emdr pain protocol mark grant. ma, maps. goals of treatment resolve or reduce pain develop pain...

EMDR pain protocol

Mark Grant. MA, MAPs

Goals of treatment

• Resolve or reduce pain

• Develop pain control skills

• Resolve trauma

• Reduce associated emotional distress

• Address identity issues

• Alleviate health fears

• Stimulate improved adjustment and functioning

Goals of treatment

“ EMDR treatment of chronic pain includes the processing and desensitization of both; •the automatic emotional response to the pain sensation and, •the automatic components of the stored memories related to the etiology of pain.”

- Mazzola et al, 2009

Elements of treatment

1 HistoryMedical diagnosis

2. PreparationSafety, Medical issuesAIP model for pain

3 AssessmentTarget: Traumatic memory, present pain, effects of pain

4. DesensitizationContinuous auditory Bls“Incomplete processing”Self-use of DAS/BlsDealing with blockages

Elements of treatment

5. Installation+’ve cognition and/or antidote imagery

6. Body Scanaddressing persistent pain

7. ClosureEducating client about how to notice and integrate

changesResources for living with pain

8. Re-evaluationPhysical vs mental changes

Stage 1. History

1 History2. Preparation3 Assessment4. Desensitization5 Installation6. Body Scan7. Closure8. Re-evaluation

History

• Medical diagnosis

• Trauma?

• Family background

• Cormobid problems

• Narrative (how, when, where, what)

• Medications?

• Suitability for EMDR

• Target sequencing

Medical diagnosis

• What is the client’s medical diagnosis?• Implications of medical diagnosis• To what degree does client

accept/understand it?• What treatments? Outcomes?• How long in pain?• Prognosis?

Trauma History

• Sexual abuse• Accident (auto, work, other)• Injury• Diagnosis of life-threatening illness• Surgery• Combat trauma• Complicated bereavement• Abortion• Assault• Torture• Rape

Developmental trauma

“unless there is solid evidence to the contrary, clinicians would be wise to assume that virtually all clients carry with them some degree of developmental fixation or stuckness.”

- Kitchur, 2005

Developmental trauma.

• Abuse, neglect, instability

• Early childhood illness

• Family breakup

• Family dynamics

• Intergeneration physical and mental health problems

Effects of developmental trauma.

• Co-morbid cluster C symptoms

• Avoidant, Dependant, Borderline

• Emotional regulation problems

• More likely to dissociate

• Relationship problems

• Identity issues (defective schema)

Co-morbid problems.

• Depression• Anxiety• Personality disorder• Insomnia• Substance abuse• Other health/medical problems• Life circumstances • Adjustment problems

Narrative (client’s story).

• Problem: What is client’s definition of presenting problem? How well does it fit the facts?

• Client: What does way client talks about problem indicate about their coping style/capacity?

• Goals/expectations: What do they really want? Or need

• Resources: What resources are discernible?• Entry point: Where might you begin?• Preparation: What inputs might be necessary

prior to desensitization?

EMDR ‘targets’

Mark Grant MA

Event NC

PAST TRAUMA:

Car accident I can’t cope

Having to live with abusive ex-wife while recovering from injuriesNeeding breathing apparatusFailed marriage

I’m trapped

I’m helplessI’m a failure

PRESENT STRESS:

Freeway phobia I’m out of control

Narrative (client’s story).

• Problem: What is client’s definition of presenting problem? How well does it fit the facts?

• Client: What does way client talks about problem indicate about their coping style/capacity?

• Goals/expectations: What do they really want? Need

• Resources: What resources are discernible?• Entry point: Where might you begin?• Preparation: What inputs might be necessary

prior to desensitization?

Psychology of Workers Insurance.

Loss of;• control•Privacy•Freedom/choices (feels trapped needs the benefits and treatment but) •Health/physical integrity•Future•Safety

How much history?

“ask for only the most basic facts, the bare minimum that will allow us to proceed with the case formulation.”

- Greenwald, 2007

History-taking.

• A process of both gathering and uncovering information about the client

• Includes verbal and non-verbal information• A function of the therapeutic relationship (eg; safety)• Also part of therapy (eg; developing a narrative)• Not necessary to complete prior to reprocessing• May continue well into therapy• Pacing is important• Goal-oriented

Case conceptualization.

Physical pain

+ – injury/illness– Trauma– Family problems, Neglect– Comorbid problems (anxiety, depression)– Current stressors– Personality factors– Resources

The Pain Pyramid.

Assessing personality

Ego strength

• Ability to; engage in satisfying relationships, • experience a relatively full range of age-expected

feelings and thoughts, • function relatively flexibly when stressed by external

forces or internal conflict, • have a clear sense of personal identity, • are well adapted to their life circumstances, • neither experience significant distress nor impose it on

others.- Psychodynamic Diagnostic Manual

Defence mechanisms.

• Denial ‘Primitive’• Dissociation• Projection• Somatization• Masochism• Repression• Sublimation (Hyperactivity - manic defence)• Intellectualization• Humour ‘Sophisticated’

Personality disorders and pain.

Avoidant Control issues *Trust and safety issues *Hypervigilance *

Borderline Affect regulation problems *Propensity to dissociate *Fear of abandonmentLack of support *Identity issues *

Histrionic High emotionality *Attention-seeking behavior

Dependant Submissive *Needing to cared for by othersFear of separation

Trauma related symptoms

• PTSD symptoms (increased physiological arousal etc)• Dissociative symptoms• Affect regulation problems• Somatization• Depression• Relationship problems• Identity issues

- van der Kolk (1996)

Brain Hemispheric Differences

LH RH“what?” “How?”Inflexible FlexibleNarrow focus attention open, sustained attentionPrefers known Likes novelty - Never fully knownEmotionally - Anger Emotionally - DepressionSelf= act of will Self in relation to othersDenotative language metaphors, symbolsCompetitive , exploitative EmpathicSequential processing Parallel processingDecontextualized world “Lived world”

Acknowledgement: Ian McGilchrist (2009)

Mark Grant

Problem of pain

•A stressful, often traumatic event

•Exacerbates pre-existing trauma

•Overwhelms coping mechanisms

(medical model):

“not my problem – the doctor should fix me”

The medical model:

Traumatic pain vs medical pain

• Traumatic pain:

A memory (‘past’)

“Stored memories related to etiology of pain”

Emotional distress with or without injury

Pain = maintained by memory • Medical pain:

An event (‘present’)

“Automatic emotional response to pain”

Pain = maintained by physical injury

Goals of treatment

“ EMDR treatment of chronic pain includes the processing and desensitization of both; •the automatic emotional response to the pain sensation and, •the automatic components of the stored memories related to the etiology of pain.”

- Mazzola et al, 2009

Pain + trauma

Mutually exacerbating problems, comprising physical and emotional factors, past and present experiences, which involve;

- Intrusive thoughts and feelings, avoidance, numbing

- Autonomic dysregulation, (sleeping problems, fatigue)

- Emotional dysregulation, (depression, hyper-sensitivity, mood swings)

Pain + injury

Pain +

Effects of pain:on physical functioning

(‘work, love and play’)sleepmoodrelationshipscopingidentity

My 5 “secret” assessment criteria

1. What is client’s affect range/capacity2. What is client’s medical diagnosis? (if

applicable)3. How much is person able to distance

themselves consciously from their problem?4. Personality (strong, stable?)5. Life circumstances (stable?)

Pain Tests.

• Impact of Event Scale (Horowitz, et al, 1979)• Pain Disability Index (Chibnall & Tait, 1994)• Beck Depression Inventory• Beck Anxiety Inventory• Pain Catastrophizing Scale (Sullivan et al,

1995)• SFMPQ, VAS• Pain Self-Efficacy Questionnaire (Nicholas,

PPI vs affect in SFMPQ

Stage 2. Preparation

1 History2. Preparation3 Assessment4. Desensitization5 Installation6. Body Scan7. Closure8. Re-evlaluation

Preparation

• Therapeutic relationship

Transference & counter transference

• Safety and containment issues

Pain control

Safe place (if necessary)

• Medical issues

• Explanation of EMDR

Transference

" A person seeking help for chronic pain could be said to be inactive with secondary physical deconditioning, to hold unhelpful beliefs, to be overly passive or reliant on others for resolution of his/her problems.."

-Nicholas, (1996).

Transference and countertransference

Therapists are always influenced by their patients:

“We hope for the best; we are saddened by their [patients] failures, gladdened by their accomplishments; and we suffer real losses when they complete therapy”

- Beitman (1983)

How to recognize your transference

1. Emotional reactions:Frustration, Anger, Guilt, Shock, Pity, Sadness.

2. Ego states:‘Helpless child’, ‘Incompetent Failure’, ‘Rescuer’, ‘Omnipotent fixer’, ‘Critic’

Uses of Transference

•Assessment tool•Facilitates therapeutic relationship•Facilitates clients exploration of feelings•Client safety•Therapy more likely to be aligned with clients capabilities•Professional development•Self-protection (avoiding burn-out)

T: I’d like you to think about some place that feels calm or safe.C: I’m on the beach. It’s a sunny day. The sand is warm and the ocean is calm.T: Bring up the image of that calm place, concentrate on the pleasant sensations in your body and follow my fingers… How do you feel now?C: I am not a good swimmer, I feel anxiousT: Feeling compassionate and hoping something else will work. Think of another place. (Client can’t find anything) T: Do you ever feel safe anywhere?C: Not really, no.

T: I just noticed that I went numb all over my body. I’m wondering if you are feeling something similar.C: Yes as a matter of fact I am. Finding a safe place is such a simple thing, Why can’t I do it?T: It seems like the memory feels safe at first, but then an unpleasant memory intrudes and destroys the safety.C: I am beginning to realize that I don’t know what safety feels like. I don’t think I have every felt safe anywhere, with anybody.Does this mean I can never feel safe.. can’t do EMDR?T: We are doing EMDR right now…for people who don’t have a safe place we can work to develop that.

Therapeutic relationship.

“The heart of the preparation stage is the feeling of trust that comes from knowing we’re engaged in the same task...”

- Mark Dworkin, 2008

Safety.

• Adequate control over pain/affect

• Freedom from threat

• Secure living conditions

• Psychological safety (safe place)

• Access to support

Explanation of EMDR

AIP model and pain

“Pain can occur for many reasons. We generally understand pain as a signal that something is wrong physically. However, sometimes pain can continue longer than expected, despite medical treatment. Pain can persist because of fatigue, stress, and biochemical changes. As a result of these changes, the pain becomes “locked” in the nervous system…

Explanation of EMDR

AIP model and pain

You are not meant to suffer from pain indefinitely. Your nervous system is actually designed to process experience, including physical and emotional pain, so that once the injury that caused the pain is healed, everything returns to normal. EMDR is a way of stimulating the nervous system to facilitate healing. Even though we might not be able to completely eliminate your pain, EMDR often stimulates feelings of relaxation, which will help.”

Stage 3. Assessment.

1 History2. Preparation3 Assessment4. Desensitization5 Installation6. Body Scan7. Closu8. Re-evaluation

Mark Grant. MA

Creating a ‘pain target’

1 What targets appear to have set groundwork for clients presenting issue?

2. What negative reactions does the client possess in the present that can be traced to experiences in the past?

3 Which of these targets appear to have potential to fill in deficits in the clients life and optimize a healthier level of functioning?

4. Is the client able to access these identified experiences and process them to successful resolution?

- Hensley, (2009)

5. What present physical discomfort is the client seeking relief from?

- Grant, (1998)

Creating a pain ‘target’

Key question:

Where to begin..past, present or future?

(Based on client’s needs and readiness)

Either:

– Traumatic pain; targeting past memory

– Medical pain; targeting present pain

Creating a pain target

1. Traumatic Pain:

- Image + pain

2. Medical pain

- Pain + image

3. Symptom-related memory

- pain-related traumatic experiences

(de-Roos & Veenstra)

Plus; NC, PC, SUD’s etc

Creating a pain target

Trauma or; Pain

Trauma target (picture)

Memory:

“What incident or event comes to mind when you feel pain?”

Sensory:

“What does the pain feel like - how would you describe it?”

Medical pain target (picture)

Sensory:

If the pain had a size, shape colour… how would you describe it?

Imaginal:

What does the pain feel like, what does it remind you of?

Can you draw a picture?

Trauma ‘Target’

Mark Grant

Pain ‘Target’

Mark Grant

Negative cognitions (trauma and pain).

Lack of safety/vulnerability:– I’m helpless– I’m going to die

Lack of control/power*:– I‘m trapped – I’m helpless’ – ‘I can’t control it (the pain)’

Responsibility/being defective*:– ‘I’m weak’ – ‘‘There’s something wrong with me’

Negative cognitions (effects of pain).

• ‘I’m worthless/useless’

• ‘I’m unloveable

• ‘I deserve to suffer’

• ‘I’m a burden’

• I’m a failure

Positive cognition.

Trauma and pain (lack of safety/vulnerability) ;•‘Its over, I’m okay’•“I’m alright”•‘I survived’

Managing on-going pain (lack of control/power) ;•“I can cope”•“I can control my pain”•‘I will survive’

Effects of pain (responsibility/being defective) ;•I’m okay/I’m alright•I can still be useful

Partial positive cognitions

• “Based on what happened today, what is the most positive statement that you can make about yourself?”

- Lazarov, 1996

• “What is the most positive thing you have learned about yourself today regarding your ability to control the pain?”

- de Roos, 2009

MVA victim (traumatic pain)

Mark Grant

Injured worker (present pain)

Mark Grant

Stage 4. Desensitization

Desensitization checklist

1. Is the client mindfully present?2. Is the client experiencing affect?3. Is the client able to adopt detached observer

stance (distance)4. Informed consent (AIP rationale, ensuring client

understands what is happening)

Set-up

“Okay, so now we are ready to see if we can help you to have less pain. So I’m going to ask you to listen to these tones whilst simultaneously focusing on your pain.

We can’t predict how your nervous system will respond to the EMDR stimulation, so try and adopt an open mind and just notice the sensations of your pain and let whatever happens happen.

Most people find it harder to concentrate on their pain, and start to feel more relaxed, but there is no right or wrong, just let whatever happens happen. Very rarely the pain can increase. In the unlikely event that this happens, just raise your hand like this (show stop signal) and I will stop.”

Focusing/Dual Attention

“So just focus on the pain [or image] now, how you see it and where you feel it in your bodyAnd the negative thoughtAnd just notice..Just let whatever happens happen..”

Commence DAS/Bls

Desensitization

1. Bls/DAS;auditory bilateral tones (recommended), (with eyes closed or open & fixated)eye-movements tapping.

2. Pause (optional) cease bls; “take a breathe”

3. Refocus attention;“what do you notice now?”“what seemed to happen then?”“What do you get now?”

Types of responses to DAS/Bls

• sensory changes (reduced intensity)• perceptual changes (distancing effect)

“The pain seems smaller, further away”• cognitive changes (decreased worry, conc’n)

“it just doesn’t seem so important..”

Don’t just rely on client self-report; also look for;physiological changes▼ pain & tension (postural changes), changes in breathing rate / facial expression

Grounding questions

• As you’re telling me that what do you notice is happening in your body?

• Where do you notice the sensations in your body?

• How would you describe those sensations? (tight, hard, stiff, heavy etc)

• What feelings go with those sensations?

Mark Grant MA

Target within target

Blockages.

• “Nothing” or “no change” responses• Intellectualization• Increased pain• Unconscious fears• Medication• Dissociation• Other psychopathology• Strong Left Hemisphere

Dominance

“Nothing” or “No change”

• “What do you mean by nothing?”

• “what were you feeling in your body whilst you were listening to the tones?”

• “Where was the pain while you were listening to the tones?”

• “What do you notice about how the rest of your body feels?

• “Some people notice feelings of distance, relaxation lightness, do you notice anything like that?”

• How does the pain feel now compared with how it felt before (present vs past dichotomy)

Pain increases

If pain increases;

1.stop2.check with client, review diagnosis3.continue or - 4.Change treatment modality

Unconscious fears

• “Is there any part of you that might need this pain?”

• “is there anything that might be stopping the pain from getting better?”

• "If there was an emotional contributor to this pain, what might it be?"

• “Is there something else your body needs in order to feel better?”

Dissociation.

I. Use grounding techniques to bring client back into present.

II. Teach client how to self-soothe instead of self-injure/not feel

III. Teach client how to attend to their pain by showing appropriate care and concern

IV. Challenge feelings of unworthinessV. Develop self-soothing strategies

Other psychopathology

• Dissociative Identity Disorder

• Bipolar Disorder

• Schizophrenia

• Autism

Strong Left hemisphere dominance

Hemispheric Dominance Inventory

Study skills page,Middle Tennessee State University

http://frank.mtsu.edu/~studskl/hd/hemispheric_dominance.html

Stage 5. Installation

Positive cognition.

Trauma and pain (lack of safety/vulnerability) ;•‘Its over, I’m okay’•“I’m alright”•‘I survived’

Managing on-going pain(lack of control/power) ;•“I can cope”•“I can control my pain”•‘I will survive’

Effects of pain (responsibility/being defective) ;•I’m okay/I’m alright•I can still be useful

Partial positive cognitions

• “Based on what happened today, what is the most positive statement that you can make about yourself?”

- Lazarov, 1996

• “What is the most positive thing you have learned about yourself today regarding your ability to control the pain?”

- de Roos, 2009

Resource installation

1. Focus on the image of the resource and the positive emotions and sensations that accompany that image (top-down)

2. Focus on strengthening the positive sensations that clients have when thinking about a friendship, safe place, etc. (Shapiro, 1995, Leeds, Kiessling 2005)

3. Focus on an image based on positive sensations client noticed following DAS/Bls. (Grant, 1998, 2009)

Resource imagery/strategies

• Healing light/light-stream• Anesthetic mist• Breathing techniques

Strengthening pre-existing resources:• Skills• Friendships• Experiences• Linking pre-injury values with present functioning

Stage 6. Body Scan

1 History2. Preparation3 Assessment4. Desensitization5 Installation6. Body Scan7. Closure

8. Reassessment

Body Scan.

•Look for changes in affective states associated with trauma but not directly targeted•Accept there may be residual pain when treating medical pain•Accept pain may return following successful ‘reprocessing’ of medical pain

Body scan.

• If I ask you to mentally scan your body for pain or discomfort, what do you notice now?

• How do you feel in your body now?

• Whats there now where the pain was before?

• Review SUD’s – emotional distress

- physical pain

Stage 7. Closure

Closure.

• Stabilizing client

• Expectations

• Homework

• Reinforcing possibility of change

Stabilizing client.

Completed session:•You’ve done well, see, you can learn how to feel different, you have learned something very important about yourself

Incomplete session:•You’ve made a good start, obviously it takes time to learn to feel different, but judging by the way you have responded today, I am sure you will continue to make progress•If you have any problems with your pain or trauma, you can always use your calm place, or the self-help CD.

Expectations.

Traumatic pain;•Because your pain is associated with a trauma, processing the trauma often leads to a reduction if not a complete resolution of the pain. •We have no way of knowing. The important for you is to just have an open mind and let whatever happens happen.

Medical pain;•The work we have done today should have a permanent effect on your pain memories. In other words even though the pain might return, it will probably return in a less severe way so keep an open mind for changes in how you experience your pain.

Reinforcing possibility of change.

• You might find that hard to believe, but you probably didn’t come here expecting anything much right?

• So its important to just have an open mind and try and observe your pain each time as if for the first time, and try and be aware of any subtle changes.

• When you’ve been in pain for a long time it seems like it can never change, but pain can change … it just has … so have an open mind let whatever happens happen.

Re-evaluation

Re-evaluation.

• Reviewing changes since last session;

Have you noticed anything different about your pain and how you experience it?

Have you noticed any other differences in how you live your everyday life?

• Reviewing previous work;

How do you feel now when you think of what we worked on last time?

• Resuming reprocessing;

Target within target

Cognitive Interweaves for pain.

• New Information:

Do notice a feeling of distance.. or lightness..• Whose responsibility is it?;

Did you ask to be in pain?

Do you like feeling like a burden?• “I’m confused”;

If you’re really so worthless how come….• Stories of survival;

We all have the ability to overcome bad things• Socratic method;

Resource installation

1. Image (of a resource) + positive emotions and sensations that accompany that image (‘top-down’)

2. Strengthening positive sensations that clients have when thinking about a friendship, safe place, etc.

3. Pleasant bodily sensations (“some part of your body that feels okay, calm, comfortable”) + image

(Shapiro, 1995, Leeds, Kiessling 2005)4. Developing imagery based on positive sensations

client noticed following DAS/Bls (‘bottom-up’)(Grant, 1998, 2009)

Mark Grant MA MAPS

Somatic resource installation

‘The more capable the body is of being affected in many ways.. the more capable of thinking is the mind.’

Spinoza, 1650

Mark Grant MA MAPS

Key assumptions

• Usual AIP precepts• DAS/Bls is de-arousing for most people• You should expect clients to feel more relaxed,

decreased pain, more distance from pain following DAS/Bls

• If client fails to report positive changes, it indicates;1. Not set up right (problem with ‘target’)2. Problem with clients ability to process sensory

input3. You are dealing with pure pain (nociception)

Mark Grant MA MAPS

Somatic Resourcing Steps

1.Help clients identify and label positive changes in sensation following DAS/Bls

2.Utilize affective changes following DAS/Bls to create resource/antidote imagery for coping with future pain

3.Install and reinforce clients ability to utilize resources/antidote imagery

Mark Grant MA MAPS

Accessing questions (resources)

Mark Grant MA

Comfort words

Cool (vs Hot)Dull (vs Sharp)Soft (vs hard)Loose (vs tight)Light (vs heavy)Ebbing (vs pulsing)Flowing (vs stuck)Tingling (vs stinging)Easing (vs worsening)

Mark Grant MA MAPS

Accessing words

• “Safe”• “Comfort”• “Relief”• “Healing”

Mark Grant MA MAPS

Hypnotic installation

“you will notice that your head has gone quiet, that the usual thoughts and preoccupations are absent for the moment… just notice that … and how different it feels .. because things are usually so busy up there... just sitting in the chair, with nothing particular to think about. And physically you’ll notice a feeling of calmness.. or emptiness.. maybe a feeling of lightness.. and that your breathing has slowed down.. just notice that.

Mark Grant MA MAPS

Hypnotic installation

You probably haven’t felt this way for a long time because of everything you’ve had to deal with… but that’s normal. You’re not actually supposed to feel anxious and tense all the time. You are supposed to feel relaxed and carefree sometimes…. Imagine what life would be like if you felt like this all the time?”

Mark Grant MA MAPS

Self-use of DAS/Bls

Affect management tool rather than relaxation Not reprocessing – so no need for PC, NC etc Effective for stress, pain, insomnia, Training effect from in-session work Can also be used without audio equipment Usual precautions apply

Mark Grant MA

Self-use of DAS/Bls

• Pain control• Alleviating anxiety • Reducing worry• Alleviating insomnia• Stress management

Mark Grant MA MAPS

Accessing questions (for resources)

• What’s there now where the pain was before?• Can you describe that feeling in terms of a size,

shape etc?• What does that feeling remind you of?

(Suggest some possibilities if client is having trouble finding words to describe)

• What image would go with that memory/description?

• What word best summarizes that feeling/image

Mark Grant MA MAPS

Stories of hope

Summary of pain protocol differences

• History - Preparation:

- attention to medical history/diagnosis

- safety as freedom from pain/physical disability

- modified version of AIP• Assessment (Targeting):

- traumatic memory or present pain

- NC/PC; 3 x possibilities - trauma, pain and coping• Desensitization:

- reliance on auditory DAS/Bls

- partial positive cognitions, incomplete processing• Installation:

- addition of antidote imagery

- self-use of DAS/Bls

Pain managementResources based on EMDR

emdr pain protocol mark grant. ma, maps. goals of treatment resolve or reduce pain develop pain...

control slide

reevaluation slide

functioning slide

emdr pain protocol mark

physical pain

present pain

pain stress

effects of pain

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