Integrating EMDR Therapy with Cognitive Behavioral Therapy (CBT)

Guest Blog Post by Dr. Jennifer Fee, PsyD

Tell us a little about you, your experience of becoming an EMDR therapist, and your experience working with CBT.

I began my career as a therapist by specializing in treating anxiety disorders using Cognitive Behavioral therapy (CBT). I went on to teach CBT to graduate students for almost 20 years. When I began my career as a therapist, EMDR therapy was brand new, so I was a little skeptical of learning something that did not yet enjoy decades of research support.

Many years into my career as a psychologist, I attended EMDR basic training after experiencing the life-changing impact of EMDR therapy as a client. At the training, I was immediately tuned into the commonalities that EMDR therapy shares with CBT. Both CBT and the theoretical model upon which EMDR is based, the Adaptive Information Processing Model or AIP recognize that life experiences (both positive and negative) greatly impact people’s current perceptions, feelings, thoughts, behavior, and body sensations. As a CBT therapist used to using structured interventions and protocols, I felt at ease with the idea of following the EMDR therapy eight phases and all its associated goals, tasks, and procedures. The adoption of EMDR therapy as a therapeutic modality felt easy and natural for me.

Can you briefly help us understand a little more about CBT, and why it is so popular in therapeutic settings?  

There have been “three waves” of CBT therapy. Behaviorism, the first wave, was a radical shift from Freudian psychoanalysis, which was the predominant therapeutic modality during the early 20th century. While behaviorism only emphasized basic learning and conditioning principles, its implementation can be researched, which helped lead to a sharp rise in behaviorism’s popularity over psychoanalysis. In fact, behaviorism was the predominant therapeutic modality from the 1920s through the mid-1950s (Schneider & Morris, 1987).

Cognitive Therapy, which later evolved into Cognitive Behavioral Therapy (CBT) was developed by Aaron Beck in the 1960s and 1970s and is part of the second wave of CBT. Beck developed cognitive therapy after observing that his patients with depression often verbalized thoughts that were not only negative in nature, but also distorted. His cognitive theory of depression states that people suffering from depression have thoughts that are characterized by negative distorted views about themselves, the future, and the world (aka the cognitive triangle of depression). He subsequently developed a therapy that emphasizes identifying and challenging these thoughts by examining the evidence for them. The goal is to create more balanced thoughts that people could then test out in real life, hence building credibility and a stronger belief in those new thoughts. Beck’s approach was revolutionary for the time because it gave people active steps to take to help themselves feel less depressed and anxious.

The “third wave” of CBT therapies expands CBT by integrating its principles with other psychotherapeutic approaches and tends to have an emphasis on the function of a person’s thoughts rather than just their content. Mindfulness, values, spirituality, and metacognition are all important concepts in third-wave CBT therapies. Examples of third-wave therapies include Dialectical Behavior Therapy (DBT), Acceptance and Commitment Therapy (ACT), and Mindfulness-based Cognitive therapy (MBCT), just to name a few. These approaches seek to take a holistic approach by helping people to examine their relationship with their thoughts, emotions, and behavior. There is an emphasis on process, skill building, and experiential strategies. These approaches are popular because of the ways in which they help people more effectively interact with themselves and their environment.

When I was a CBT therapist, the approach I was most attracted to was that of Christine Padesky, who integrates CBT interventions with Seymour Epstein’s Cognitive-experiential self-theory (CEST). CEST proposes that people use two distinct systems to process information, an analytical-rational system and an intuitive-experiential system. Padesky often refers to these systems as the “two minds.” The rational mind is slow, rational, and logical, whereas the experiential mind is automatic, emotionally driven, and based on past experiences and associations. Padesky’s approach to CBT incorporates interventions that involve both the rational and experiential minds.

While CEST theory is different from the Adaptive Information Processing (AIP) model, both emphasize the importance of past experiences and the idea that those experiences are instrumental in shaping current beliefs, emotions, body reactions, and behavior. An EMDR therapist activates the AIP during Phase 4 desensitization to process through distressing material. A third-wave CBT therapist who integrates CEST theory is going to use interventions that give the experiential mind opportunities to process through maladaptive beliefs and schemas. Indeed, I have found that the best CBT interventions are those that directly impact the experiential mind, such as experiments and somatic-focused interventions.

How can EMDR therapy and CBT complement each other in treatment? What successes have you seen? 

As an EMDR therapist, I see tremendous value in using CBT interventions that support the work of EMDR therapy. For example, in my Go With That Magazine® article, “A Three-Pronged Approach to Treating Anxiety with EMDR Therapy,” I describe how a 69-year-old client and I created a fear hierarchy related to her fear of going to the DMV to take a written test in order to renew her driver’s license at age 70. A fear hierarchy is a CBT method for breaking an event down into smaller events with the least feared event at the bottom and the most feared at the top. A CBT therapist would then take the events on the hierarchy and then either do imaginal or in vivo exposure. With my client, however, we used some of the events on the hierarchy as targets for EMDR processing.

Another example of integrating a CBT intervention into EMDR therapy would be the use of activity schedules or other types of logs and diaries. EMDR therapists already use something extremely similar when they introduce the TICES log to clients. However, there are so many other potential uses for schedules, logs, and diaries. The activity schedule, for example, is a CBT technique that helps people set aside time for specific activities that they might not ordinarily do if they are not on one’s calendar. If we want someone to utilize a Calm Place, for example, it might be useful to have a client schedule time to use it rather than relying on them to remember to use it when they would benefit from shifting states. By setting up specific times to use the Calm Place, we can potentially help clients to experience state change on a more regular basis.

Are there any cautionary measures you would like to mention regarding using EMDR therapy and CBT? 

While CBT interventions are not complex, it is a good idea to get some training in CBT before using them to complement your EMDR therapy. There are three parts to any intervention, setting it up so the client understands what you are asking of them and why, carrying out the intervention correctly (or giving the client enough tools to carry out the intervention outside of session), and then processing the experience of the intervention with the client (which may involve some troubleshooting).

If a client does not understand why they are being asked to do something, they are less likely to do it. Similarly, if they do not have enough information to carry out an intervention properly, they are far less likely to have success completing it. It can be helpful for therapists to try a variety of interventions out on themselves to gain an understanding of what they are like, how they work, and what challenges a client might face while trying them. Any CBT intervention added to EMDR therapy ought to be done for the purpose of supporting the goals of EMDR therapy. Whenever we are using something in therapy, we ought to have a sound therapeutic reason for doing so.

Are there any myths you would like to bust about EMDR and CBT work? 

Some people think that EMDR therapy and CBT therapy are so different that they cannot be integrated together. Chances are, some EMDR therapists are already using CBT approaches without realizing it. If an EMDR therapist uses Socratic dialogue, for example, to explore a client’s history or find negative cognitions, then they are using a key CBT technique.

Another myth I hear a lot is that only one type of therapy can be done in a single session. I often hear consultees make statements like, “We did not do EMDR this session,” or “We just did some CBT.” Often what people mean is that they did not engage in Phase 4 of EMDR therapy (desensitization) when they make such statements. However, EMDR therapy is a modality based on the AIP model and that theoretical framework is meant to guide all aspects of EMDR therapy, including the incorporation of interventions from other modalities, like CBT.

What complexities or difficulties might people undergoing the integration of EMDR and CBT face? How does this affect therapy? 

It is challenging enough to gain competence in one therapeutic modality, like either EMDR therapy or CBT. It seems wise for therapists to focus on utilizing one modality with clients until they gain a certain level of experience and expertise before making efforts to integrate the two. While perfection is never the goal, it is easier to examine progress and mistakes during supervision or consultation while focused on learning each modality well.

Integration needs to be a thoughtful and deliberate process. A solid case conceptualization, which in turn will inform treatment planning, is a therapist’s best friend when it comes to considering how to integrate CBT approaches into EMDR therapy.

What multicultural considerations might EMDR therapists need to keep in mind regarding EMDR therapy and CBT? 

There’s always so much we can explore with this question. In my last blog on EMDR therapy and anxiety, I emphasized the importance of being mindful of how people from different cultures experience and express their anxiety. This time around I would like to emphasize both the need for building rapport and trust in the therapeutic relationship.

Both EMDR therapy and CBT therapy are designed to be collaborative, and client-focused, however therapeutic relationships always contain a power differential. For some people, the view of the therapist as someone in a position of authority is going to be more pronounced than with other people. Such people might not openly disagree with their therapist, therefore it will be critical for therapists to use broaching (click here for a free OnDemand presentation regarding broaching in consultation or here for a paid course regarding broaching within the context of EMDR). It is important to remain observant of a client’s nonverbal cues for subtle changes in body language and verbal expression that might give clues to disagreement that they might not be willing or able to verbalize.

Building trust and rapport is essential before any trauma processing or CBT interventions can take place. It is critical not to use prescriptive language, which is a pitfall that new therapists (or those learning a new approach) can find themselves in danger of falling into. Whether using EMDR, CBT, or an integration of both, it is important to help the people be an active participant in their therapy. Creating a collaborative relationship in part includes validating and respecting people’s experiences, using transparent communication to explain the therapeutic process, and working to set mutual goals.

What is your favorite free resource that you would suggest to other EMDR therapists interested in learning more about using EMDR and CBT?

Christine Padesky has some free tools for clinicians on her website along with some videos that give tips on how to use some of the tools.
The Journal of EMDR Practice and Research printed a case study regarding the integration of EMDR and CBT with a client with Bulimia.

What would you like people outside the EMDR community to know about the use of EMDR therapy and CBT? 

Both EMDR and CBT therapy have broad clinical applications. Mental health is about developing good health, and the focus of each therapy touches on a variety of aspects of that goal. EMDR therapy resolves maladaptively linked events from the past that affect the present and future, and CBT can help strengthen one’s ability to live a full and healthy life.

Jennifer L. Fee, Psy.D. is a clinical psychologist and EMDR Consultant™ who has helped people with anxiety disorders for over 30 years. In addition to private practice, Dr. Fee spent a significant portion of her career in graduate education and directed a master’s level program. She currently works at the EMDR International Association as the professional practice content specialist. Dr. Fee is passionate about fighting the stigma that surrounds mental health issues and advocating for EMDR therapy via writing and speaking. She has given a TEDx talk and made two appearances on Monique Coleman’s Discovery channel series, “Gimme MO,” discussing sexual assault, mental health, and EMDR therapy.

References

Fee, J. L. (2024, February 23). A three-pronged approach to treating anxiety with EMDR therapy. Go With That Magazine®, 29(1), 12–17. https://www.emdria.org/blog/emdr-therapy-and-anxiety-gwt-magazine-issue/

Greenberger, D., & Padesky, C. A. (1995). Mind Over Mood: Change How You Feel by Changing the Way You Think. New York: Guilford Press.

Kuyken, W., Padesky, C. A., & Dudley, R. (2009). Collaborative case conceptualization: Working effectively with clients in cognitive-behavioral therapy. New York: Guilford Press.

Schneider, S. M., & Morris, E. K. (1987). A history of the term radical behaviorism: From Watson to Skinner. The Behavior Analyst, 10, 27-39. Open access: https://doi.org/10.1007/BF03392404

Shapiro, F. (2018). Eye Movement Desensitization and Reprocessing: Basic principles, protocols and procedures (3rd ed.). New York, NY: Guilford Press. 

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Additional Resources

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Integrating EMDR Therapy with Cognitive Behavioral Therapy (CBT)