EMDR and Theoretical Orientation: A Qualitative Study of How Therapists Integrate Eye Movement Desensitization and Reprocessing Into Their Approach to Psychotherapy Kimberly E. DiGiorgio, Diane B. Arnkoff, Carol R. Glass, Kristina E. Lyhus, and Rebecca C. Walter The Catholic University of America This study examined how 3 therapists from differing theoretical orientations (psychodynamic, humanistic, and cognitive–behavioral) integrate eye movement desensitization and reprocessing (EMDR) into their work with clients. The consensual qualitative research method was used to analyze interview responses from each of the therapists. All of the therapists deviated from the standard EMDR protocol to some degree, and their decisions to either add to or leave out various aspects of the protocol were greatly influenced by their theoretical orientation. They reported that the integration of EMDR into their usual therapy styles varied depending on their clients. The present study expands on previous psychotherapy integration research because it provides detailed descriptions as to how therapists actually use a specific method with clients. Findings may be particularly useful for researchers and therapists interested in the practice of EMDR, as well as the process of assimilative integration. Therapists often report that they integrate various theoretical approaches in their psychotherapy. For example, some clinicians have integrated behavioral aspects (i.e., systematic desensitization and exposure) into psychodynamic therapy approaches (Kraft, 1969; Wachtel, 1977; Kimberly E. DiGiorgio, Diane B. Arnkoff, Carol R. Glass, Kristina E. Lyhus, and Rebecca C. Walter, Department of Psychology, The Catholic University of America. Kristina E. Lyhus is now at the Office of Counseling and Health, Drexel University. We would like to thank Clara Hill for providing us with information on the CQR method, allowing us to sit in on several of her research group meetings, and consulting with us during data analysis. Correspondence concerning this article should be addressed to Diane B. Arnkoff, Department of Psychology, The Catholic University of America, Washington, DC 20064. E-mail:[email protected] 227 Journal of Psychotherapy Integration 2004, Vol. 14, No. 3, 227–252 Copyright 2004 by the Educational Publishing Foundation 1053-0479/04/$12.00 DOI: 10.1037/1053-0422.214.171.124 228 DiGiorgio, Arnkoff, Glass, Lyhus, and Walter Weitzman, 1967). Survey studies have found that practicing psychologists tend to favor eclectic therapeutic approaches that combine aspects from cognitive, behavioral, and psychodynamic orientations (Norcross, Alford, & DeMichele, 1992; Norcross & Prochaska, 1988). Psychotherapy integration has grown in popularity, partly because clinicians have found that methods from single theoretical orientations are often insufficient (Beitman, Goldfried, & Norcross, 1989; Garfield & Kurtz, 1977; Stricker, 1994, 1997). Goldfried (1991) also has suggested that there is an interest in psychotherapy integration because outcome research has consistently been unable to demonstrate the superiority of one theoretical orientation over another. Despite the growing interest in psychotherapy integration and therapists’ claims that they practice eclectic or integrative therapy, research to date has not examined what integrative therapists actually do during their sessions. Researchers are increasingly recommending that typical treatments used in practice settings be examined to better understand their use with clients (Street, Niederehe, & Lebowitz, 2000). To more closely examine the process of psychotherapy integration, in the present study we chose to focus on the treatment known as eye movement desensitization and reprocessing (EMDR; Shapiro, 1989, 1995). EMDR incorporates aspects of behavioral, cognitive, psychodynamic, and experiential approaches in its use of exposure, negative and positive cognitions, an emphasis on early childhood experiences, and selfexploration and body awareness, respectively (Shapiro, 1995; Shapiro & Forrest, 1997). In addition to the integrative nature of EMDR, many therapists who use EMDR report that they integrate it into the therapeutic techniques they normally practice. This type of integration is called assimilative integration, because therapists are assimilating techniques from other approaches into their primary theoretical structure (Messer, 1992, 2000; Stricker, 1994). Assimilative integration draws on differing therapy approaches but is guided by a unitary theoretical understanding (Stricker, 1994). For example, Wachtel (2002) described how he has used EMDR in combination with his cyclical psychodynamic approach, in which he conducts EMDR but interjects interpretive comments during the desensitization process. Specifically, Wachtel has explained that he helps clients both structure and make sense of their thoughts, in addition to pointing out conflicts that his clients may not be aware of. Young, Zangwill, and Behary (2002) described how EMDR can be combined with cognitive-schema– focused therapy to better help clients recognize and deal with painful schemas. Bohart and Greenberg (2002) discussed how EMDR often centers around clients’ emotional and physical sensations while encouraging client- EMDR and Theoretical Orientation 229 centered methods of healing that are not therapist directed. EMDR appears to be used differently by clinicians from differing theoretical orientations, but this issue has not been systematically studied to date. Because EMDR is integrative both in its protocol and in how it is used by therapists, studying therapists’ use of EMDR is a unique opportunity to study psychotherapy integration. EMDR particularly lends itself to this kind of investigation because it is a highly structured protocol, which makes therapists’ changes in the method easier to assess. Other researchers have used surveys to ask EMDR-trained therapists about their experiences with and fidelity to the EMDR protocol. For example, Lipke (1994) surveyed therapists who had completed Level I and Level II training in EMDR to learn about their experiences while using EMDR with clients. His survey yielded some interesting findings related to therapists’ perceived effectiveness and negative effects but did not provide any information as to the different ways that the therapists used EMDR. Consequently, Kleiner (1999) constructed a survey that attempted to reveal how therapists were actually using EMDR and whether their use differed from the training protocol. She found that some clinicians did report deviating from the standard protocol in such areas as session length and completion of the body scan. Although her findings provide some insight into treatment fidelity, more specific questions as to how therapists use EMDR remain unanswered. The quantitative data obtained from such surveys provide useful information but often fail to capture the complexity and depth of the phenomena being studied. Hill, Thompson, and Williams (1997) concluded that survey studies are often inadequate when studying phenomena that occur during the course of a therapy session. Even when surveys contain open-ended questions, some of the richness of the data is lost when the responses are categorized and then analyzed statistically. Consequently, Hill et al. recommended that researchers use qualitative methods to analyze open-ended questions, allowing the responses to serve as guides for the categorization of the phenomena. Hill et al. argued that, through interviews, qualitative researchers can inquire about and explore phenomena as they naturally occur, without being constricted by previously determined constructs, as in quantitative surveys. This allows qualitative researchers to organize and describe the phenomena under study with greater richness and depth. For example, Rennie (1992) conducted a qualitative analysis of a client’s experience of psychotherapy and analyzed the data using the grounded theory approach. This approach encourages researchers to focus on generating rather than verifying theories. Throughout this process, researchers record any theoretical ideas and hunches they may develop along the way, form descriptive categories that are based on commonalities found 230 DiGiorgio, Arnkoff, Glass, Lyhus, and Walter within the data, and explore relationships between and among these categories and the data. Another method for analyzing qualitative data, the consensual qualitative research (CQR) method, was developed by Hill et al. (1997) with the understanding that complex issues discussed during interviews often involve “multiple perspectives and levels of awareness” (p. 523). Consequently, CQR requires that researchers on a team openly discuss any ambiguities in meanings that may exist in the data obtained during the interviews. This open discussion allows for clarification and often promotes more accurate conceptualizations of the data. CQR directs researchers to group data into domains (clusters of similar topics), construct core ideas (summaries of domain content), and conduct cross-analyses (identification of the themes in the core ideas across the cases) to determine the categories in which the core ideas fit. Several studies on psychotherapy have used the CQR method to analyze the qualitative data obtained during interviews (e.g., Gelso, Hill, Mohr, Rochlen, & Zack, 1999; Hayes, McCracken, Hill, Harp, & Carozzoni, 1998; Knox, Goldberg, Woodhouse, & Hill, 1999). For example, Hayes et al. (1998) used the CQR method to examine therapists’ perspectives on countertransference, whereas Gelso et al. (1999) used the CQR method to answer questions about therapists’ perceptions of transference in long-term therapy. In the present study we used the CQR method to examine what three well-known psychotherapists from differing theoretical orientations (Paul Wachtel, Art Bohart, and John Marquis) said they actually do while using EMDR with clients. We chose to interview only three psychotherapists because of the exploratory nature of the study, which was designed to get an initial understanding as to how therapists combine the techniques of EMDR with their own primary therapeutic approaches. Findings were predicted to be useful for therapists and researchers who want to better understand how therapists use EMDR with their clients. In addition, findings may provide insight as to how theoretical orientation may influence the practice of EMDR, as well as the process of assimilative integration. METHOD Participants Therapists Three well-known psychotherapists from differing theoretical orientations trained in EMDR served as participants. All of the participants were male Caucasians who ranged in age from 57 to 71 years. Specifically, John Marquis, Paul Wachtel, and Art Bohart represented cognitive–behavioral, psychodynamic, and humanistic theoretical orientations, respectively. EMDR and Theoretical Orientation 231 Interviewer and Judges Kimberly E. DiGiorgio, a clinical psychology doctoral student with Level I EMDR training, conducted the audiotaped interviews and served as one of the judges on the primary research team. The primary research team also consisted of Diane B. Arnkoff (a licensed clinical psychologist and professor with Level I EMDR training), a clinical psychology doctoral student with Level I EMDR training, and a clinical doctoral student who had not been trained in EMDR. Carol R. Glass, who is a licensed clinical psychologist and professor of psychology, served as the auditor, who independently evaluated the work of the rest of the team and offered suggestions for changes. She had completed Level I and Level II training in EMDR. All 5 of the team members reported that their current theoretical orientation was primarily integrative, with 2 having a psychodynamic base, 2 having a cognitive–behavioral base, and 1 still undecided. In a discussion of whether it is important to adhere to the EMDR protocol, the team members believed that therapists should initially adhere to the protocol until they become comfortable enough to deviate from it. Ultimately, they agreed that adherence to and deviation from the protocol should be dependent on the client. In terms of why EMDR works, team members suggested that exposure, divided attention, free association, access to emotions, and client-demand characteristics may contribute to its success. Measures Demographic Questionnaire The demographic form asked for basic information about the participants: gender, age, race/ethnicity, highest professional degree obtained, field of specialization, number of years as a licensed psychotherapist, and training in EMDR. In addition, therapists were asked to select the setting(s) in which they typically practice, indicate the number of clients treated with EMDR, and rate on a scale from 1 (not at all) to 7 (to a great degree) the extent to which their work was guided by the following theoretical frameworks: psychoanalytic or psychodynamic, behavioral or cognitive, and humanistic/experiential. Next, therapists selected the theoretical framework that best represented their primary pure-form theoretical orientation. Last, therapists indicated (on a 7-point scale, ranging from 1 [not at all] to 7 [to a great degree]) the extent to which they regarded their orientation as eclectic/integrative. 232 DiGiorgio, Arnkoff, Glass, Lyhus, and Walter Interview The interview consisted of 16 questions that were designed to get at the core of what therapists say they actually do while using EMDR with clients in private practice. Each of the three interviews began with general questions asking therapists to describe their initial training in psychotherapy, their current theoretical orientation, and the typical therapy approach they use with clients, apart from EMDR. The remaining questions included asking the therapists about the types of clients with whom they typically use EMDR, how they integrate EMDR with their typical approach, changes they make to the standard EMDR protocol, and their thoughts on why they think EMDR works. Procedure Recruiting Therapists After a discussion of the types of theoretical orientations that we wanted to be represented in this study, the research team agreed on 3 therapists, all of whom use EMDR, to recruit for participation. The therapists were recruited through an e-mail letter that asked if they would be willing to participate in the study. Each of the 3 therapists agreed to participate and was mailed a research packet that contained an informed consent form, a list of the questions that would be asked in the interview, and the demographic form. The therapists mailed the signed consent form and the completed demographic form back to Kimberly E. DiGiorgio. The therapists was asked to think about the interview questions and how they would respond to them prior to the actual interview. After the interview, participants were sent an e-mail message asking if they consented to being named in publications from the study. Each consented through an e-mail response. Interviewing After arranging interview times through e-mail, Wachtel and Marquis were interviewed over the telephone and Bohart was interviewed in person by Kimberly DiGiorgio for 50, 72, and 60 min, respectively. Interviews were audiotaped with permission of the participants. At the end of each interview, the interviewer made brief notes on the interview, making sure to record how long the interview lasted and the extent of the rapport EMDR and Theoretical Orientation 233 between the interviewer and the interviewee. The interview concluded with a brief debriefing for each participant about the study. Transcripts The audiotapes were transcribed verbatim by Kimberly DiGiorgio and then checked by another graduate student on the research team. Before any of the transcripts were read, the primary research team explored their own expectations and/or biases by answering each of the interview questions that were given to the therapists. Once these expectations and biases were identified, the four primary team members met to discuss them with each other. Procedures for Analyzing Data The data were analyzed using the CQR method (Hill et al., 1997). The main goal of CQR is to have researchers arrive at consensus about meaning, significance, and categorization of the data. Consensus is accomplished through open discussion among team members of the interview topics. The main disagreements that arose within the primary research team occurred in the development of domains and the subsequent segmenting of raw material into the domains. These disagreements were resolved through a discussion among the team members. For example, some members of the team initially disagreed as to whether Domain 2 (current practice) should be divided into integrative and nonintegrative. After a detailed discussion that considered many options, the team agreed on the use of these subcategories. Another disagreement occurred when developing Domain 3 (initial training and history of experience in EMDR). Specifically, the team debated and eventually reached consensus that this domain should include a division that referred to experience and comfort level, in addition to initial interest and training. Determination of Domains The domains (topic areas) were initially developed by the primary research team by clustering the interview questions into similar topics. These original domains were then modified accordingly so that they best reflected the data, resulting in 14 domains in total. 234 DiGiorgio, Arnkoff, Glass, Lyhus, and Walter Domain Coding Each primary research team member independently read through the first individual transcript and assigned each block of data (one complete thought, ranging from a phrase to several sentences) to a domain. Then, as a group, the primary team discussed under which domain each block of data should be placed, until they reached consensus. This process was repeated for the remaining two transcripts. For example, the following excerpt, taken directly from Wachtel’s transcript, was placed into Domain 6 (procedural variations for different clients). Interviewer: (p. 5) Do you use EMDR differently with different clients? And if maybe you could give an example of how you do that? Wachtel: Well, I think the example I just gave sort of illustrates in general how my use of it is sort of geared to the particular situation of the particular person. There are some for example with someone for whom intrusiveness has been an issue. I might make fewer interpretive comments and let it be closer to just what comes up. For someone for whom emotional abandonment has been an issue, I might be more inclined to be more actively structuring, responding, giving my own input and so on. To provide a check on the development of the domains, the auditor reviewed the classifications and decided whether the raw material was in the correct domain. The primary team reviewed the auditor’s comments and agreed on which changes to make. Core Ideas Primary team members next independently read through all of the raw data for each domain and prepared a brief summary. Then, core ideas were written to express the general ideas of the data in concise and abstract terms. As Hill et al. (1997) recommended, we adhered very closely to the explicit meaning of the data, rather than making inferences that were not based purely on the data. Next, the team met as a whole and discussed the core ideas until a consensus was reached. For example, using the same excerpt taken from Wachtel’s transcript, the group developed the following core idea to describe the data that had been placed into Domain 6: He uses EMDR differently, geared to the individual client’s situation, as an extension of the way he generally works. With clients for whom intrusiveness is an issue, he might make fewer interpretive comments. With clients for whom emotional abandonment is an issue, he might be more active in the process by structuring, responding, and providing some of his own input. EMDR and Theoretical Orientation 235 The auditor reviewed whether the material in the domains was appropriately abstracted into core ideas and whether the wording of the core ideas was reflective of its content. After receiving comments from the auditor, the primary team decided whether they wanted to make the suggested changes. Cross-Analysis Once a final consensus on the domains and core ideas was reached, we moved beyond considering individual transcripts and instead looked across transcripts to determine whether there were similarities among the cases in the sample. To do this, the core ideas in each domain were combined across the cases. Next, the core ideas within the domains were examined by the primary team to determine how they would likely cluster into categories. Team members worked as a group to determine how the categories could best describe the phenomenon in words. For example, the five crossanalysis categories derived from the set of core ideas in Domain 6 are included in Table 1. Categories were classified as being general, typical, or variant depending on whether they applied to all three cases, two cases, or one case, respectively. Audit of Cross-Analysis Once the categories were agreed on, the auditor reviewed the crossanalysis and made suggestions for improvements. The primary team members then decided whether to make the suggested changes. RESULTS Responses to the demographic questionnaire indicated that each of the therapists typically conducts therapy in an independent practice setting. Marquis reported that he also sees clients in general hospitals–medical centers and veterans affairs–military medical centers. When asked to approximate the number of clients each had treated with EMDR, Marquis reported treating the greatest number of clients (>100), followed by Wachtel (6–10), and Bohart (1–5). In addition, all of the therapists indicated that they regard their theoretical orientations as being eclectic/integrative, at least to some extent, with Wachtel considering his approach to be the more integrative (7 on a scale from 1 to 7), followed by Bohart (4) and Marquis (4), who consider their approaches to be somewhat integrative. 236 DiGiorgio, Arnkoff, Glass, Lyhus, and Walter Table 1. Domains, Cross-Analysis Categories, and Frequencies Questions, domains, and categories How did you become interested in EMDR? Domain 3a: Initial interest and training in EMDR Received training in EMDR Initially skeptical Interest based to some degree on EMDR’s effectiveness Obtained training because asked to write chapter in Shapiro’s (2002) book Experienced a strong emotional reaction during EMDR training Domain 3b: Experience and comfort level Use it with a full range or majority of clients Not a great deal of experience Sought EMDR therapy to experience client’s perspective Among the first group to be trained and am in training now Not comfortable enough to deviate from general EMDR protocol Use feels exploratory and nonsystematic What types of clients do you use EMDR with? Domain 4a: Clients, issues, and processes suitable for EMDR Use when there is a traumatic memory, anxiety, or fear Use with a variety of clients whose problems range from specific disorders/issues to less specific issues Use based on client markers/experiences Use with less specific/less identifiable problems Use for issues where it has been shown to be effective When would you not use EMDR with a client? Domain 5: Contraindications for EMDR Cautious or would not use with dissociative clients Would not use with a client who seemed skeptical, resistant, or opposed Would not use with some clients with OCD Would not use initially with emotionally volatile, labile, or sexually abused clients Would not use without an appropriate target, with a problem that could be addressed another way, or when it would open up things the client was not ready for Cautious about use if it could delay client taking action Is EMDR used differently with different clients? Domain 6: Procedural variations for different clients Use differently depending on the client Degree of therapist activity depends on client’s need Eye movements used with and without full protocol Number of associations and themes addressed depends on client functioning and pathology Add therapeutic techniques when clients have low self-esteem and are progressing slowly How do you decide when in the course of therapy to first use EMDR with a client? Domain 7a: Decision rules: first introduction Use to address a specific issue or trauma May first use if client has reached an impasse Decision depends on diagnosis and degree of pathology Use when a client is just talking intellectually Use when a client brings up an experience that distills many experiences Use when a client brings up interest in EMDR Frequency General Typical Typical Variant Variant General Typical Variant Variant Variant Variant General Typical Variant Variant Variant General Typical Typical Variant Variant Variant Typical Variant Variant Variant Variant General Typical Variant Variant Variant Variant EMDR and Theoretical Orientation 237 Table 1. (continued) Questions, domains, and categories After using EMDR for a particular target memory or experience, how do you decide whether to use EMDR again with that client? Domain 7b: Decision rules: continued use Continue if other problems/fears arise for which EMDR could be useful Use again if it led to progress Use if there is an impasse Use if there is an idea to install What does EMDR add to your work with clients that other strategies you use do not provide as well? Domain 8: Ways that EMDR makes a positive contribution to clinical practice Works more quickly than other approaches, at least sometimes Engages some clients more effectively Produces emotion-laden/deeper and broader set of associations Facilitates the use of other interventions by reducing emotional blocks/resistances Serves as a reinforcing/opening-up function and allows clients to reexperience events in the moment Allows clients to deal more thoroughly with traumatic issues Allows clients to change perspective and body sensations How do you go about combining/integrating your typical approach with EMDR? Domain 9: Integration of EMDR with typical approach EMDR can be a supplement to other procedures Other methods can be used as supplements to EMDR Use my typical methods to help the client reflect on the EMDR experience Integrate EMDR into a 2-person psychoanalytic model Integrate differently depending on whether I am using EMDR to reinforce learning or to explore When you use EMDR, what, if anything, do you tend to leave out or add to the standard EMDR protocol you learned during the Level I and Level II training? Domain 10a: Possible deviations from EMDR protocol: additions Interested in adding to the EMDR protocol in ways that enhance its effectiveness Use EMDR interactively, adding interpretations and reflection Add behavioral approaches and more cognitive interweave Domain 10b: Possible deviations from EMDR protocol: subtractions Leave out various elements to maintain natural flow of session Use EMDR as the client wants Leave out the negative and positive cognitions Domain 10c: Possible deviations from EMDR protocol: no change Stick to the standard protocol at first Use full protocol when there is a specific issue to target or if it is otherwise warranted Do not feel adept enough to deviate Stick to the standard protocol if difficulties arise In what way, if any, has including EMDR into your therapy with clients changed the nature of the therapeutic relationship? Domain 11a: Effect of EMDR use on therapeutic relationship: no change Style of using EMDR is the same as my usual style (Table Frequency General Typical Variant Variant General Typical Variant Variant Variant Variant Variant Typical Typical Typical Variant Variant Typical Variant Variant General Variant Variant Typical Variant Variant Variant Typical continues) 238 DiGiorgio, Arnkoff, Glass, Lyhus, and Walter Table 1. (continued) Questions, domains, and categories Domain 11b: Effect of EMDR use on therapeutic relationship: change Improved relationship due to quick and dramatic results Changed when using eye movements due to differences in physical proximity What is the most challenging experience you have had while doing EMDR? Domain 12: Challenging experience with EMDR Client was unable to engage in the procedure successfully Challenging when clients have very low self-esteem, or are multiply traumatized and dissociative Why or how do you think EMDR works? Domain 13a: How and why EMDR works: mechanisms/theories of change in EMDR Bilateral stimulation may facilitate communication among parts of the brain May be a placebo or an alternate form of exposure Is not just a form of exposure therapy but may involve reciprocal inhibition Disrupts intellectual, overly critical thinking and facilitates observing lettingin mode of processing Produces more rapid and emotion-laden responses May promote free association and access to experience Domain 13b: How and why EMDR works: similarities to other therapy approaches Disruption of an overly critical way of attending to the self and shift into a more receptive mode of processing Frequency Variant Variant Typical Variant Typical Variant Variant Variant Variant Variant Variant Note. General ⳱ this was stated by all three therapists; typical ⳱ this was stated by two therapists; variant ⳱ this was stated by one therapist. EMDR ⳱ eye movement desensitization and reprocessing; OCD ⳱ obsessive–compulsive disorder. The members of the primary research team decided not to create categories for those domains that primarily related to initial training and orientation, broadening–change of approach (Domain 1), and current practice (Domain 2), because the therapists were specifically chosen because they were different in each of these areas. Creating categories for these domains thus would not have provided additional information for the team. Instead, these domains were used both to affirm that the therapists represented various theoretical backgrounds and to foster the overall understanding of the cases. Domain 14 (other) was also not categorized. With regard to initial training and orientation, Wachtel was initially trained in psychoanalytic/ego psychology and received postdoctoral training in psychoanalysis. Bohart’s initial training was eclectic and included supervision from behavioral, Gestalt, and psychodynamic approaches. However, he eventually aligned himself with a client-centered/experiential orientation. Similarly, Marquis’s initial training had a variety of influences, including psychodynamic, therapy that was based on Kelly’s (1955) psychology of personal constructs, and client centered. However, unlike Bohart, Marquis adopted a primarily cognitive–behavioral orientation. In terms of broadening–changing of approach, Wachtel and Bohart reported that they increasingly began incorporating new techniques into EMDR and Theoretical Orientation 239 their regular approaches but did so for varying reasons. Wachtel explained that he was dissatisfied with certain aspects of the psychoanalytic approach (particularly a refusal to examine closely issues of intervention) and thus sought to create an integrative model that used efficacious aspects from other approaches (e.g., behavioral). Bohart decided to expand on his original approach because of others’ insistence that aspects of client-centered therapy were inadequate. He explained that he continues to explore and use new techniques as long as his clients like them. On the other hand, Marquis has not moved beyond cognitive–behavioral approaches but instead tries to broaden the application of behavioral techniques to various psychological problems. Furthermore, with respect to current practice of therapy, Wachtel and Bohart described their therapy as being integrative to some degree. Although Wachtel uses a nonintegrative psychoanalytic style while listening and talking to clients, he explained that he is integrative and often incorporates exposure, systematic desensitization, and reinforcement into his work with clients. In addition, Wachtel sometimes uses family-system approaches and techniques (e.g., paradox and reframing) when attending to family dynamics and how they may shape the client’s experiences. Bohart, although fundamentally client centered and experiential, is primarily integrative and uses such methods as cognitive–behavioral, family systems, solution focused, coaching, and, occasionally, psychodynamic. The methods he decides to use are influenced by the client’s preferences. Unlike the first 2 therapists, Marquis is not integrative in his practice of therapy. Instead, he uses a number of behavioral and cognitive–behavioral interventions including but not limited to skills training, communication training, cognitive therapy, relaxation training, and exposure. The results for the rest of the domains and their categories are presented in Table 1, with the exception of Domain 4b (specific client examples) and Domain 14 (other). Each of the domains are discussed and examples of some of the core ideas for these domains are provided to summarize the responses from the therapists. How Did You Become Interested in EMDR? Initial Interest and Training in EMDR (Domain 3a) Although Wachtel and Bohart were initially skeptical (typical response; i.e., applying to 2 participants), all 3 therapists received training in EMDR (general response; i.e., applying to all 3). While in search of new therapy techniques, Wachtel and Marquis were particularly impressed with EMDR’s effectiveness and the thoughtfulness of Shapiro’s (1999) discus- 240 DiGiorgio, Arnkoff, Glass, Lyhus, and Walter sion of the pros and cons of the outcome research (typical). During the training, Wachtel experienced a strong emotional reaction while targeting a childhood experience in the client role. Bohart became interested in EMDR after being asked to write a chapter on EMDR and experiential psychotherapy for Shapiro’s book on what experts from various theoretical orientations have to say about the integrative nature of EMDR (Shapiro, 2002). Experience and Comfort Level (Domain 3b) Not surprisingly, the therapists varied in the degree to which they felt comfortable using EMDR with their clients. Marquis was among the first group to be trained and is currently training other therapists in EMDR. On the other hand, Wachtel and Bohart described themselves as lacking depth of experience in EMDR (typical). Specifically, Bohart said he is not comfortable enough to deviate from the general EMDR protocol, and Wachtel suggested that his use of EMDR feels exploratory and nonsystematic. Despite the varying degrees of comfort level and experience, all of the therapists described using EMDR with a full range of their clients (general). Clients, Issues, and Processes Suitable for EMDR (Domain 4) Regardless of their theoretical orientations, each of the therapists indicated that he uses EMDR when there is a traumatic memory, anxiety, or fear that needs to be worked through and resolved (general). Wachtel and Marquis explained that they use EMDR with a variety of clients whose problems range from specific disorders/issues to less specific (typical). For example, Marquis suggested that EMDR be used with less specific and less identifiable problems such as career, relationship, and self-esteem issues. He described a client with low self-esteem who struggled to gain a conviction that what she cared about was worthwhile. They targeted a specific memory of her father’s dismissiveness, with the goal of helping her become less intimidated by his disapproval and more accepting of her own interests. In addition, Wachtel suggested that EMDR be used for issues where it has been shown to lead to rapid resolution. Furthermore, Bohart explained that he bases its use on client markers or experiences. Specifically, he reported using EMDR with clients who appear to be stuck and not productively exploring, with clients who are talking intellectually and without any felt experience, or when there is a specific target that needs to be worked on. Therefore, each of the therapists suggested some similar uses of EMDR but also differ in some ways. EMDR and Theoretical Orientation 241 When Would You Not Use EMDR With a Client? Contraindications for EMDR (Domain 5) Each of the therapists indicated that they would be cautious or would not use EMDR with dissociative clients (general). In addition, Bohart and Marquis explained that they would not use EMDR with some obsessive– compulsive clients because it is often difficult for them to access emotions (typical). Wachtel and Marquis also reported that they would not use EMDR with clients who seem skeptical, resistant, or opposed to it (typical). Marquis explained that further contraindications for the use of EMDR involve situations where there is not an appropriate target, when client problems can be addressed using other methods, or when the therapist believes EMDR would open up experiences for which the client is not ready. Furthermore, Wachtel explained that he would be cautious about its use with clients for whom it could delay their taking action in the world by placing too much emphasis on working through what is inside their heads. Bohart also suggested that EMDR not be used initially with emotionally volatile, labile, or sexually abused clients. Although the therapists had some differing views on contraindications for the use of EMDR, they expressed some similar concerns and hesitations. Is EMDR Used Differently With Different Clients? Procedural Variations for Different Clients (Domain 6) Often, the therapists’ use of EMDR differs depending on the client (typical). Wachtel explained that the degree of therapist activity depends on his client’s needs. Thus, with clients for whom intrusiveness is an issue, he tends to make fewer interpretive comments. However, with clients for whom emotional abandonment is an issue, he is more active in the process by structuring, responding, and providing some of his own input. Furthermore, Marquis suggested that the number of associations and themes addressed during therapy depends on the client’s functioning and pathology. For example, clients who are high functioning and logical are able to stick with one theme and resolve it quickly. On the other hand, clients who are more pathological and especially imaginative (who usually had traumatic childhoods) tend to bring up numerous associations that need to be worked through. In addition, Bohart explained that his use of eye movements depends on the material the client comes up with during the session. Therefore, he reported that he tends to use eye movements as part of the protocol, to 242 DiGiorgio, Arnkoff, Glass, Lyhus, and Walter reinforce the client insight in the moment, and to target a specific fear without following the full protocol. Thus, despite the fact that each of the therapists have different procedural variations, they indicated that the variations depend on the clients with whom they are working. When to First Use and Continue to Use EMDR With Clients Decision Rules: First Introduction (Domain 7a) All therapists agreed that they would first use EMDR when addressing a specific issue or trauma (general). Furthermore, Wachtel and Bohart explained that they would first use EMDR if their clients reach an impasse and are no longer progressing (typical). Marquis suggested that his decision to first use it depends on the diagnosis and degree of pathology of the client. For example, before introducing EMDR to a moderately pathological client, he would assess for at least one session before setting up the target memory for EMDR. Also, with clients who are seldom happy or relaxed, he reported that he would likely address other pressing issues first. Bohart also explained that he tends to first introduce EMDR to clients who talk intellectually without accessing emotions. Wachtel emphasized that his decision to first use EMDR depends on whether the client is interested in it. He explained that it was useful in a situation in which his client was looking for a way to move beyond a distressing experience. The use of EMDR allowed her to bring up an experience that appeared to be a distillation of many events that had shaped her life. Wachtel suggested that EMDR brought up associative links to the original experience that enabled her to resolve it to some degree. Decision Rules: Continued Use (Domain 7b) Each of the therapists supported the continued use of EMDR in situations in which other problems/fears emerge and need to be worked through (general). Wachtel and Bohart agreed that they would continue to use EMDR if its initial use leads to progress in the client (typical). Additional reasons for continually using EMDR included situations in which clients reach an impasse (Wachtel) and instances when there is an idea that needs to be “installed” (Bohart). Therefore, decisions regarding the continued use of EMDR often depend on clients’ progress in therapy. EMDR and Theoretical Orientation 243 What Does EMDR Add to Your Work With Clients? Ways That EMDR Makes a Positive Contribution to Clinical Practice (Domain 8) The therapists agreed that EMDR sometimes works more quickly than other approaches (general). Also, Bohart and Marquis believe EMDR engages some clients more effectively (typical). Although still exploring the positive contributions of EMDR, Wachtel suggested that it produces emotion-laden/deeper and broader sets of associations that enable clients to experience material with greater affective intensity. Marquis explained that EMDR helps to facilitate the use of other interventions by reducing emotional blocks and resistances that would otherwise prevent learning. He also suggested that EMDR tends to be particularly useful in allowing clients to deal more thoroughly with traumatic issues. Bohart explained that an additional contribution of EMDR centers around its usefulness in allowing clients to change perspective and body sensations. For example, one of his clients targeted an immense feeling of being overwhelmed, immediately became troubled, and shifted from feeling anxiety to feeling extremely frustrated. As indicated above, all of the therapists believe EMDR positively contributes to their work with clients, although in differing ways that are consistent with their primary theoretical orientation. How Do You Combine/Integrate Your Typical Approach With EMDR? Integration of EMDR With Typical Approach (Domain 9) Bohart and Marquis suggested that EMDR can serve as a supplement to other procedures (typical) and that other methods can sometimes be used as supplements to EMDR (typical). For example, Bohart has started with EMDR and then supplemented it with traditional Rogerian therapy, and Marquis has followed EMDR with in vivo exposure for specific phobias. Marquis and Bohart have also preceded the use of EMDR with acceptance and commitment therapies and Gestalt procedures, respectively. Furthermore, Bohart and Wachtel explained that they often use their standard methods to help their clients process the EMDR experience (typical). Wachtel described how he and his clients often reflect on the EMDR experience and any transference issues that may surface. He suggested that this process fits within a two-person psychoanalytic model where EMDR associations are a joint product of what is in the client’s head and how that is shaped by the experience of being with the therapist. Bohart uses clientcentered therapy to explore what the client learned from the EMDR ex- 244 DiGiorgio, Arnkoff, Glass, Lyhus, and Walter perience. He emphasized that his integration of EMDR into his typical approach is dependent on whether he is using EMDR to reinforce learning or to explore client experiences. Taken together, each of the therapists integrates EMDR into his typical approach in different ways depending on his orientation and his clients. What If Anything Do You Tend to Leave Out or Add to the Standard EMDR Protocol? Possible Deviations From EMDR Protocol: Additions (Domain 10a) Wachtel and Marquis expressed an interest in adding to the EMDR protocol in ways that enhance its effectiveness (typical). Specifically, Wachtel explained that he is interested in determining whether his innovations enhance or diminish the effectiveness of EMDR. He said he uses EMDR interactively and often adds interpretations and reflection on what happened during EMDR and what the experience was like for the client and the therapist. Marquis explained that he tends to add behavioral approaches and more cognitive interweave into his work. For example, when working with sex offenders, he has combined EMDR with McConaghy’s (1998) urge-reduction protocol because of the empirical evidence of the latter’s effectiveness, to eliminate the urge and condition the new inhibition to the mental image of the stimulus situation. In both cases, the therapists add to the standard EMDR protocol because they believe the additions enhance the overall effectiveness of the treatment. As predicted, what they add is drawn from their primary theoretical approach to therapy. Possible Deviations From EMDR Protocol: Subtractions (Domain 10b) Each of the therapists explained that he leaves out various elements to maintain the natural flow or pace of his sessions with clients (general). For example, Bohart reported that he uses EMDR as the client wants and has stopped before the end of the procedure when the client has requested. In addition, he does not always install positive cognitions because he believes it seems too artificial at times and may even distract the client. Wachtel also mentioned that he tends to leave out the negative and positive cognitions because he thinks that the way the standard protocol uses the cognitions feels too mechanical and artificial. Despite differences in how they deviate, the therapists indicated that they do not follow the standard EMDR protocol all of the time when working with clients. EMDR and Theoretical Orientation 245 Possible Deviation From EMDR Protocol: No Change (Domain 10c) Bohart and Marquis explained that they adhere to the standard protocol at first but offered differing reasons as to why they do so (typical). Marquis said that he believes the standard protocol is very good and useful to follow if difficulties arise, whereas Bohart indicated that he does not feel comfortable enough to deviate. Although Bohart tries to stick to the general protocol, he emphasized that he does not follow the protocols designed for specific problems. Wachtel explained that he tends to use EMDR more traditionally when faced with a specific issue that needs to be worked through or when a client’s expectations or style recommend it be used in this way. Therefore, each of the therapists reported using the standard EMDR protocol in different ways and at different points during the treatment of clients. Has Including EMDR in Your Therapy With Clients Changed the Nature of the Therapeutic Relationship? Effect of EMDR Use on Therapeutic Relationship: No Change (Domain 11a) Marquis’s response did not fit within this domain. However, Wachtel and Bohart suggested that their style of using EMDR is the same as their usual style of conducting therapy (typical). For example, Wachtel explained that he does not notice much of a change because he is already interactive with his clients. Bohart reported that the therapeutic relationship does not change because he does not force EMDR onto his clients but instead works collaboratively with them by offering suggestions and then responding to how the client feels about the method. Taken together, 2 of the therapists suggested that the therapeutic relationship is similar both when they do and do not incorporate EMDR into their work. Effect of EMDR Use on Therapeutic Relationship: Change (Domain 11b) Responses to this question failed to produce similarities between the therapists. Instead, the 2 therapists who responded to this question offered differing explanations as to how EMDR improved the therapeutic relationship. Marquis asserted that EMDR improves the therapeutic relationship because clients feel that they are being helped quickly and dramatically. Wachtel reported that the process of doing eye movements with 246 DiGiorgio, Arnkoff, Glass, Lyhus, and Walter clients improves the therapeutic relationship because he is physically much closer to the clients than he normally would be. Thus, 2 of the 3 therapists view EMDR as improving the therapeutic relationship; however, 1 focused on the effects of improvement and the other focused on the actual process of EMDR. What Was the Most Challenging Experience While Doing EMDR? Challenging Experience With EMDR (Domain 12) Wachtel and Bohart recalled instances when their clients were unable to successfully engage in the procedure (typical). For example, one of Wachtel’s clients was unable to move beyond saying phrases like, “what comes to mind is that your finger is moving.” However, Wachtel used this situation as an opportunity to explore the fears that restricted the client’s access to other experiences, as well as the client’s beliefs that in saying only that the therapist’s finger was moving, he had “failed” in the therapeutic task. This led to the client becoming aware of the fact that he tends to keep his feelings and emotions to himself. Another example of an unsuccessful EMDR session occurred when a client with obsessive–compulsive disorder was unable to experience any emotional unfolding or shift. Bohart explained that he was concerned the client would feel like a failure, so he consulted with Shapiro, who suggested that he make sure the client’s issue was a recent fear. Unlike the other therapists, Marquis focused on how the psychopathology of the clients contributes to the level of challenge. Marquis said that his most challenging clients were those who had very low self-esteem or were multiply traumatized and dissociative because they were often easily offended and tended to end the therapy prematurely. Therefore, the therapists have different explanations as to why they believe EMDR is challenging at times. Why and How Does EMDR Work? Mechanisms/Theories of Change in EMDR (Domain 13a) Wachtel and Marquis agreed that it is possible that some form of bilateral stimulation may facilitate communication between parts of the brain through its promotion of information processing or reconnection of thoughts and emotions (typical). Although these 2 therapists agree on the effects of bilateral stimulation, their additional explanations and theories EMDR and Theoretical Orientation 247 are different. Wachtel hypothesized that EMDR may be an alternative form of exposure or even a placebo. He also postulated that EMDR may put free association in fast forward, giving clients access to aspects of their experiences that they might not have had otherwise. Additionally, he suggested that EMDR produces more rapid and intense, emotion-laden responses because the clients and therapists are contributing jointly to the overall process. Marquis asserted that EMDR is not just a form of exposure therapy because it may involve some type of reciprocal inhibition. He offered a hypothesis, on the basis of the work of Stickgold, Scott, Rittenhouse, and Hobson (1999), that eye movements work the physiological processes of rapid eye movement (REM) sleep in reverse to facilitate communication between the limbic system and the frontal lobes, resulting in quicker information processing. Bohart took a different perspective and theorized that EMDR may disrupt overly intellectual analytical thinking, allowing clients to shift into more active listening and receptive modes of processing. He believes that the suspension of overly intellectual thinking would lead to emerging insights and shifts. In general, the therapists offered very different theories on why and how EMDR works, with some of the ideas focusing on biological explanations and others focusing on cognitive or affective processes. Similarities to Other Therapy Approaches (Domain 13b) Only Bohart offered a response that fit within this domain. He explained that the view that people have an overly critical way of attending to themselves is common to cognitive, cognitive–behavioral, humanistic, and psychodynamic theories. He said that the process of shifting people into a more receptive mode of processing also happens in meditation, hypnosis, experiential, client-centered, cognitive, and cognitive–behavioral therapy. DISCUSSION Because EMDR is an integrative therapy that incorporates aspects from various theoretical approaches, it lends itself to being used by therapists from many different orientations. Findings from the present study indicate that the therapists deviated from the standard EMDR protocol to differing degrees and in different ways. For example, Wachtel and Marquis often added to the EMDR protocol, and all of the therapists tended to 248 DiGiorgio, Arnkoff, Glass, Lyhus, and Walter leave out some aspects of the protocol for differing reasons. Results suggested that the therapists’ different uses of EMDR is a product of both their theoretical orientations and the types of clients with whom they typically work. The finding that the therapists deviated from the EMDR protocol is similar to Kleiner’s (1999) report that some clinicians deviated from the standard EMDR protocol. However, the present study goes further and reveals how therapists actually use EMDR with their clients, which is consistent with Street et al.’s (2000) suggestion that the practice of psychotherapy be more closely examined. In the present study, Wachtel reported using reflection and interpretation in combination with EMDR, Marquis described how he uses a variety of behavioral techniques (i.e., acceptance and commitment therapy) in addition to EMDR, and Bohart explained that he collaboratively uses EMDR with his clients to open up and explore previously unfelt experiences. Therefore, each of the therapists adds to the standard EMDR protocol in ways that are consistent with his primary orientation. In addition, both Wachtel and Bohart indicated that they often leave cognitions out of the standard EMDR protocol because they believe that the use of cognitions feels artificial at times. Marquis, on the other hand, does not leave out cognitions, which is consistent with his primarily cognitive–behavioral orientation. Therefore, the therapists tended to leave out aspects of the EMDR protocol that do not fit within their primary orientation. The finding that EMDR is used differently by therapists from differing theoretical orientations is consistent with Zabukovec, Lazrove, and Shapiro’s (2000) hypothesis that therapists tend to use and interpret EMDR in a manner that is consistent with their own theoretical models. Taken together, findings from the present study indicate that the therapists assimilate aspects of EMDR into their typical therapy styles. All of the therapists reported that they deviate from the EMDR protocol at times, by either adding to or subtracting from the standard protocol. Specifically, Wachtel and Marquis add to the EMDR protocol (e.g., by using interpretation and cognitive interweave, respectively) when they feel it will enhance its effectiveness. Additionally, each of the therapists explained that he leaves out elements of the protocol (e.g., Wachtel leaves out negative and positive cognitions at times) to maintain the natural flow of the session. Thus, the therapists choose to assimilate into their work with clients those aspects of the EMDR protocol that are consistent with their theoretical approaches and are more likely to leave out those elements that are different. Regardless, the fact that the therapists assimilate EMDR into their primary approach suggests that pure-form therapies may lack the flexibility these therapists desire when working with a wide variety of clients. This idea is consistent with Stricker’s (1994) assertion that thera- EMDR and Theoretical Orientation 249 pists often use assimilative integration as an alternative to relying on pureform therapies that are sometimes perceived to be insufficient. Despite some differences in their use of EMDR, each of the therapists reported that they integrate EMDR into their usual therapy styles with a full range of clients. The therapists explained that the way in which they use EMDR is often dependent on their clients. This finding is consistent with Stricker and Gold’s (1996) assertion that therapists often use differing therapeutic techniques (e.g., cognitive, behavioral, or experiential) depending on the client. Also, Gold (2000) suggested that therapists often use assimilative integration in situations in which clients are dissatisfied with their progress in therapy and/or are ready to expand on the work they do with their therapists. Shapiro (1999) attributed some of the success of EMDR to its integrative nature and its ability to be used with many different clients. In addition, regardless of theoretical orientation, the therapists expressed similar concerns and hesitations about using EMDR with dissociative clients, although emphasizing its usefulness with traumatic memories, anxieties, and fears. Indeed, Van Etten and Taylor (1998) found that EMDR tends to be very effective and efficient in its treatment of traumatic memories. In his discussion as part of a symposium on EMDR and assimilative integration, after papers were presented by the same 3 therapists interviewed for this study, Messer (2002) concluded that each of the therapists conducts therapy in a manner that is consistent with assimilative integration, incorporating aspects of EMDR into their primary theoretical approach. Specifically, Wachtel assimilates those aspects of EMDR that are most consistent with psychoanalytic therapy (e.g., simultaneous focus on emotion and cognition) into his psychodynamic approach. Bohart similarly incorporates into his humanistic approach those aspects of EMDR that he perceives to be compatible with his typical mode of doing therapy (e.g., the facilitation of client self-healing without the use of therapist-imposed solutions). Last, Messer expressed that Marquis is likely the most assimilative of the 3 therapists, because behavioral therapists tend to routinely use interventions that are often very compatible with some of the techniques of EMDR (e.g., both use systematic desensitization, breathing exercises). We used the CQR method to qualitatively analyze the responses of the therapists to get a detailed understanding as to how and when they integrate aspects of EMDR into their typical therapy approaches. Specifically, the CQR method allowed us to first closely examine the individual transcripts of the therapists and then to look across the transcripts to determine which commonalities and differences existed. Qualitative studies such as this one present clear examples of how practicing clinicians can contribute to research on psychotherapy integration. 250 DiGiorgio, Arnkoff, Glass, Lyhus, and Walter There were a few limitations of the study that should be considered when interpreting the above findings. First, the sample size was small given that only 3 therapists were interviewed for the purpose of gaining an initial understanding as to how therapists integrate EMDR into their typical therapeutic styles. However, Hill et al. (1997) emphasized that qualitative studies often have very small sample sizes to better enable researchers to gain an in-depth understanding of each of their cases. Increasing the sample size is not always realistic because of the time it takes to intensively examine each case, and Hill and colleagues further noted that larger sample sizes do not always yield new data that are useful. Nevertheless, future studies that are based on interviews with a larger number of therapists could potentially yield findings that are more representative of the practice of integrative clinicians. In addition, in the present study, the therapists represented three different theoretical orientations so they could be compared. However, this did not allow for the examination of possible differences in how therapists from similar theoretical orientations integrate EMDR with their typical approaches. Thus, future studies should consider interviewing more than one therapist from each theoretical orientation to determine if within-group differences exist. The therapists also varied in terms of the number of clients they treated using EMDR and their overall experience in using EMDR. However, these therapists were chosen because of their national recognition as being experts in psychodynamic, cognitive–behavioral, and humanistic approaches, therefore making their observations and conclusions potentially representative of other therapists from similar backgrounds. In addition, Street et al. (2000) have suggested that studies of clinical practice often find that therapists have a wide range of experience levels with the intervention being studied. Therefore, even if we had incorporated a larger number of therapists into our study, we would not have necessarily found that the therapists had similar levels of experience with EMDR. Thus, future studies could examine further why some therapists may be more or less likely to treat their clients with EMDR and how this may be related to experience level with this approach. Last, further studies could incorporate a wider range of theoretical approaches into their research design to more effectively examine how theoretical orientation may impact therapists’ integration of EMDR into their typical approaches. Despite the limitations, the present study expanded on previous psychotherapy integration research by providing a detailed description of how therapists actually use EMDR with clients. The CQR method was particularly useful in organizing the qualitative data in a manner that preserved the richness and depth of the therapists’ responses. 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