EMDR and Theoretical Orientation: A Qualitative Study of How

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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]
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Journal of Psychotherapy Integration
2004, Vol. 14, No. 3, 227–252
Copyright 2004 by the Educational Publishing Foundation
1053-0479/04/$12.00 DOI: 10.1037/1053-0479.14.3.227
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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-
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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
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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.
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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.
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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
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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.
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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.
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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.
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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
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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)
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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
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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-
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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
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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-
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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
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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
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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.
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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. Similar to other psychotherapy studies that used the CQR method (e.g., Gelso et al., 1999), a
qualitative approach allowed for the systematic examination of complex
EMDR and Theoretical Orientation
251
issues from multiple sources. In using the CQR method, in the present
study we found that therapists integrate EMDR into their therapy styles in
ways that are consistent with their guiding theoretical models and the types
of clients with whom they work. Future studies could use the CQR approach to examine further how theoretical orientation and client characteristics influence therapists’ use of EMDR and how EMDR lends itself to
the process of assimilative integration.
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