Transference and Countertransference, Phase by Phase

8.7.1 Phase 1: Client History Taking and Treatment Planning (Trauma Case Conceptualization)

In this phase, the clinician determines whether the client will benefit from EMDR and creates an action plan. The clinician begins by asking the client about specific traumas associated to the presenting problem. Although the client expects to be asked these kinds of questions, and the clinician has made it clear the client does not have to answer until he or she is ready, the very act of asking for traumatic memories may activate memory networks with painful emotions. Even with the instruction that the client can choose not to disclose until he or she is ready, the client may experience the clinician as intrusive, judgmental, overly analytical, or, on the other hand, understanding. And the clinician may react with fear, shame, hurt, or gratitude. This may occur in any type of psychotherapy, but it is espe- cially necessary to be mindful of it in EMDR because of the nature of trauma treatment.

Though the clinician and client are only in Phase 1, and the clinician has not yet explained EMDR, many clients will have been informed by friends, books, or articles about the strong reactions people have to EMDR processing. This can cause anticipatory anxiety during the initial phases of treatment. Many hopes and magical wishes may surface, with the client expecting EMDR to provide healing overnight (as in the case of Walter). Alternatively, the client may be very skeptical. And then there are the clients who have low expectations of success, having seen several clinicians before, none of whom helped them to release their pain and process their memo- ries, and those who simply believe that psychotherapy is for weaklings (as in the case of Madeline).

The client’s hopes and wishes must be carefully attended to. Embedded in them are state-dependent memories that are potentially transferential. What happens if I start experiencing my client’s fears and doubts while he or she is hypervigilantly attuned to my reactions? What if I am activated by

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my own old state-dependent memories? Clients’ state-dependent memo- ries may become activated by what they think they observed, possibly set- ting off a chain reaction of transferential and countertransferential events. This is why EMDR trainers strongly suggest that newcomers to the method start using it with clients they know well, who do not have major dissociative disorders and who like to try out new methods their clinicians have learned.

In Phase 1, the clinician must accurately assess the physical health of the client. Consultation with the client’s doctor is often advised. Not doing so in the face of significant health issues could simply be the clinician’s coun- tertransferential wish to do more than he or she is capable of doing. This can inadvertently create problems. Undiscovered health issues may arise in treatment and create transferential or countertransferential reactions. A clinician once told me about a case he was working on. He had done everything correctly; I had carefully assessed his work. Shortly after the session, the client had a seizure. The clinician stated that “the client had not told me about his condition because he had heard that EMDR is not done with epileptics” (this is not the case; there is no indication that EMDR has adverse effects for people with epilepsy). There was no way of knowing that this might happen. The seizure may or may not have been precipitated by the work. The clinician had done due diligence in every aspect of the history taking and preparation. But due to countertransfer- ential issues of feeling betrayed by the client’s omission and being vicari- ously traumatized by EMDR’s “power,” the clinician never used EMDR again.

Also during this phase, symptoms such as flashbacks, intrusive thoughts, and other manifestations of PTSD must be thoroughly evalu- ated. The client’s current triggers and their duration, frequency, timing, location, and other characteristics must be assessed. In a rush on the part of both client and clinician to alleviate suffering, many important details can be missed. Again, this may lead to negative outcomes. Remember, transferential demands such as “Cure me” will be strong and may activate painful memory networks in the clinician. It is crucial that the clinician understand the importance of history taking and not rush into active trauma treatment in an implicit effort to avoid or act out grandiose coun- tertransference issues of being a “magical healer.” Rushing ahead to Phase 4 is especially a temptation when informed clients enter treatment specif- ically to use EMDR. The client’s transferential state of mind may stimu- late a clinician’s state-dependent memories based on dysfunctional patterns of subservience or defensive grandiosity and push the clinician to relieve the client’s suffering as quickly as possible. Ironically, these

corresponding countertransferential states of mind and dysfunctional reactions (such as skipping details during the history taking) may inhibit the healing process and — worse — result in both client and clinician feeling traumatized.

There are relational advantages to sticking to the protocol. The clinician can ascertain the client’s negative cognitions simply by listening; during history taking these negative cognitions can provide clues to possible transferential themes in the client, and induced countertransferential states in the clinician. For example, the cognition “No one understands what I’m going through” is a common theme that can trigger a counter- transferential state of wishing to be the one person who can “heal” this long-suffering soul. This alone may create a sense of urgency in the EMDR clinician who then may neglect vital issues in the history taking and estab- lishing of the alliance goals and tasks, thus rushing prematurely into active trauma work. This may trigger a state of implicit collusion when the clini- cian becomes anxious (due to a defectiveness schema about failing to per- form EMDR’s “magic” immediately), and the client’s wish for this pain to be magically gotten rid of.

Empathic attunement must begin in Phase1, not when the client is deep in an abreaction mode in Phase 4. These potential issues must be identi- fied as quickly as possible so that the clinician does not act in a way that will actually be a defense against the client. In a best-case scenario, on the other hand, this time could mark the beginning of a deeper empathic state of resonance with the client’s struggle.

Negative transference based on, for example, a client’s defectiveness schema manifested during history taking, may stimulate negative counter- transference in the clinician, perhaps due to old mental models connected to maladaptive schemas of unrelenting standards. For example, although it is standard EMDR procedure to target the oldest memories first, the cli- ent’s wishes are equally important. The client may be right about what he or she needs. If the clinician believes otherwise, then the clinician can reit- erate the EMDR protocol that was discussed in Phase 2 and again offer the client the choice of where to begin the next round of processing. Often cli- ents want to work on current-day matters because these are what are pressing. That is fine.

When the client needs to have a lot of control due to schemas such as vulnerability to harm or entitlement, he or she will usually not get far. His or her transferential reaction to authority will dictate that he or she con- tinue defending and blocking. The client may implicitly resist the free-associational part of bilateral stimulation, since that would mean exposing vulnerable state-dependent memories that have been long disso-

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ciated. And that is fine, too. This is simply another opportunity to review EMDR procedure gently, give the rationale behind it, and then wonder if it might be difficult for the client to have experiences that are out of his or her control. When this awareness is present in me, I am usually able to restimulate mental state resonance. In practicing this way I am limiting potential ruptures in the working alliance. I share what I am experiencing from the client empathically, and this provides an opening for us safely to deepen our super system (Siegel, 1999) or super state of mind (meaning the “melding of my state of mind with that of the client”), which may enable the client to re-associate to dissociated states that have heretofore blocked the processing.

Trauma processing may not be the treatment of choice for every client, or at least not right away. The client’s freedom to say no — or not yet — and to give reasons may stir up transferential issues of abandonment or defectiveness. This moment may resonate negatively with state-dependent memories of traumas where the client was told he or she was inadequate by a significant attachment figure. In addition, being able to say no com- fortably, without guilt, is a challenge for some clinicians. Saying no may stimulate vulnerability to harm or subservient schemas in them. Woe is the clinician who says yes even though the client’s current-day functioning is sufficiently impaired that a longer stabilization phase is needed. This can lead to disaster during trauma processing.

Too often clinicians are inadequately informed about the standard method of EMDR, or they are grandiose in their assessment of their ability to heal their clients. These are their own learning or countertransferential problems, stimulated by the client. Some clinicians have inappropriate defectiveness schemas and need to prove their worth, so they implicitly compensate for feelings and irrational beliefs about their own inadequacy. More than one clinician has told me that he or she does not follow the stan- dard protocol because he or she “knows better.” Others have said they do not want to be “told what to do” by the EMDR methodology. This last remark strikes me as a negative transferential reaction to EMDR. If active trauma work is initiated without a comprehensive history, the clinician is either not familiar enough with the method or is acting out his or her own needs.

The initial history taking may go smoothly with more highly function- ing clients with limited trauma. The client who has had more disturbed early attachment patterns may react very emotionally to being asked ques- tions and revealing “private matters.” He or she may have felt disappointed or betrayed in the past when telling the story. What is more, there is always the possibility of retraumatization when the client tells the story. At highest risk are clients whose dissociative symptoms take the form of

flashbacks (positive psychoform dissociation); psychological amnesias (negative psychoform dissociation); physical pain that cannot be explained (positive somatoform dissociation); or psychic numbing, the inability to feel the effects of unresolved trauma in their bodies. In my experience, this last form of dissociation (negative somatoform dissocia- tion) is the most common. Many times these experiences are specific to the treatment situation. Several clients have told me that they were aware of feeling certain sensations when thinking about their trauma on the way to a session but could not retrieve (a function of the right orbitofrontal cortex) those same sensations in my presence. These kinds of transferen- tial manifestations must be addressed with tact, sensitivity, and good tim- ing. They provide a clue that state-dependent memories have become activated by the clinician’s presence. That is fine. When this process is understood by both parties, it becomes “grist for the mill.”

A potential client came for his first session. He had been bullied in school and developed a vulnerability to harm schema. He remembered feeling very sad on the way to my office. However, when he arrived, he stated that while he could remember the details of the experience, he had become numb to his sadness. I asked him what might help him feel safe experiencing this sadness. He replied, “Time. I don’t know you, and I don’t trust you yet.” I accepted his need to defend himself, and we explored his issue around safety. Staying with him in this process allowed him to asso- ciate to many times when caretakers were not there for him when he needed them. The worst memory of this type was of his father’s reaction when he told him of being bullied. Instead of nurturing him adequately, his father shamed him, saying that he was not a man and had better become one pretty quickly or he would have a life of being a coward. So I asked the client gently which part of this memory hurt the most. He burst into tears, remarking that it was his father’s criticism. He realized that he had implicitly projected that memory onto me. Once we cleared the field between us (making a past–present duality), we deepened our mental state resonance.

Clinicians themselves may be triggered right in the first session by the feelings and beliefs that their clients’ stories present and activate in them. Present constraints on a client because of the trauma can induce in the cli- nician rescue fantasies or angry reactions to the abusers. Whenever I take a history, I tune in carefully to my own physical sensations as I hear the material presented.

I am also on the lookout for the client’s need to please or my own dys- functional need to be very, very wise in that session. Many times clients have informed me that they knew I was the right clinician for them when

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they heard the sound of my voice on the phone and experienced my razor-sharp intuition. When I hear this, I immediately ask what the client believes he or she will experience when I make my first mistake. This usu- ally shocks the client, but it also sets the tone appropriately: There are two fallible human beings in the room.

Transferential characteristics can manifest because of insufficient trust, a high susceptibility to demand characteristics, or a desire to avoid further painful material. Because of these, some clients (as with Michael in the case of “The Death of Toto”) will inaccurately report a lower level of dis- tress than they actually feel. This may be a transferential assessment of the clinician’s capabilities, or it may reflect the state-dependent fear that the client will experience more harm. Sometimes, though, it is not dysfunc- tional memory; sometimes the client might be right. The client may implicitly be reading something in the clinician that is “off.” Clinicians should be aware of this possibility as well. Not every reaction is transferential.

The interpersonal field is ripe for reactive responses from both client and clinician. Clinicians need to be keenly attuned to their own and their clients’ appraisals and negative arousals. These are important clues! This is critical even in Phase 1. (Remember, information processing goes on dur- ing the waking and sleeping moments of every person with a brain.) In addition, EMDR clinicians need to be careful in monitoring our reactions to the traumatic events our clients recount. We need to be aware whether any of the content or the manner of presentation is triggering us. (I will dis- cuss this in more detail later.) Another hazard stems from either failing to assess for affect tolerance or misjudging it. This can potentiate negative transference, putting the clinician at risk of countertransferential reactions ranging from believing he or she is incompetent to feeling shame and doubt. This is especially common in clinicians who have unrelenting schemas.

While I believe that clinicians should be on call 24/7 for clients going through the active trauma phases of EMDR, this does not mean that we should take responsibility for keeping them stable. If we buy into the idea that we should, I suggest that the client has demonstrated transferential dependency needs that have resulted in the countertransferential reaction of self-sacrifice. Clinicians may implicitly act out their own state-dependent memories relating to dependency by being too available in an attempt to take care of their clients. That is why RDI and teaching other resourcing techniques to clients is so important. These will limit the client’s patholog- ical dependency on the clinician by giving the compassionate message that the clinician believes the client is capable of learning to master his or her difficult emotional states. Some of my clients are not happy with my stance. They want me to provide the answers. I give them the old adage,

“Feed a person a fish, you feed them for a day; teach a person to fish, you feed them for a lifetime.” Those clients not willing to practice EMDR resourcing strategies are violating agreements that they have made when we set up the collaborative working alliance. I remind them. Some get back on the train, learn, and practice. Others decide that I’m not the “right train” for them. I don’t consider this a breach of the alliance, but rather a deeper level of desire that manifests after the initial high of creating the working alliance. This is why I continue to say that while the alliance is necessary, it remains insufficient in working with traumatized clients. It is living with them in the moment-to-moment experience of their pain and how they and I deal with it that constitutes the full expression of the thera- peutic relationship in EMDR.

Earlier, in the chapter on Phase 1, I discussed asking the client to describe times in the past when he or she had used self-control techniques. The importance of obtaining this information cannot be overstated. If the client can honestly give examples of self-control, then moments of misat- tunement may be diminished. This is because the client has the ability to acknowledge that he or she is the one who is responsible for containing his or her emotions during trauma processing (while the clinician is responsi- ble for facilitating the processing).

Having a strong working alliance and therapeutic relationship may also limit moments of misattunement because the more mature aspects of the client’s personality have been engaged successfully, and the clinician and client will have become stronger allies. I do not mean to imply that trans- ferential and countertransferential reactions will not occur. They will. However, there will be a point of reference to return to in reminding the client about what role each participant plays in EMDR treatment. With this reminder, transferential reactions can be clarified more easily, since the clinician can rule out the possibility that the client does not under- stand the treatment process.

8.7.2 Phase 2: Client Preparation (Testing Affect Tolerance and Body Awareness)

During Phase 2, the clinician educates the client on EMDR and continues to make diagnostic evaluations about how ready the client is to do the work. This includes use of the Safe Place exercise to assess the client’s abil- ity to move from a level of comfort to a level of disturbance and back