological
response. Gradually, granddad loses his hold on Sandy and becomes more and more
distant.
We discover that as Sandy releases her fear and rage toward her grandfather other
affects emerge. She is angry at her mother who had ignored the abuse but was also critical
of and competitive with her. She experiences deep sorrow and regret regarding her
inability to love and parent her children, who have not spoken to her in several years, and
she longs to make amends. As the EMDR aspect of our work fades and we return to a
more spontaneous and improvisational mode, an element of play appears as well (Ringstrom, 2007). It is Halloween, and Sandy brings in a skull, a black wig, and a broom.
Together, we confront the mother/witch to try and loosen her hold over Sandy. In a
ceremonial ritual we set the objects on a chair and Sandy tells her mother/witch how
betrayed, disappointed, and abandoned she felt with no one to offer her support and
protection. As she talks to her mother, Sandy recognizes that her mother is terrified as
well and that she has rigidly held on to the organization and structure of her life in order
not to fall apart. She too may have been abused by her father (Sandys grandfather) but,
if so, she cannot tolerate this knowledge. This recognition about her mother seems to free
Sandy to view her mother in a new way. Her mother is no longer the powerful witch but
a fragile old woman for whom Sandy feels empathy and compassion.

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The EMDR procedure allows us to open up the therapeutic space to painful self states
that we were unable to access previously, but eventually Sandy no longer needs the safety
and security of the structured procedure. There is sufficient trust between us that she is
able to tolerate the uncertainty and open-ended nature of a more dynamic process. She has
started to trust herself and to trust me that we will figure out where we need to go and will
survive it. We spend a long time reflecting on what had happened and deepening our
understanding of the trauma and its impact on her life. Sandy realizes that she has built
protective masks around herselfthe Grandpa mask that is self confident, charming, and
arrogant and the Mother Mary mask that is kind, loving and caring but that she still
does not know who she really is. Sandy brings me a book she has designed that captures
some of her poignant self states: The frightened child cowering in a corner, the old crone
whose gnarly hands have become roots planted in the ground, and the wise woman who
sees everything but who is still quite fragile.

The Integration of EMDR With a Relational Approach

Much like other exposure therapies, such as prolonged exposure (Foa et al., 2005) and
somatic experiencing (Fisher & Ogden, 2009), EMDR does not emphasize the intersubjective process between therapist and patient, which is central in a relational psychoanalytic treatment. Rather, the therapist acts as a facilitator utilizing a structured procedure,
and their subjectivity remains largely irrelevant except for providing a context of safety
and trust that allows the patient to undertake the difficult task of retrieving and reliving
past traumatic events. With Sandy, the EMDR procedure was undertaken as an adjunctive
technique within a relational treatment framework; it was utilized for a time to help access
dissociated memories and self states that may otherwise have been inaccessible, although
I did try to show how countertransference factors as well as my own vulnerability were
very much part of the process.
A relational approach in the treatment of trauma can help investigate and elaborate on
the intersubjective implications of the traumatic experience. These intersubjective processes include the cycle of rupture and repair, enactments, and spontaneous relational
moments in the treatment. A focus on these relational dynamics between patient and
therapist can help to recognize and integrate dissociated self states and can highlight and
eventually change maladaptive relational patterns. Contemporary relational and interpersonal authors suggest that the self is not a unitary entity but is composed of multiple states
and experiences that are frequently disconnected and dissociated, both as an outcome of
traumatic experiences and as a function of unconscious everyday life (Bromberg, 2011;
Stern, 1997). Traumatized patients organize their experience around separate and incompatible self states that allow them to compartmentalize unbearable memories and relational experiences. These polarized self states inevitably manifest in the patienttherapist
relationship through what Benjamin called the doer done to dilemma (Benjamin, 2004).
This conflict is enacted when each member of the dyad takes on binary roles in relation
to the other, as I described in terms of our enactment of abandoning mother and abandoned
child. In this paradigm, patient and therapist become victim and perpetrator or victim and
abandoning/rejecting caregiver, thereby enacting the early trauma between the patient and
significant others as well as between incompatible self states within the patient. It is
suggested that a way out of these polarized positions is to arrive at a third relational
dimension where patient and therapist can find a new, collaborative ways to relate to one

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another (Aron, 2006; Benjamin, 2004) or when the patient can hold conflicting self states
without the need to dissociate (Bromberg, 2011).
After working through early traumatic events that curtailed Sandys capacity for creative
and interpersonal expression, we gained a better understanding of how the traumatic events of
her past shaped the dynamics between the two of us. For example, Sandys habitual pattern of
frequently calling in sick, missing sessions, and not paying, which was initially understood as
a byproduct of her unpredictable attacks of fibromyalgia and other physical disabilities,
became more accessible for investigation and for mutual negotiation. Sandy admitted that she
preferred to go on spending sprees in order to sooth her emotional hunger and to distract
herself from flashbacks, rather than face me and discuss her painful memories and intolerable
feelings. She inevitably went deeper into debt, and at times could not pay for her sessions. At
times, I felt torn. I wanted to be the reliable, loving parent who provided Sandy with
unconditional love, but I also recognized that I felt manipulated and resentful. I acknowledged
and validated Sandys pain, but I realized that I had my own needs and that I felt dismissed
and victimized by her. In this enactment, I had become the victim, and I felt that it would be
important for us to process and understand together how Sandys past had shadowed our own
relationship. I told Sandy that I thought it was important that we discuss the implications of her
behavior on both of us. I expressed my disappointment, and at times resentment, while waiting
for her and when not getting paid. It was important for me, and for Sandy, to see that she had
an impact on me and that her actions held consequences for others who could also feel hurt
and dismissed. Sandy began to cry. She told me that she valued me and the work we were
doing, but that at times she was afraid to come to the session, afraid of me, afraid of the pain.
At times, she just wanted to act on her impulses and shop in order to avoid her feelings and
flashbacks, rather than face them with me. Eventually, we negotiated an arrangement that we
both felt was fair.

Conclusion
Attachment research indicates that disorganized attachment is transmitted from parent to
child and that the consequently children take on roles that helps them control, organize,
and manage chaotic, frightening experiences with caregivers who themselves are traumatized and helpless or are frightening and abusive (Hesse et al., 2003). The roles of
caretaker, aggressor, helpless victim, and helpless caregiver manifest between child and
caregiver and between patient and therapist and can be processed and worked through
during a relational treatment process.
A relational focus on the intersubjective process between patient and therapist, along
with EMDRs emphasis on the implicit, nonverbal aspects of traumatic experience, can
work well as complementary models in the treatment of trauma. This case suggests that
with adult survivors of sexual abuse it is important at times to utilize an approach that
integrates the uncertainty and fluid nature of a dynamic approach with a more structured,
linear model such as EMDR. Current neuroscientific data (Bucci, 2011a, 2011b; Schore,
2011) supports the notion that nonverbal, implicit processes within the patient, within the
therapist, and between patient and therapist are vital conduits of memory and experience,
especially in the case of early trauma that had occurred before cognitive and verbal
functions were well developed.
EMDR is one among several trauma-focused approaches including prolonged exposure (Foa et al., 2005) and sensorimotor therapy (Fisher & Ogden, 2009), all of which may
help to access traumatic experiences through physiological and affective channels. Subsequent reflective processing and insight can then help to integrate previously dissociated

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traumatic events from the patients life. A relational treatment process based on the
intersubjective dynamics between patient and therapist elaborates on the interpersonal
aftermath of the trauma through the lens of the patient-therapist relationship. It therefore
provides an opportunity to elaborate on the meaning of the trauma and to enhance the
affective experiences that have been elicited.

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