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Article 22

EMDR: An Approach to Healing Betrayal Woundsin Couples Counseling

Frederick Capps, Helena Andrade, and Rochelle Cade

Since its introduction by Francine Shapiro in1989, eye movement desensitization and reprocessing(EMDR) has gained wide acceptance as an efficaciousclinical treatment. It is particularly useful in thetreatment of posttraumatic stress disorder (PTSD) (Alto,2001). Despite its relative novelty, EMDR has been usedto treat survivors, emergency workers, and disasterrelief counselors worldwide. EMDR therapists havesuccessfully employed EMDR in Oklahoma City,Belfast, Zagreb, Rwanda, Dunblane, Sarajevo,Columbine, and Londonderry. EMDR has also beenused in the treatment of PTSD for combat veterans fromWorld War II, the Korean War, Beirut, and the VietnamWar (Silver & Rogers, 2002, p. xix). EMDR effectsexceed those of nonspecific effects shared by alltreatments and are independent of client expectations.Moreover, EMDR effects are at least equal to effectsof cognitive behavioral therapy, and EMDR requiresless time than other models with less client attrition(Silver & Rogers, p. 254). Importantly, the AmericanPsychological Association has listed EMDR as anefficacious treatment for civilian PTSD (Alto, 2001).

Almost all research on EMDR has been conductedwith individual subjects, with families and couplesreceiving short shrift. Thus, despite conjoint therapybeing a time-honored clinical practice (Bowen, 1978;Satir, 1972), little is known about the effectiveness ofEMDR in conjoint sessions. Shapiro mentioned a mixedresult of the use of EMDR in couples work (1995,2001). A study involving the use of EMDR in couplestherapy found that EMDR fits within experientiallybased treatment and argued that it can increasetherapeutic effectiveness (Protinsky, Sparks, & Flemke,2001). More recently, Flemke and Protinsky havereported successfully integrating EMDR with imagorelationship therapy (2003).

Maryhelen Snyder reported the effective use ofEMDR within an experiential couples counselingcontext. Her techniques included the cultivation ofintimacy through experiential techniques. Specifically,Snyder instructed the supportive partner to hold theother while the other experienced a catharsis involving

emotional pain stemming from childhood sexual abuse.Snyder utilized EMDR for remembering and processingtraumatic material (Snyder, 1996). Both the Protinskygroup and Snyder found that combining EMDR andexperiential couples counseling strengthened emotionalintimacy.

Experiential therapy has been shown to beeffective in symptom reduction in depression(Greenberg & Watson, 1998). Experiential techniqueshave also been used effectively in dealing with traumaand with attachment injuries in couples counseling(Greenberg & Malcolm, 2002; Johnson, 2003; Johnson,Makinen, & Millikin, 2001). Combining EMDR withexperiential therapy in couples counseling may providethe supportive partner the opportunity to experience thetrauma and the trauma resolution of the traumatizedpartner at a deep level, thereby gaining awareness andempathy for the partner. The result of the relief oftrauma/reframing by the traumatized partner togetherwith the newfound awareness and empathy of thesupporting partner is believed to encourage increasedemotional intimacy that will lead to a strongerrelationship (Hook, Gerstein, Detterich, & Gridley,2003). In keeping with traditional experiential familytherapy, the goal of integrating EMDR in couplescounseling is growth and integrity, that is, congruencebetween inner experience and outward behavior(Nichols & Schwartz, 1991). A study using emotionalfocused couples therapy (EFT) found that emotionaldeepening is effective in increasing emotional intimacyin couples (Johnson, Hunsley, Greenberg, & Schindler,1999).

In a case study article, Gestalt therapy combinedwith EMDR techniques appeared to be helpful inresolving trauma and in increasing emotional intimacywithin the relationship in each of three trauma relatedscenarios: infidelity, domestic violence, and substanceabuse related behavior (Capps, in press). Unlike couplescounseling research that deals with attachment injuriesor trauma from childhood, the focus in this research ison psychological injuries that have more recentlyoccurred in the context of the primary relationship. The

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current study attempted to replicate the clinical findingsof Capps and his colleagues in the treatment of betrayalby way of sexual infidelity, and to examine the efficacyof EMDR in a single session treatment where theEMDR therapist has limited or no contact with thecouple beyond the EMDR protocol.

Rationale

Betrayal by infidelity in a primary relationship isa common theme in couples counseling. The symptomsof posttraumatic stress disorder are typically noticed,albeit often at a subclinical level, in the presentation ofthe offended partner. The obstacle to relational intimacyposed by the vivid reprocessing of the betrayal materialis experienced by the offended partner as a severe lifestressor and often is cited as the cause of the demise ofan otherwise viable primary relationship. Yet little isknown about the efficacy of EMDR in resolving thisissue (Whisman, 1999). If the infidelity is in the pastand is unlikely to be repeated, conjoint counselingprovides a context that could offer several benefits tothe partners. The traumatized partner could experiencerelief from the betrayal related trauma through theapplication of the EMDR protocol that could lead to arevival of trust as closeness and support from theoffending partner is offered. The offending partner couldgain understanding of his or her partner’s pain fromexperiencing the trauma resolution as an intimatewitness to the EMDR protocol. This newfoundawareness could lead to congruence for the offenderand empathy toward the offended. These expectedresults could then lead to a deepening of intimacybetween the partners and strengthen the resolve of bothtoward their respective commitment to the relationship.

Because of the rapid processing that is associatedwith the use of EMDR (Alto, 2001; Shapiro, 1995;Shapiro, 2001; Shapiro & Forrest, 1997), the researchersin this study hypothesized that EMDR could be appliedin a single session of couples counseling. The EMDRtherapist, in the role of consulting specialist, would beintroduced and, with the couple’s consent, treat thecouple using the EMDR protocol for couples aspresented in earlier research by Capps.

Method

EMDR and experiential couples therapy is utilizedto treat the couple in this case. In a previous session,the primary counselor utilized experiential techniquesto help the couple examine the process of therelationship and to deepen the couple’s understandingof the impact of non-verbal behavior. In the secondsession, a mask-making exercise was used with both

partners and the 9-year-old daughter of the femalepartner. The purpose of the exercise was to illustrateeach person’s perceived outer presentation on one sideof the mask and their inner feelings on the other. Onthe third therapy session, in which only the couple andthe primary counselor were present, the EMDR therapistwas introduced as a consultant, who interacted with thecouple to provide treatment utilizing the EMDRprotocol. The EMDR therapist and the primarycounselor had consulted before the session forapproximately 1 hour, discussing specifics of the caseand deciding if EMDR might be a helpful technique.The primary counselor consulted with the couple,explaining the EMDR protocol and securing thecouple’s consent to bring the EMDR consultant intothe counseling session.

The standard EMDR protocol includes sevenphases: (a) client history; (b) preparation, whichincludes creating a safe place; (c) assessment, whichincludes identifying negative and developing positivecognitions and establishing a baseline self-estimate ofvalidity of the positive cognition (VoC) on a seven-pointLikert scale and a baseline of self-estimate ofdisturbance as reported by the subjective units ofdisturbance (SUDs) scale (Wolpe, 1990) where 0indicates neutral or no disturbance and 10 indicates themost disturbance imaginable; (d) desensitization; (e)installation; (f) body scan; and (g) closure (Shapiro,1995, p. xiii-xiv).

In the case presented, the offending partner hadadmitted to a sexual liaison with a third party some 3years prior to the therapy session. The repetitiveintrusive memories and feelings of the offended partnerhad become an obstacle to reconciliation. Sherepeatedly stated, “I can’t get over it.”

After explaining the EMDR protocol andproposing the couples counseling context for treatment,both partners agreed to the treatment. In keeping withMark Moses’ recommendations concerning safety,balance, and containment (2003), the male partner wasinstructed to be present and to sit close to the femalepartner, but not to interrupt or touch his partner in anyway unless invited to do so by the female partner or bythe counselor. After taking the history, preparing thecouple, and assessing the positive and negativecognitions, saccades of eye movements were initiatedin the desensitization phase of treatment. From an initialvalidity of cognition of 1 (completely false) for thepositive cognition, “I’m really worth it,” the treatmentresulted in a VoC of 7 (completely true). The subjectiveunits of disturbance (SUDs) level moved from a 10 (asdisturbed as could possibly be) to a 0 (neutral or nodisturbance). The female partner stated, “It’s still there.I can see it (the target image), but it’s not important.”

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The male partner indicated that he felt overwhelmed athow hurt his wife was, and rated the value of thetreatment (on a Likert scale of 1 to 7 where 1 is “novalue at all” and 7 is “the best experience you couldimagine”) at 7. A 30 day follow-up revealed that thecouple had ended their separation and felt closer thanever before. The couple was contacted by telephoneagain at 90 days. They reported sustained relief fromtrauma-related memories and feelings and a sense ofdeepened intimacy. The couple declined furthercounseling, stating that they felt, “We’re doing fine.We’ll call if we ever need help again.”

Discussion

The research on EMDR has often been criticized,and rightly so, for the abundance of anecdotal evidenceand the paucity of empirical data. The current study ismost certainly a candidate for that type of criticism.Instrumentation is virtually nonexistent in EMDRtechnology, which relies heavily on self-reported VoCand SUDs measurements. At the same time, it isprecisely the self-reported resolution of an issue that isthe gold standard in measuring clinical success. Onemight argue that objective observation of symptomabatement is a better empirical measure. Objectivelaboratory results as the measure of a cure of a medicalcondition would serve as an illustration. However, acloser examination might reveal that it is theinterpretation of well-being by the patient as evidencedby the laboratory report that makes the patient feelbetter, as suggested by numerous placebo studies.However, like the current study, EMDR studies oftenutilize a case study approach that preventsgeneralizability. To overcome this shortcoming,empirical research needs to be conducted.

Generalizability is one of the many questions thatlinger in EMDR studies. While shown to be useful inPTSD, what is not known is how often EMDR doesnot work and what consequences that produces. DoesEMDR, if ineffective, create a larger problem? Couldit exacerbate depression if it does not work? Althoughthe consensus of EMDR therapists seems to suggestthat EMDR is not harmful when it is not effective, whatempirical evidence exists that validates this opinion?One of the apparent dangers of case study research isthat when a clinical technique does not work, the clientsimply does not return for further sessions. Lackingthorough follow-up leaves the question of consequencerelatively unexamined.

Another issue related to generalizability could beaddressed through more empirical studies. Candidatesfor EMDR are, for the most part, drawn from a criterionspecific population, as was the couple for this study.

When deciding to whom the EMDR therapistadministers treatment, does the inherent bias of thetherapist influence selection? Perhaps the EMDRtherapist intuitively selects candidates who are morelikely to benefit from EMDR, while consciously citingsymptom presentation as the ostensible deciding factor.

There are many unknown and unexplored issuesregarding the effectiveness of EMDR technology thatwill provide researchers a wealth of topics for theforeseeable future. One recurring theme stands out,nonetheless. The apparent promise of EMDR as anefficacious treatment for the relief of human sufferingis as exciting as its explanation is mysterious.

References

Alto, C. (2001). Meta-analysis of eye movementdesensitization and reprocessing efficacy studies inthe treatment of PTSD. Retrieved September 9, 2003,from Digital Dissertations database. (UMI No.3015591)

Bowen, M. (1978). Family therapy in clinical practice.New York: Jason Aronson.

Capps, F. M. (in press). Combining eye movementdesensitization and reprocessing with Gestalttechniques in couples counseling.

Flemke, K., & Protinsky, H. (2003). Imago dialogues:Treatment enhancement with EMDR. Journal ofFamily Psychotherapy, 14, 31-45.

Greenberg, L. S., & Malcolm, W. (2002). Relatingprocess to outcome. Journal of Consulting andClinical Psychology, 70, 406-416.

Greenberg, L. S., & Watson, J. (1998). Experientialtherapy of depression: Differential effects of client-centered relationship conditions and processexperiential interventions. Psychotherapy Research,8, 210-224.

Hook, M. K., Gerstein, L. H., Detterich, L., & Gridley,B. (2003). How close are we? Measuring intimacyand examining gender differences. Journal ofCounseling & Development, 81, 462-472.

Johnson, S. M. (2003). The revolution in coupletherapy: A practitioner-scientist perspective. Journalof Marital and Family Therapy, 29, 365-384.

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Johnson, S. M., Hunsley, J., Greenberg, L., & Schindler,D. (1999). Emotionally focused couples therapy:Status and challenges. Clinical Psychology: Scienceand Practice, 6, 67-79.

Johnson, S. M., Makinen, J. A., & Millikin, J. W. (2001).Attachment injuries in couple relationships: A newperspective on impasses in couples therapy. Journalof Marital and Family Therapy, 27, 145-155.

Moses, M. D. (2003, March). Protocol for EMDR andconjoint couples therapy. EMDRIA Newsletter, 8(1),4-13. (Available from EMDR InternationalAssociation, P.O. Box 141295, Austin, TX 78714-1925)

Nichols, M. P., & Schwartz, R. C. (1991). Familytherapy: Concepts and methods (2nd ed.). Boston:Allyn & Bacon.

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Satir, V. (1972). Peoplemaking. Palo Alto, CA: Scienceand Behavior Books.

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Silver, S. M., & Rogers, S. (2002). Light in the heart ofdarkness: EMDR and the treatment of war andterrorism survivors. New York:Norton.

Snyder, M. (1996). Intimate partners: A context for theintensification and healing of emotional pain. In M.Hill & E. D. Rothblum (Eds.), Couples therapy:Feminist perspectives (pp. 79-92). Albuquerque,NM: Haworth Press.

Whisman, M. A. (1999). Marital dissatisfaction andpsychiatric disorders: Results from the National Co-morbidity Study. Journal of Abnormal Psychology,108, 701-706.

Wolpe, J. (1990). The practice of behavior therapy (4thed.). New York: Pergamon Press.