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This document is copyrighted by the American Psychological Association or one of its allied publishers.

This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

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 child’s development of
disorganized attachment patterns. Research shows that attachment disorganization is
based on the child’s fear of the caregiver or the child’s 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

Fosshage. right-brain communication through facial expression. Bucci agrees with this formulation. Fosshage argues that therapeutic action is based on the interplay between affective. analytic. 2011a. kinesthetic. and implicit processes. Fosshage asserts that imagistic symbolic thinking. and tactile functions (Hershberg. Schore & Schore. The subsymbolic level becomes activated during a traumatic event and in the subsequent interaction between patient and therapist. 2011. attunement. Bucci’s theory of the mind is similar to Fosshage’s notion of organizing patterns of self and of self with others (Fosshage. but proposes a theory of greater interaction between what she calls the subsymbolic and symbolic parts of the mind (Bucci. but can be reached through sensory. 2011. Like Bucci. explicit self versus a deeper non verbal. the therapist’s own unresolved traumatic schema may be elicited during the treatment. 2011). Empathic sensing. However. holistic. and shame elicited in response to patients’ traumatic narratives and demands of or disappointment in the therapist. The implicit domain of communication is central in trauma work when verbal and reflective capacities are not available and therefore. Schore. conscious. and because the therapist’s subjectivity is an inherent aspect of the intersubjective treatment process. Schore emphasizes the important function of right brain-to-right brain implicit and unconscious communication between patient and therapist and differentiates the “surface. However. Therapists’ own emotional schema. right-brain pathways that are not always available for verbal expression and insight. tone of voice. it is important to be cognizant of these affective responses and to work through potential enactments that may occur during the treatment (Davies & Frawley. both implicit and insight-oriented. 2011b. 2011a). 2011). and other physiological and sensory processes become the main conduits of dissociated memories. which is based on their subsymbolic schema and on past relational experiences. 1994). 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. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. guilt. 2008). p. The symbolic level contains nonverbal processes. verbal. emotional corporeal implicit self” (Schore. and responsiveness by the therapist are important modes of understanding and relating. sensory. is the earliest mode of memory and that organizing relational patterns develop based on experiences of self and others that accumulate throughout development. imaginal. fear. 77). becomes activated in response to intersubjective interactions with patients. and affective methods (Bucci.This document is copyrighted by the American Psychological Association or one of its allied publishers. or thinking through images generated in sensory processes. verbal approaches should take place in order for the trauma to be accessed and integrated. 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. culminating in cognitive shifts in perception and beliefs. 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. as well as on explicit processes of reflection and insight. Enactments are inevitable based on the interplay of traumatic schemas between patient and therapist and are an important . unconscious. Therefore. 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. 2011. Both Bucci (2011a. such as visual. This may involve the therapist’s own unresolved traumatic experiences culminating in their desire to save and protect the patient or may involve their feelings of anger. 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. INTEGRATIVE MODEL IN TRAUMA TREATMENT 135 implicit.

they both denied the abuse and called her a liar. Follette & Ruzek. Enactments happen when patient and therapist fall into binary roles from the patient’s traumatic past. and digestive problems. At times. Ruptures and repair may occur. when the patient feels misunderstood or rejected by the therapist. she is timid and fearful. 2009). The memories came back gradually. are you ready for me. its emphasis on accessing sensory and affective traumatic memories can be utilized as an adjunctive procedure with a relational psychodynamic approach. terrified. Introduction to Case Illustration I wait for Sandy to enter the room. and hyperarousal manifested through anger and rage toward her children. is hiding from her grandfather in the closet and he is looking for her. whereas on other days she looks old and tired. while the family spent summers and holidays at her grandparents’ home. Her physical appearance reflects her shifting self states. Sandy. EMDR has been shown to be effective with the treatment of posttraumatic stress disorder (PTSD. she is timid and hesitant. 136 RINGEL opportunity of working through. as well as fear and dissociation during sexual contacts with her husband. She has a memory of trying to tell her mother of the abuse when she was six and her mother’s turning her back on her without a word and walking away. such as the role of victim and perpetrator or victim and abandoning parent (Davies & Frawley. fibromyalgia. We have skirted the particulars of the abuse many times before. A relational approach can therefore help to elaborate the intersubjective implications of the trauma. She was aware that in the wake of remembering she has started to experience chronic pain. Nevertheless. as if asking “can I come in. withdrawal. pretending that they are playing hide and seek. 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. and avoidance. am I welcome?” She is apologetic for being too early or too late and she takes careful steps. social fear. However. but when Sandy confronted her mother and grandfather. because Sandy has not felt ready to speak of it directly. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. headaches. Memories of the abuse were dissociated until Sandy was married with her own young children. In one memory fragment. Some days she seems very young and fragile. withdrawal. Sandy had been sexually abused by her grandfather from ages 3– 6. Patient and therapist may then process the enactment and recognize how the patient’s trauma impacted the therapeutic space as well as other relationships in the patient’s life. 2007). Other symptoms that have constricted Sandy’s life include reexperiencing the abuse through memories and flashbacks infused with fear and shame (Stolorow. as a result of the abuse her life has been severely diminished. and at other times imperious and demanding. 2007). or retaliation that may reconfirm the patient’s deeply embedded traumatic schemas. for example. 1994). 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. . As always. The patient–therapist interactions can help process the relational aftermath of trauma through intersubjective rupture and repair sequences and enactments. This approach focuses on the intersubjective relationship between patient and therapist and on developing reflective and meaning-making capacities in the patient. and the two can then process the interaction and come to a mutual understanding about the meaning of what had occurred. its success in treating chronic dissociative disorders related to complex PTSD is still unclear (Steele & van der Hart.This document is copyrighted by the American Psychological Association or one of its allied publishers. Consequently.

& Bianchi. and the caregiver. 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. including reexperiencing through flashbacks. avoidance. showing strong mutual dependence. At times she tells me how much she needs my love and understanding and wishes to be hugged. 2006. who paid attention to her and promised her treats. and acting out. betrayed. 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. has significant impact for the infant’s subsequent development..INTEGRATIVE MODEL IN TRAUMA TREATMENT 137 This document is copyrighted by the American Psychological Association or one of its allied publishers. shame. infants and mothers appear unresponsive to one another. Sandy’s ambivalence is still apparent in her deep desire for others’ approval and love. 2003. For example. and hurt her. or punitive and aggressive behaviors to regulate their affect and interactions with others. Sandy’s ambivalence is present between us as well. Dutra. sadness. The people on whom Sandy relied on for security and nurturing abused and rejected her. 2009. The cycle of disruption and repair between infant and caregiver. Lyons-Ruth & Jacobvitz. either fear of the caregiver or the child’s perception of the caregiver as fearful. Dysregulated. Sandy’s history suggests that her fear of her abusive grandfather and her sense of her mother’s fearfulness contributed to the disorganization and dissociative mechanisms that she developed. the parent’s own PTSD symptoms. A significant number of these children’s mothers were found to have unresolved traumatic histories that were transmitted to the child in verbal and nonverbal ways. the infant may experience the parent as ignoring their distress and rejecting them. In these tenuously bonded dyads. but that insecure dyads are either rigid and inflexible. Caregivers’ capacity and willingness to recognize their own misattuned or hurtful behaviors and acknowledge or adjust them to their children’s needs are critical in repairing attachment ruptures. The mother’s unresolved trauma directly affects the child’s disorganized responses and contributes to a disorganized attachment pattern in the child (Hesse et al. as well as dissociative behaviors such as freezing and repetitive rituals. These coping mechanisms may intrude into everyday functioning. whereas at other times she cancels sessions and avoids me. as seen with Sandy and her mother. The grandfather whom she admired and idolized. Beebe and colleagues (2000) found that secure and mutual interactions between mothers and infants are characterized by novelty and flexibility. or are emotionally distant and have a minimal level of attunement. Lyons-Ruth. dissociation. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. Attachment Theory and Trauma Attachment studies show that attachment disorganization is based on fear. recognizing the . They also find it difficult to accept their children’s affect or to be emotionally responsive to their children. can be frightening to the child. Parents who themselves suffer from unresolved trauma have difficulty regulating their affects and modeling affect regulation to their children. Early sexual abuse involves overwhelming and intolerable emotions of fear. 1990). during which the infant may experience rejection by the caregiver. was also the one who manipulated. Children with disorganized attachment do not develop consistent attachment strategies and alternate between ambivalent and avoidant behaviors. Main & Solomon. 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. and anger that the child learns to avoid or regulate through dissociation. At times. Children whose caregivers are misattuned or dysregulated as a consequence of their own unresolved trauma will rely on strategies of isolation. alternating with her fear and distrust of others and her withdrawal from social contact. withdrawal. Schuder. or hyperarousal.

2009). and later cognitive processes. a working-through period of remembrance and mourning. and relational conflicts. Such phenomena are experienced by the patient as “not me” states. and reducing maladaptive responses to external and internal stimuli (Steele & van der Hart. The EMDR therapist uses a directive procedure to help desensitize the client’s traumatic memories through an imaginal exposure technique that emphasizes sensory. Treatment With Sandy The work with traumatized patients who have learned to use dissociative processes to protect against overwhelming affects involves initial stabilization. supporting optimal functioning in everyday life. but she is afraid and does not know how to enter the horrific terrain of her childhood experiences. About 2 years into the treatment. regulation of affect and titration of psychological arousal (especially during the exposure part of the treatment). may then try to repair the rupture by proceeding to sooth and comfort the child. the symptoms. and cognitions. The EMDR protocol includes a three-pronged approach to address the etiology of traumatic memories. 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. 2011. and dissociation and later through angry and controlling behaviors with her own children. We decide to try.This document is copyrighted by the American Psychological Association or one of its allied publishers. She does not feel safe with our spontaneous but uncertain dynamic therapeutic process. The traumatic impact of the sexual abuse was exacerbated by Sandy’s grandfather’s pattern of promises and betrayals (to be elaborated on). Shapiro & Maxfield. a structured protocol that will guide us through the horror and pain. These cycles of disruption and repair are instrumental in developing the child’s sense of agency and security. to tell her what to do and to accompany her as she plunges into this frightening territory. She wants me to offer her reassurance and protection. or ego dystonic feelings.. 2011). Dissociation can mean alternate and disconnected identities. and the distorted cognitive templates that develop following traumatic experiences (Shapiro. and she thinks it is a good idea. Herman outlines a stage model for the treatment of trauma that includes instilling safety. 1998) to help integrate and reduce the distress of traumatic memories and has been utilized for the treatment of trauma. affective. It was proven to be effective in comparison with other trauma focused techniques (Bisson & Andrew. 2007. 138 RINGEL child’s hurt and disappointment. For the next 2 months. these affects and cognitions are activated through bilateral stimulation. related sensory experiences. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. affects. We both feel that we need a reliable structure to depend on. we go through an EMDR protocol during which we process Sandy’s memories related to the abuse. In her groundbreaking book. Her mother’s denial of the abuse and her withdrawal from Sandy further contributed to the deep sense of abandonment and rejection that Sandy experienced. 2007). Sandy gradually realizes how deeply her life is still affected by the aftermath of the abuse. 1992). This is achieved through a therapeutic relationship based on safety and security. 2005). somatic sensations. van der Kolk et al. According to Shapiro. on a twice weekly basis. and finally reconnecting with others through reconciliation with oneself (Herman. either by providing . isolation. Sandy and I spend a long time on establishing safety and trust. She learned to regulate her untenable affects through avoidance. I explain to Sandy how EMDR works. acknowledging their misattuned behavior. EMDR was developed by Francine Shapiro (Shapiro.

1998. the little girl self state takes over her still fragile adult self that she has worked so hard to develop. and that she can return whenever she is ready. During the EMDR procedure. Gradually. the EMDR therapist also prompts the patient to attend to bodily sensations associated with the trauma.This document is copyrighted by the American Psychological Association or one of its allied publishers. but never followed through. The feelings of disappointment and betrayal by her grandfather who she idolized and admired are confusing and painful. Bromberg suggests that traumatized patients develop a mental structure of separate. However. and this is particularly helpful with trauma patients who. and improvisational nature of our previous work in which Sandy took the lead. 1999). The protocol has been adapted for adults with complex childhood trauma (Parnell. INTEGRATIVE MODEL IN TRAUMA TREATMENT 139 visual stimuli. Sandy typically disappears for weeks. she could stop at any time when the memories became too overwhelming. This little girl does not trust anyone’s words and promises. sound. especially during the Christmas holidays. During the Christmas season. there is an emphasis on physiological and affective experiences. Although this can be frustrating—and at times I am very concerned about her—I try to be as flexible as I can and let her know that I am available. When she returns. The EMDR process occurred twice weekly for approximately 2 months. for example. As we progressed. the EMDR protocol gradually changed into a more spontaneous. creative. Along with visual. she disappears for weeks and does not respond to my phone calls. As discussed previously. do not always possess the language to describe their experience. when the abuse usually took place. She haltingly reports the sense of pressure. or alternate tactile tapping. during the EMDR procedure. patients experience a threat to the dismantling of their familiar and protective dissociative structure that may render them more vulnerable for retraumatization (Bromberg. the tastes. At those times. and her difficulty in breathing under a heavy weight. but she is also terrified and feels suffocated and trapped. dynamic format. angry. 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. affective. and which refuses to come out. 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. thoughts. incompatible self states. During the desensitization procedure. but her body remembers. directive model of EMDR contrasts with the unstructured. and cognitive focus. that she is on my mind. and later on cognitive integration. Many of her experiences have no words or visual images. I encourage Sandy to describe to me the memories associated with the abuse and the images that come to her mind. the client is encouraged to reexperience aspects of their traumatic past and is then taught to integrate these experiences into more adaptive cognitive structures. Sandy is aware of the little girl self-state but feels helpless to manage her when she becomes fearful. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. EMDR includes a structured approach that seemed to offer comfort and security for Sandy. fearful and resentful. . She is longing for love and attention from her grandfather and would do anything to please him. the linear. and negative cognitions associated with the memories. spontaneous. or demanding. whereby. We agreed on basic ground rules. He would promise her treats after she had been “nice” to him. when we resumed our unstructured. 2003). When Sandy feels threatened by our exploration of her dissociated self states. and dynamic process where Sandy decided what she wanted to work through and how. I become acquainted with Sandy’s little-girl self state. which is usually in hiding. and I readily followed. I ask her to experience her bodily sensations and the feelings. like Sandy. 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.

and blood flow from Sandy’s nose and mouth. She describes a box. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. an element of play appears as well (Ringstrom. on the other hand. for both the adult Sandy and the child. She experiences deep sorrow and regret regarding her inability to love and parent her children. It is Halloween.” 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. you see?” Sandy seems much lighter as she leaves my office. I ask her to describe the part of herself that she would like to enter. and Sandy brings in a skull. cursing and enraged. Sandy is able to draw on our connection and her deepening trust in me and in our work. Gradually. I. like her mother. saliva. how to play with her but also how to set reasonable limits. He is in every stranger she meets and therefore she cannot trust anyone. another self state emerges—a powerful and angry Sandy whose voice is loud and imposing. 140 RINGEL Eventually. and we continue to forge on. but she is also impulsive and stubborn. As she talks to her “mother. Her mother is no longer the powerful witch but a fragile old woman for whom Sandy feels empathy and compassion. Sandy recognizes that. Sandy and I learn together how to comfort and reassure her. and abandoned she felt with no one to offer her support and protection. In this enactment. I also encourage Sandy to listen and communicate with the little girl part of herself and to invite her in as often as possible. Tears. disappointed. At this point. we confront the mother/witch to try and loosen her hold over Sandy. Her adult self is still fragile and tenuous. When she disappears.This document is copyrighted by the American Psychological Association or one of its allied publishers. she needs to feel loved by me. feel quite overwhelmed by Sandy’s unexpected physiological response. Together. She then envisions a wall she dares not look beyond. She too may have been abused by her father (Sandy’s grandfather) but. I experience loving maternal feelings. She is angry at her mother who had ignored the abuse but was also critical of and competitive with her. we are both startled as Sandy cries out. 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. An old monster leers at her and threatens to control and overpower her. . but she comes to recognize how constrained and boxed in her life has become. and her disappearance triggers my own vulnerability to abandonment. though staying there leaves her isolated and withdrawn. She is afraid of people. but she is starting to learn how to regulate and comfort her childlike self. she cannot tolerate this knowledge. a black wig. both safe and confining. she had also abandoned this part of herself and that her little girl self is still longing for attention and recognition. because it is too raw and painful. I worry about her. As the EMDR aspect of our work fades and we return to a more spontaneous and improvisational mode. if so. Suddenly. fear. Although I validate (little) Sandy’s outrage. as the fear subsides. and sense of isolation and betrayal. who have not spoken to her in several years. and she longs to make amends. Her little girl can be playful and lovable at times. Sandy does not want to talk about what happened with her grandfather. 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. granddad loses his hold on Sandy and becomes more and more distant. and he no longer matters. I know that in order for Sandy to love the child. I recognize that my experience mirrors Sandy’s memory of her mother. 2007). he has lost his power. This recognition about her mother seems to free Sandy to view her mother in a new way. “You see what he has done to me. and a broom. which has imprisoned her all of these years. and how fearful it is to leave it. We discover that as Sandy releases her fear and rage toward her grandfather other affects emerge. At first. who confronts her grandfather. In a ceremonial ritual we set the objects on a chair and Sandy tells her mother/witch how betrayed.

which is central in a relational psychoanalytic treatment. 1997). Stern. 2009). and the wise woman who sees everything but who is still quite fragile. 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. She has started to trust herself and to trust me that we will figure out where we need to go and will survive it. the EMDR procedure was undertaken as an adjunctive technique within a relational treatment framework. collaborative ways to relate to one . There is sufficient trust between us that she is able to tolerate the uncertainty and open-ended nature of a more dynamic process.This document is copyrighted by the American Psychological Association or one of its allied publishers. 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. thereby enacting the early trauma between the patient and significant others as well as between incompatible self states within the patient. such as prolonged exposure (Foa et al. both as an outcome of traumatic experiences and as a function of unconscious everyday life (Bromberg.. Rather. 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. INTEGRATIVE MODEL IN TRAUMA TREATMENT 141 The EMDR procedure allows us to open up the therapeutic space to painful self states that we were unable to access previously. and spontaneous relational moments in the treatment. as I described in terms of our enactment of abandoning mother and abandoned child. These intersubjective processes include the cycle of rupture and repair. A relational approach in the treatment of trauma can help investigate and elaborate on the intersubjective implications of the traumatic experience. Traumatized patients organize their experience around separate and incompatible self states that allow them to compartmentalize unbearable memories and relational experiences. charming. The Integration of EMDR With a Relational Approach Much like other exposure therapies. but eventually Sandy no longer needs the safety and security of the structured procedure. Sandy realizes that she has built protective masks around herself—the Grandpa mask that is self confident. enactments. This conflict is enacted when each member of the dyad takes on binary roles in relation to the other. These polarized self states inevitably manifest in the patient–therapist relationship through what Benjamin called the “doer done to” dilemma (Benjamin. 2005) and somatic experiencing (Fisher & Ogden. the therapist acts as a facilitator utilizing a structured procedure. 2004). In this paradigm. With Sandy. it was utilized for a time to help access dissociated memories and self states that may otherwise have been inaccessible. 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. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. 2011. patient and therapist become victim and perpetrator or victim and abandoning/rejecting caregiver. and arrogant and the “Mother Mary” mask that is kind. We spend a long time reflecting on what had happened and deepening our understanding of the trauma and its impact on her life. 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. loving and caring— but that she still does not know who she really is. although I did try to show how countertransference factors as well as my own vulnerability were very much part of the process. EMDR does not emphasize the intersubjective process between therapist and patient.

and for Sandy. Schore. implicit processes within the patient. I wanted to be the reliable. she just wanted to act on her impulses and shop in order to avoid her feelings and flashbacks. but I also recognized that I felt manipulated and resentful. I felt torn. Sandy began to cry. to see that she had an impact on me and that her actions held consequences for others who could also feel hurt and dismissed. 2011a. we negotiated an arrangement that we both felt was fair. 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. 2009). rather than face them with me. afraid of me. I had become the victim. linear model such as EMDR. 2011). but I realized that I had my own needs and that I felt dismissed and victimized by her. At times. but that at times she was afraid to come to the session. nonverbal aspects of traumatic experience. Current neuroscientific data (Bucci. I acknowledged and validated Sandy’s pain. frightening experiences with caregivers who themselves are traumatized and helpless or are frightening and abusive (Hesse et al. She told me that she valued me and the work we were doing. 2005) and sensorimotor therapy (Fisher & Ogden. 2011) supports the notion that nonverbal. Subsequent reflective processing and insight can then help to integrate previously dissociated . organize. which was initially understood as a byproduct of her unpredictable attacks of fibromyalgia and other physical disabilities.. 2003). became more accessible for investigation and for mutual negotiation. I told Sandy that I thought it was important that we discuss the implications of her behavior on both of us. The roles of caretaker. It was important for me.. Benjamin. and manage chaotic. Sandy’s habitual pattern of frequently calling in sick. missing sessions. After working through early traumatic events that curtailed Sandy’s capacity for creative and interpersonal expression. 2004) or when the patient can hold conflicting self states without the need to dissociate (Bromberg. 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. For example. 2011b. and I felt that it would be important for us to process and understand together how Sandy’s past had shadowed our own relationship.This document is copyrighted by the American Psychological Association or one of its allied publishers. rather than face me and discuss her painful memories and intolerable feelings. while waiting for her and when not getting paid. and at times resentment. She inevitably went deeper into debt. I expressed my disappointment. 142 RINGEL another (Aron. loving parent who provided Sandy with unconditional love. we gained a better understanding of how the traumatic events of her past shaped the dynamics between the two of us. EMDR is one among several trauma-focused approaches including prolonged exposure (Foa et al. Eventually. 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. helpless victim. all of which may help to access traumatic experiences through physiological and affective channels. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. Sandy admitted that she preferred to go on spending sprees in order to sooth her emotional hunger and to distract herself from flashbacks. and at times could not pay for her sessions. can work well as complementary models in the treatment of trauma. along with EMDR’s emphasis on the implicit. and between patient and therapist are vital conduits of memory and experience. afraid of the pain. within the therapist. and not paying. A relational focus on the intersubjective process between patient and therapist. aggressor. 2006. In this enactment. At times. especially in the case of early trauma that had occurred before cognitive and verbal functions were well developed.

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