EMDR Therapy Quarterly

Background

In their 2021 position paper on EMDR therapy, the EMDR Council of Scholars (CoS) describe EMDR as being at a “crossroads”, losing out to other trauma treatments through being conceived as a protocol or tool rather than a whole therapy. “Our community stands at a crossroads, where a lack of agreed-upon guidelines endangers the essential, unique elements of EMDR therapy, and a rigid traditional stance risks losing important developments and innovations essential to keeping the [EMDR] model dynamic, which has been a core value in the EMDR community from its inception” (Laliotis et al., 2021, p. 187). This article is offered by way of response to the CoS statement, that they “welcome all comments” (p. 187).

References to “EMDR Therapy” arise in the writings of Francine Shapiro from as long ago as 2010. The Council of Scholars (CoS) workgroup on ‘What is EMDR?’ – which has, in effect, taken over her mantle as the chief source of conceptual innovation – has redefined EMDR Therapy as: “an integrative, client-centred approach that treats problems of daily living based on disturbing life experiences that continue to have a negative impact on a person throughout the lifespan” (Laliotis, D., et al, 2021, p. 187).

In the Council’s position paper, three categories of EMDR therapy were proposed: EMDR psychotherapy, EMDR treatment protocols, and EMDR-derived techniques. Drawing on the insights of others (Hersey, 2013; O’Shea Brown, 2020; Twombly & Schwartz, 2008) this article suggests that the first of these categories, EMDR psychotherapy, would benefit from being informed by an Internal Family Systems approach. Crucially, this would add to EMDR a framework of understanding the mind from the perspective of multiplicity, one of the central tenets of IFS, along with the concept of Self that IFS places at the core of its healing model. This would complement EMDR therapy, which places the Adaptive Information Processing (AIP) theory at the core of its eight phases and three-pronged approach.

In fact, these two therapies both share a “concept of innate healing which is well known to EMDR therapists, so for them, the idea that clients have the capacity to heal themselves is familiar and comfortable and leads to an easier acceptance of the existence of the Self” (Twombly & Schwartz, 2008, p. 296). The reference is to the concept of the Adaptive Information Processing (AIP) model in EMDR, which tells us that the brain, like other parts of the body, has a natural tendency to move towards health. “However, if the system is blocked or becomes imbalanced by the impact of a trauma, maladaptive responses are observed… If the block is removed, [here, through the use of EMDR], processing resumes and takes the information toward a state of adaptive resolution and functional integration” (Shapiro, 2018, p. 28).

Gilligan calls this integration of memories a “special learning state” when he considers the parallels between EMDR and hypnosis: “Perhaps the most important similarity is the premise that there exists a special learning state in which traumatic identity and disturbing experiences may be transformed into healthy, integrated states. In direct hypnosis and Ericksonian hypnosis, the terms hypnosis and trance are used to describe this state; in EMDR, the new and somewhat unwieldy term of accelerated information processing is used.” (Gilligan, 2002, p. 230). Gilligan continues, reflecting traditional precepts of western medicine, whereby the practitioner seeks to “surgically implant better ideas into the mind.” EMDR practitioners, on the other hand, value and seek to “activate and guide… the patient’s own innate healing potential” (p. 232).

To seek and explore such complementarities is in keeping with Francine Shapiro’s concept of EMDR as lending itself to integration with other therapy approaches: “It is not that any one element is credited for healing but rather that the complex and integrative procedures and protocols incorporate elements of all the major psychological traditions” (Shapiro, 2002, p. 27).

In 2002, Shapiro edited a collection of chapters on EMDR as an integrative therapy approach, inviting leading clinicians from diverse therapies such as hypnosis, CBT, schema therapy, attachment theory and neurobiology to explore how EMDR could be strengthened; how EMDR complements and extends outcomes in their own field, and how certain elements of EMDR are routinely represented in and compatible with their various therapeutic traditions. One contribution concludes “Each model (schema and EMDR) can be tremendously beneficial to clinicians and their clients. Combining aspects of each often yields better results than using either one alone” (Young, Zangwill, & Behary, 2002, p. 182). Given the development and acceptance of IFS, a new edition of this work might include a chapter by Richard Schwartz, the creator of the Internal Family Systems model, on IFS-informed EMDR.

The problem facing EMDR is that it has become siloed and misconceived as a simple desensitisation technique for traumatic symptoms. In the words of the CoS: “a rigid traditional stance risks losing important developments and innovations essential to keeping the model dynamic, which has been a core value in the EMDR community from its inception” (Laliotis et al., 2021, p. 187).

This is not helped by current basic training in EMDR which only teaches the standard protocol (SP), leaving trainees ill-equipped to deal with most of the complex presentations experienced by practitioners today. One supervisee told me that during her basic training she felt scared of EMDR, like she was being sent into a war zone and told “use it, don’t use it”(personal communication, April 13^th, 2022). I know I did not use EMDR for three years after my basic training and probably would not have bothered had it not been for an enthusiastic colleague and brilliant supervisor who was integrating EMDR into their own clinical approach and encouraged me to go back to the basic training handouts.

A simple solution is to extend the length of the basic training but also to reinforce those “important developments and innovations,” which include conceiving of EMDR as a flexible protocol that enhances other therapies, as outlined in Shapiro’s book two decades ago. This is the vision of the CoS: “one can envision a multi-year, in-depth EMDR therapy training curriculum that will produce EMDR psychotherapists who are well-trained to offer a broad range of services in different contexts” (Laliotis et al., 2021, p. 195). In the meantime, they suggest offering a brief training in the standard protocol as a taster.

This article is aimed at those EMDR therapists who struggle to apply the apparently linear, standard protocol in an eight-phase model to the complexity of presentations by clients who walk in the door with anxiety, phobias, attachment issues, self-esteem, addiction, Covid grief, stress, and more. “Although EMDR can be used successfully with most clients, there are times when its effectiveness is limited, and clients for whom it simply does not work. Often this occurs when the affect is partially or completely unavailable and the flow of the processing becomes partially or completely blocked. The Internal Family Systems Model (IFS), (Schwartz, 1995) is an elegant, efficient and powerful ego state treatment modality that, when used with EMDR, can increase its range of effectiveness” (Twombly & Schwartz, 2008, p. 295).

It would be irresponsible at this point to go further in commending the merits of IFS as a complementary approach to EMDR, in a publication most of whose readers are EMDR practitioners, without acknowledging the capacity constraints on the availability of IFS training. To secure a place on a Level 1 accredited training offered by the IFS Institute requires (at the time of writing) the applicant to enter a lottery, for a course that takes eight days and costs (in the UK) £3,000.

With an IFS framework of understanding, resistance and dissociation are no longer seen as obstacles, but instead seen as opportunities to help the client understand, befriend and locate the wise inner leaders of their own internal world. “Integrating IFS into the standard EMDR protocol provides additional perspective for the IFS-trained EMDR therapist in terms of ego states, defenses, and relational phenomena, which can cause blocking beliefs and resistance to trauma processing” (O’Shea Brown, 2020, p. 115). Indeed, every memory targeted in EMDR is actually a part, or “a sacred inner being” (Schwartz, 2020) as seen in IFS. Ana Gomez, in her trainings, describes parts as ‘story keepers’ or metaphors (Gomez, 2021). But Schwartz & Falconer maintain that “parts are not [mere] metaphors – instead they are real sub-minds, each with autonomy and with power to influence and sometimes take over the person’s perspective, emotional state, or actions” (2017, p. 94). Twombly and Schwartz endorse this emphasis on the system-level scope and range of parts: “Because IFS grew out of systems thinking and family therapy, the focus has not been on getting to know and change each part individually, but instead on working within the network of internal relationships in which each part is embedded” (Twombly & Schwartz, 2008, p. 297).

When administered by itself, EMDR offers no way to identify and distinguish what function a part being targeted (as a memory) might perform. So, changing the way the memory is stored could upset the delicate internal balance of protection, whether from overwhelming feelings from the past or re-enactments in the present. So EMDR can easily hit resistance and appear not to work. Warnings about this are given in EMDR basic training. With no strategy to overcome this effect, however, trainees can simply be put off using it.  Hence the argument for an IFS-informed approach, to provide a guide for the client’s inner world. IFS equips EMDR therapists with a map of the internal system, to understand what is going on, rather than being afraid of it; thus, inviting clients to befriend and appreciate their own internal family as an eco-system.

Embracing parts and acknowledging their need-based roles is congruent, Schwartz and Falconer argue, with Dan Siegel’s description of mental health. “Siegel … has stated that all the diagnoses of the DSM can be seen as examples of too much rigidity, too much chaos, or both … The core significance for us is related to Siegel’s thinking. When we consider the mind as a complex system, it implies that within the mind are separate agents, and these agents are not hooked up in lockstep together; they are nonlinearly connected. Health is not uniting all the parts into a single entity, nor does it involve exerting a lot of top-down control over them. Instead, in healthy complex systems the parts are connected to one another and, at least in human systems, feel valued and connected to an organizing purpose related to the thriving of the larger system in which they are embedded” (Schwartz & Falconer, 2017, pp. 140-141). A useful metaphor here for the integration of parts with the mind, is as a fruit salad, rather than a smoothie.

There are two main types of parts in the IFS model: exiles, who hold all the distress, pain, shame, and loneliness from the trauma of the past; and protectors, who are trying to stop someone from feeling this distress. There are two kinds of protectors: managers and firefighters, who differ in how they prevent the distress. Managers, who try to control the environment, are usually critical of the person to make them look good to others. Firefighters act to distract from the distress, often taking such forms as dissociation, avoidance, or addictive behaviours like binge eating, drinking or self-harm, thereby providing a short-term solution to exiles getting out. “These protectors will resist intrusions by well-meaning therapists if their fears are not respected and addressed. This phenomenon is what leads EMDR processing to become blocked at times” (Twombly & Schwartz, 2008, p. 297).

The IFS model holds that parts are not created by trauma but that the parts are already there. The symptoms are created by the parts being burdened by trauma, “it is the burdens that parts carry, not the parts themselves, that cause problems” (Twombly & Schwartz, 2008, p. 297). Schwartz and Falconer (2017) explain that compartmentalisation is the natural state of the human mind. They describe how anthropological studies have traced this phenomenon back to the beginning of culture and advances in human knowledge that emerged from human capacity to compartmentalise tasks. However, the notion of inner voices has often been suppressed and pathologised, which the authors attribute in large part to the influence of Cartesian teaching in enlightenment philosophy, modelling a unitary ego.

Points of comparison and contrast

An exploration of the similarities, differences and strengths of the EMDR and IFS models follows, to show how together they can offer a more robust and comprehensive treatment for complex presentations. In this, it follows contributions from the EMDR community, such as by Gillian O’Shea Brown (2020); Bruce Hersey in his trainings and Joanna Twombly along with Richard Schwartz (2008) have already begun to map out such comparisons. Another collection is forthcoming from the psychotherapy imprint, Phoenix Press, incorporating contributions from several of the writers quoted here and edited by a clinical psychiatrist, Dr Millia Begum.

• The goal of EMDR, like IFS, is memory reconsolidation, in other words changing the ways the memories are stored to allow someone to choose their responses rather than be driven by reactions to current triggers. Or, “get past your past” (Shapiro, 2012).
• EMDR and IFS share the capacity to access deep emotionally vulnerable states. Both conceive of these as frozen traumatic memories that can be healed as part of the memory reconsolidation process.
• In IFS, the memory is seen as a story to be shared by the part who experienced the trauma. The Self witnesses this story, along with the therapist, with compassion and curiosity. It is the Self that steps into the scene so the exile is no longer alone.

There are similarities with EMDR dual awareness: one foot in the past, one foot in the present. But there is something more explicit in consciously inviting the Self to step into the scene and asking the part in the scene if it knows the Self is there.

• A central and crucial difference between IFS and EMDR is that IFS treats the system as a whole, as mentioned earlier. In missing this element of the system, Twombly & Schwartz go on to say, “EMDR can sometimes override managers and access exiles before the system is ready to handle them” (p. 304). IFS on the other hand has tools to negotiate with managers and resolve inner conflicts: “By applying concepts and methods from the structure, strategies, and narrative of family therapy and subpersonalities, the IFS model provides a language necessary to understand one’s parts and work through unresolved internal conflicts” (O’Shea Brown, 2020, p. 120).
• The other main difference between the two modalities is that there is no bilateral stimulation in IFS. Instead, the source of healing is Self-energy: analogous to the AIP with some differences between them (to be explored later).
• There is no history taking in IFS, and preparation is kept to a minimum in terms of grounding and affect regulation. Grounding is not deemed necessary in IFS because it is seen as potentially dismissive of a part, such as dissociation, plus exiles can “dial down their feelings in the body” (Schwartz & Sweezy, 2020, p. 270). There are those beginning to challenge this view in IFS such as Chris Burris (2022) and Joanna Twombly (2013).
• In EMDR, considerable time is spent on phase one: obtaining a client’s history and their experience of trauma whether as a timeline, list of worst events or a genogram. Phase two: preparation involves a variety of techniques, from breathing and grounding to installing (with BLS) the safe place image, and in complex cases additional time is spent on Resource Development Installation (RDI) (Leeds & Korn, 2002). Others such as Laurel Parnell (2013) suggest a team of figures including nurturers, protectors and wise beings.
• A key preparation step in IFS is establishing a part-to-Self connection.

In the beginning of IFS work most of the parts are protectors: “When we teach the IFS model, we offer six steps to working with protector parts so they will trust the Self to work with vulnerable exiles” (McConnell, 2020, p. 24). These are the six F’s: Find, Focus, Flesh out, Feel toward, Fear, beFriend. “These six steps are not a strict formula and are not necessarily sequential. They are helpful for the therapist to guide the session along” (p. 25). EMDR, by focusing on grounding in phase two potentially ignores or bypasses the protectors and runs the risk of them blocking further stages of EMDR.

• In IFS key preparation is to create access to Self-energy, in order to be able to witness an exile: “The initial step in the IFS treatment process is to differentiate the parts from the Self or to unblend parts from the Self” (Twombly & Schwartz, 2008, p. 298). Schwartz describes stumbling across unblending as a way of accessing a client’s wise essence: “As people started to notice and then separate from their parts, they would have a sudden identity shift and would come to realize that they weren’t their burdened parts and instead were the Self (2021, p. 101)”.
• Like phase four desensitisation in EMDR, IFS has a process of unburdening, where the part, usually an exile, has their trauma witnessed by the Self. The part is then invited to release all their uncomfortable feelings from the body. This is quite a shamanic approach, inviting the client to name how they would like to release all their uncomfortable thoughts (analogous to negative cognitions [NC]s in EMDR) and feelings (analogous to SUDs in EMDR). Often, they are released to the earth, the air, the fire, or the water and this can be experienced as a creative process. Clients in the author’s own experience have made such suggestions as: “the cloud would like to rain into the black hole”; “the little one would like to put all her shame and worthlessness on the fire”; “that part would like to throw all the worry into the waterfall”; “that little one would like to step out of the uncomfortable fat suit she’s been wearing, stuffed with other people’s toxic emotions”.  
• As with EMDR, an IFS therapist will check back with the part to ensure all the burdensome disturbing thoughts and emotions have gone, much like a body scan: “ask that part if all those uncomfortable thoughts and feelings have left the body, or is there more to go?”
• Then, like installing a PC, the IFS therapist asks the client what this part would rather feel and believe about themselves.
• The next step in IFS differs from EMDR, by going back to the protector(s) to explore how it was for him/her/them to witness this shift in the exile. To find out if they would like a new job, particularly as the old role was leaving them so tired.
• Finally, in closure, all the parts are invited to share anything before the session ends. And the exile is asked if he/she/they would like the Self to check in regularly between now and the next session. Perhaps that might be daily, even three times a day.  This is more thorough than in EMDR where a SUDs of 0, VoC of 7 and clear body scan is the end of the session. From an IFS perspective there is an absence in EMDR of reinforcing such developing internal relationships. In IFS it is all about the part’s new attachment to the Self, like inner children connecting to a parent.
• With incomplete EMDR sessions closure may be with another technique such as going to the safe place or using the light stream technique. Marich (2022) argues that the safe place in EMDR is dissociative. It potentially abandons a wounded child in a trauma memory by inviting the adult client to dissociate to the safe place.
• Reassessment is a step that both therapies share, in IFS checking how the exile has been during the week; in EMDR checking the TICES (Trigger, Image, Cognition, Emotion, Sensation) log from the week and anything else the client has noticed. Here again, IFS is more relational; EMDR more mechanical.
• IFS therapy does not include a future template. This step is an important part of the EMDR’s three prongs of past, present and future approach, and allows EMDR to help clients prepare for a future event, to process any catastrophic fears with the flash forward (Logie & de Jongh, 2014) or rehearse how they will handle something challenging with a future template.

Blending EMDR and IFS

A point of crossover between the two approaches that requires more detailed attention is the concept that a disturbing memory in EMDR can be conceptualised as a burdened part in IFS.  What if EMDR’s phase three assessment was enhanced with relational parts language, such that a sacred inner person, in IFS terms, is first asked for their permission to explore a memory, then dialogued with about why they think and behave as they do. Perhaps then EMDR might flow more easily with more clients?

Bruce Hersey, who is both an IFS approved clinical consultant and EMDRIA-approved EMDR Consultant, recommends using parts language at the outset in phase three to select the target for desensitisation by asking: “What part do you want to process today with EMDR? Is this a part you know about through an emotion, sensation, image, or thought?” In this way the six F’s can be easily folded into an EMDR target assessment: Find, Focus, Flesh out, Feel toward, Fear, beFriend. Find and Focus can direct attention to the body: “Is it OK to go inside and find the part right now? Where is it in your body? Can you focus on it and let it know you notice it is there?” This is a relational way of connecting to the part so the part can then be asked for EMDR target-related information: “Is the part showing you any images, or can you see the part? Are there any thoughts or beliefs that go with the image and feelings of the part?” (Hersey, 2013).

For an IFS therapist, the most useful question to a client will often be: “how do you feel towards this part?” This ascertains the amount of Self presence and whether there is any interference from other parts. If the client feels very compassionate and curious, they might even be asked, Hersey suggests, for a measure he calls Presence of Self (POS), which, as with a VoC, is assessed on a one-to-seven scale. With higher client resistance, the POS is low and the part is telling the therapist very critical things about the target part (memory) such as, “I don’t like that part”; or “she doesn’t deserve any attention”, the part can be confidently identified as a protector. There is little access to Self, the Self is blended with the part. Essentially, permission has not been obtained to reach that exile, so further time is needed to help the protector to unblend, to allow for more Self-presence and trust within the system.

This may be quick or may take several sessions in dialoguing with a protector, to “identify agendas or concerns or urges in protectors”. Hersey suggests exploring such agendas via the Protector Positive Intention (PPI) and Level of Urge to Protect (LUP). The PPI is the protector’s cognition, whilst the urge to protect is an energy and intensity that can be measured locating the LUP as a sensation in the body and measuring its strength on a zero to 10 scale: “process these with some BLS, and do some Self resourcing (POS) before moving on to next step”. Readers of Jim Knipe (2015) will recognise the similarity of the LUP with Knipe’s the Level of Urge to Avoid or Use, as useful steps in dealing with resistance and avoidance in EMDR processing. The difference with IFS is the concept that there are ‘no bad parts’ (Schwartz, 2021), so the intention of the protector is always positive. In working with a client recently suffering from endometriosis, the pain in her pelvis was a purply black pebble with a SUDS = 10. She felt frustration towards the pebble, so she was invited to unblend from the frustration. She was able to ask the pebble how old it was, five years old, and it told her its intention was to protect her from her mother. The PPI was safety and when asked how much that pebble, that had now become a dome, wanted to protect her, for a LUP = 10. Through a few sets of BLS the pebble dissolved, to make way for a distressing memory held by the five-year-old involving her narcissistic mother.

IFS questions to befriend the protectors can be used in interweaves either in preparation or in phase four desensitisation when the processing gets blocked. The therapist asks, of the part:

• “How did it get this job?”
• “How effective is the job?”
• “If it didn’t have to do this job, what would it rather do?”
• “How old is it?”
• “How old does it think you are?”
• “What else does it want you to know?”
• “What does it want for you?”
• “What would happen if it stopped doing this job?”

Conclusion

This article has welcomed the clear definition of EMDR therapy and the 2021 position paper from the ‘What is EMDR?’ workgroup of the EMDR Council of Scholars, particularly in its concentration on the potential of EMDR as an integrative relational psychotherapy, needing to move beyond conceiving of EMDR as a simple desensitisation technique.

The position paper draws on writings by Francine Shapiro (2002, 2012, 2018) to argue that EMDR was always intended and destined to evolve further by seeking out and combining with complementary approaches in other leading therapies including schema, psychodynamic and transpersonal therapies. This article has argued that the Internal Family Systems model offers an especially propitious and fruitful field of integration. It has set out the areas of consonance and dissonance between IFS and EMDR, including by reference to existing scholarship that has considered such linkages.

Further illustration of how these two approaches can be integrated in practice will be provided in a composite case study in the next issue. It will show how an IFS-informed EMDR approach enabled a client with a complex presentation to find inner peace, transformation and healing.

These considerations have implications for the training of EMDR therapists. As the CoS put it: “A more in-depth curriculum may also enable university-based programs to teach EMDR therapy as a framework for students who are just beginning their psychotherapy education/training, as well as provide advanced training for licensed clinicians” (Laliotis et al., 2021, p. 195). In such training, IFS may have a prominent place, amongst other therapeutic approaches that offer complementary elements to the powerful therapeutic toolkit afforded by EMDR.