emdria 2017 conference: bellevue, wa, usa · pdf fileobsessive compulsive disorder ... to give...

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EMDRIA 2017 CONFERENCE: BELLEVUE, WA, USA AUGUST 2017

Dr Derek Farrell CPsychol, PhD, Csci, AFBPsS

University of Worcester – Institute of Health & SocietyChartered Psychologist, Principal Lecturer in PsychologyEMDR Europe Accredited Trainer and ConsultantBABCP Accredited Cognitive Behavioural PsychotherapistVice-President EMDR EuropePresident Trauma Aid Europe

©Derek Farrell/July 2017

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Overview of what is OCD and theoretical concepts

Theoretical Rationale for the use EMDR Therapy with client’s with OCD

Exploring EDR Therapy Protocol Options Standard Protocol Flash-forward Blind 2Therapist Protocol

Pluralism & Integrationism in working with OCD

Empirical Evidence in support of the EMDR Therapy with OCD

Case Material demonstrating use of EMDR Therapy

Self-experience

Implications for future research and development

©Derek Farrell/July 2017 2

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• During this workshop we will be engaging in various exercises and self-experience

• All exercises and self-experiences are entirely voluntary

• You are responsible for your own well-being

• Please feel free to utilize any self-care or internal resources as you feel necessary

• All material shared is confidential

• You are clinically responsible for how you practice EMDR Therapy


oEye Movement Desensitization and Reprocessing (EMDR) therapy is an eight-phase psychotherapeutic approach that emphasizes the physiological information processing system in the origin and treatment of mental health issues. (Shapiro, 2001, 2014a).


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o Its theoretical basis is the Adaptive Information Processing (AIP) model, which holds that the primary source of psychopathology is the presence of memories of adverse life experiences that have been inadequately processed.

oThese inappropriately stored episodic memories, which include the perceptions, sensations, beliefs and emotions that occurred at the time of the adverse life event, can be triggered by current internal and external stimuli, contributing to ongoing dysfunction.


oThis model was developed in the early 1990s and since then has been supported by research demonstrating the role played by disturbing life events in the genesis of many forms of psychological and somatic symptomology (e.g., Affifi et al., 2012; Felitti et al., 1998).

EMDR Therapy (3)Ref: Shapiro, 2016: ISTSS Stress Points e-Quarterly Newsletter


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1. Access a Dysfunctionally Stored Trauma Memory

2. Stimulate – Bilaterally and via Dual Attention

3. Move it oNeurobiological

oArchitecture

oCharacter - SUD

oConstruct and meaning


oEMDR therapy is a trans-diagnostic, integrative psychotherapy approach that is intrinsically ‘Client-Centered’ at its core. It has been extensively researched and proven effective for the treatment of adverse life experiences. It utilises a theoretical framework known as adaptive information processing (AIP).

oThe context of AIP is that adverse life experiences cause imbalance in the nervous system thus creating blockages or incomplete information processing – namely trauma memories

o [Farrell (2015) Trans-generational Trauma and EMDR Therapy, BACP Private Practice Journal, Winter Edition 2015]


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For CBT the pathology lies in the presence of dysfunctional beliefs and behaviours, and hence the treatment proceeds by manipulating these beliefs and behaviours.

For EMDR Therapy the pathology is deemed to stem from unprocessed, physiologically stored memories, and hence the treatment aims to access and process these past memories, present triggers and future templates (Shapiro 2014)


CBT – Disturbance from the Adverse Life Event is generated by the MEANING that is attributed to this experience rather than the experience itself Therefore beliefs/ cognitions are INDEPENDENT

VARIABLES

EMDR Therapy – Disturbance from the Adverse Life Event is generated by the MEMORY of the experience which is then DYSFUNCTIONALLY STORED Therefore beliefs/ cognitions are DEPENDENT

VARIABLES


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People with OCD have also encountered ADVERSE LIFE EVENTS Adaptive Information Processing Case (AIP) Conceptualisation

Reformulation of the OCD (PAST)

Dysfunctional Memory Network

Compulsions reinforce OCD – Safety Behaviour (Present)

OCD is driven by a ‘Worst Fear/ Catastrophic Event (Future) Dysfunctional Memory Network


1. Adaptive Information Processing Case Conceptualisation

2. Trauma Stabilisation and Resourcing

3. Trauma Processing and Confrontation

4. Therapeutic Relationship and Attunement


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What is Obsessive Compulsive Disorder?

OCD is a mental disorder that includes obsessions and/or compulsions.

Most people experience both obsessions and compulsions – however some just obsessions (known as “pure ‘O’”.

These obsessions and compulsions are very upsetting, and cause great distress and impairment


• Intrusive thoughts, Images and Impulses

• Obsessions and or Compulsions

• Compulsions are meaningfully related to fears

• By definition, the person seeks to ignore or supress intrusions

• Key to diagnosis: distress/disability


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What is Obsessive Compulsive Disorder?

OCD is a mental disorder that includes obsessions and/or compulsions.

Most people experience both obsessions and compulsions – however some just obsessions (known as “pure ‘O’”.

These obsessions and compulsions are very upsetting, and cause great distress and impairment


It is estimated that some 112 million people in the world suffer from OCD and is one of the leading causes of disability

The average age that OCD becomes clinically significant is around 19 and a half years old. That being said, it can start in early childhood, with males often getting the disorder earlier.

Additionally, most people have some symptoms before the disorder reaches a clinically significant threshold.


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Phobias

Substance Abuse Disorders

Major Depressive Disorders (MDD)

Obsessive Compulsive Disorder (OCD)Co-morbidity

Alcohol/ Substance misuse Generalised Anxiety Disorder Specific Phobia Eating Disorders Personality Disorder


Currently there is no known complete or permanent cure for OCD exists; however, with proper treatment the symptoms can be made much more manageable, or kept completely under control.

Cognitive behavioural therapy (CBT) is a common technique used for people struggling with OCD.

This method teaches people with OCD how to confront their fears and reduce anxiety without acting out on compulsions.

The most effective type of CBT for OCD is called Exposure and Response/Ritual Prevention (abbreviated as either ERP or EX/RP).


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Research also supports the usage of Antidepressant medications. This helps to reduce obsessions

Combination approach indicates the best results - Antidepressant & ERP

ERP is the best and most durable solution for OCD.

If someone is properly treated with ERP, the OCD can be very well controlled if not almost eliminated.

However, even if the OCD is mostly gone, the sufferer will need to be on guard to prevent it from returning. So, relapse prevention is an important part of treatment as well.


Each time a person with OCD gives into an obsession by performing a compulsion, it strengthens the OCD.

The opposite also holds true that each time one does not give into the obsessions, the fear weakens.

So, with ERP one is in effect strengthening the brain by forging out a new pathway.

ERP is more than ‘willpower’ - most OCD sufferers have tried to resist the obsessions, but it must be done properly to work, and so willpower alone is not enough.

ERP takes a graduate approach, and this has been scientifically developed and proven, to give people the tools to control their OCD.


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Medication is an effective treatment for OCD.

About 7 out of 10 people with OCD will benefit from either medication or Exposure and Response Prevention (ERP)

Research indicates that for the people who benefit from medication, they usually see their OCD symptoms reduced by 40-60%.

Medical advise is to continue to take medication regularly

However about half of OCD patients stop taking their medication due to side effects or for other reasons.


Tricyclic Antidepressants – Ineffective for treating OCD Amitriptyline

Imipramine

Serotonin Selective Re-uptake Inhibitors (SSRI’s) more effective Fluvoxamine (Luvox®)

Fluoxetine (Prozac®)

Sertraline (Zoloft®)

Paroxetine (Paxil®)

Citalopram (Celexa®)

Venlafaxine (Effexor®)

Escitalopram (Lexapro®)


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Despite strong empiricism for CBT [ERP] in the treatment of OCD it should be acknowledged that not all clients respond well to this particular psychological treatment approach and that recovery levels vary significantly (Roth and Fonagy 2006).

Cognitive Therapy may not be as effective as ERP (Purdon, 2009)

Group interventions not as effective as individual treatment (McClean, 2001)

Rector et al (2009) reports high ‘drop out’ rates amongst clients diagnosed with OCD and treated with CBT.


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CBT is effective at reducing the intensity of OCD symptoms for about 50 to 60% of patient's who complete treatment

However ‘Full remission’ of OCD symptoms (e.g. recovery is used as an index of improvement the efficacy drops to 25% (Fisher & Wells 2005)

Maher el al (2010) consider that EX/RP is less than appropriate or effective for around 50% of those treated


o Although Ex/RP can be highly effective for around 50% of people who complete treatment, there are a number of recognised drawbacks (Marr 2012)

oEx/RP is much less effective in clients who experience obsessive ruminations rather than overt compulsions

o The actual level of improvement is extremely variable (Roth 2006)

o High Drop out rates [40%], (Rector et al 2009)

o High relapse rates [57.3%] (WHO 2010)


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Phase 1: History Taking Developing a collaborative therapeutic relationship

Ascertaining degree of motivation for change

OCD through the lens of AIP

Behavioural Analysis of pattern of behaviour & cognitions

Maintenance factors and ‘contributions to chaos’

OCD & Secondary Gain

Ascertaining goals for treatment

EMDR Therapy/ AIP Target Selection


Outlining the struggle with OCD

First experiences/ recollections/ memory of OCD

Other issues that may have been going on at the time

Worst OCD experience/ memory

Viewing OCD through the lens of: Past – Present – Future

Impact of the OCD on life’s journey: relationships, family, friendships, work, social, etc.,

How might your life be different if you were free from OCD?


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Obsessions Current Past

o Aggression

o Contamination

o Sexual Obsessions

o Hoarding/ Saving

o Religious obsessions

o Symmetry and exactness

o Miscellaneous: lucky numbers, sounds, colours, remembering things, etc.,

o Somatic


Compulsions Current Past

o Cleaning/ washing

o Checking

o Repeating

o Counting

o Ordering/ Arranging

o Hoarding/ Collecting

o Miscellaneous: mental rituals, needing to touch, ritualised eating, superstition, hair pulling


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Cognitive Behavioural Therapy EMDR Therapy/ Adaptive Information Processing

oObsessionsoCompulsionsoAvoidance

Primary Focio Obsessionso Compulsionso Avoidanceo Maintenance factors

Primary Focio Dysfunctionally stored memory

networks – past, present and futureo Obsessions, compulsions and

avoidance and maintenance factors seen as consequences


Weight loss

Sleep changes

Loss of appetite

Lack of energy

Feelings of sadness

Crying or frequent tearfulness

Suicidal thoughts – with or without intent

Feelings of hopelessness/ despair/ helplessness

Lack of interest

Lack of joy


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Phase 2: Preparation Stabilisation & Resourcing

Psychoeducation

Paradigm Approach – pluralism, integrationism, etc.

Recruiting co-therapists

Identification of ‘Core Beliefs’ & maintenance factors


Phase 3 – 7 Target Selections for processing Interventions – Target Focussed

Standard Protocol

Standard Protocol & In-vivo Desensitisation

Interventions – Underlying Conflicts

Flash-forward

Flash-forward & Imaginal Exposure


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“Imagine all these parts of your brain screaming at you when your OCD symptoms are at their worst: The thalamus sends messages from other parts of your body, making you hyperaware of everything

going on around you

The caudate nucleus opens the gate and lets in unwanted intrusive thoughts

The orbital cortex mixes thoughts and emotions, then tells you, ‘Something is wrong here! Take cover!’

The cingulate gyrus tells you to perform compulsions to relieve the anxiety the rest of your brain has heaped on you

Meanwhile, your synaptic clefts are screaming, ‘Send in some Serotonin! We’re running short here’

With all this going on – ‘No wonder I have problems’


‘Keeping Eyes on the Prize’ Resolution or ‘symptom reduction’

Type I and Type II OCD

Managing relapses

Dealing with future obsessions


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Worst Picture

Image, Cognitions (beliefs, Emotions & Body Sensations)

Traumatic Memory

(Past)Compulsion triggering situation

Stimulus Focus

Imaginary/ Real Trigger (Obsessions)


Flash-Forwards

Underlying validation / Catastrophe scenario

Worst Case Scenario

Automatic & Intrusive Mental Images

Flash-Forward

Future Orientated

Targets


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Future Anticipatory Anxiety (Standard Protocol)

Compulsion cannot be executed

Blocking Compulsion

Imagery

Standard Protocol

Image, Cognitions (beliefs, Emotions & Body Sensations)

Underlying Conflict


Experience (Event) – Real or Fantasy

Worst Fear

Representation of an Event

Generalisation

Sound

Perpetrator/ Relationship

Emotion

Somatic Experience

Cognitions/ Belief Systems

Unspoken


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Obsessional thoughts in OCD are very similar to Negative Cognitions in EMDR Therapy

Rationality and Irrationality (Client insight)

In search of empiricism – Cognitive Gymnastics

Exploring the link between ‘core beliefs’ and ‘target selection’

Challenging risk


All or nothing thinking:

Magical thinking

Overestimating risk/ danger

Perfectionism

Hyper-morality

Over-responsibility

Thought, Action, Fusion

Over-importance of thought

Exclusivity error

Nobility Gambit (Martyr syndrome)

‘What if’

Intolerance of uncertainty


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Derek Farrell


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NAZARI, ET AL (2011) COMPARISON OF EMDR WITH CITALOPRAM IN THE TREATMENT OF OCD.

• 90 subjects with a diagnosis of OCD were randomly assigned into two groups. They either received EMDR or Citalopram over 12 weeks.

• Both groups assessed using Y-BOC, pre and post treatment. Both groups demonstrated significant improvement, however in the short term EMDR was shown to be more effective.


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EMDR & OCD (BOHM & VODERHOLZER, 2010)

3 case studies, applying EMDR in different ways EMDR followed by ERP. (early traumatic memories) : [checking behaviours] ERP followed by EMDR: [Intrusive thoughts] EMDR (resource instillation and future template) : [cleaning compulsions]

All 3 clients showed 60% improvement [Y-BOC, BDI, DES, SUDS


• Treated (14-16 sessions) 4 subjects using EMDR Therapy Phobia Protocol.

• The Adapted EMDR Phobia Protocol: (start with current triggers –OCD Obsession and Compulsions then future template, then past related disturbing memories [if there are any] and the Adapted EMDR Phobia Protocol with Video Playback. (Client plays a video/memory of the first time they remember being scared by their obsessional thought, when the client is aware of feeling stressed, stop, identify image, NC, PC, VOC, SUD and Body sensation –process in the usual way-. Video playback is then used to monitor desensitisation and identify other stressors.

• Marr’s work is based on the theoretical view that OCD is a self perpetuating disorder, with OCD compulsions and obsessions and current triggers reinforcing and maintaining the disorder (Marr 2012)

• Clients were assessed using the Yale-Brown Obsessive Compulsive Inventory (Goodman et al 1989), (Y-BOC) significant improvement was noted in all clients at the end of therapy and at follow up.


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o 8 subjects, who have been diagnosed with OCD, have had CBT intervention within the last 5 years but symptoms have not abated.

o Subjects will be excluded from the project, if they have an active psychotic condition, are suffering with a sever clinical depression ,are actively suicidal or over using benzodiazepines, alcohol or street drugs.

o Following assessment (participant information and consent to engage in project), subjects will complete 4 psychometric questionnaires:

o Y-BOC (Goodman et al 1989)

o PHQ-9 (Kroenke et al 2001)

o GAD-7 (Spitzer et al 2006)

o Each subject will receive 8 sessions of EMDR, [in an effort to mirror IAPT services] plus 2 follow up appointments (EMDR will not be administered at follow up)

o Normal EMDR protocol will be used for clients with past aversive life events (PALE); EMDR focussing on “Intolerance of uncertainty”will be used where no PALE was identified.


Age - ranged from 20 – 59 with the average being 40 years old

Gender - 50:50

87.5% in employment

62.5% on anti-depressant medication

All research participants had been previously diagnosed by either a Consultant Psychiatrist or Psychologist as meeting the DSM 5 criteria for OCD


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Ref: Treating Obsessive Compulsive Disorder (OCD) using Eye Movement Desensitisation and Reprocessing (EMDR) Therapy: An Ethno-Phenomenological Case Series (Keenan & Farrell et al, in press)


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SUD 0-10 VOC 1-7



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Ref: Treating Obsessive Compulsive Disorder (OCD) using Eye Movement Desensitisation and Reprocessing (EMDR) Therapy: An Ethno-Phenomenological Case Series (Keenan & Farrell et al, in press)©Derek Farrell/July 2017

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EMDR Therapy has demonstrated that it is a safe and well tolerated treatment for Obsessive Compulsive Disorder

The Theoretical paradigm of EMDR Therapy – Adaptive Information Processing is useful part of case conceptualisation

EMDR Therapy is effective Reducing SUD Increasing VOC Reduction in YBOC, GAD-7 & PHQ-9

More research is needed to further explore the utilisation of EMDR Therapy with OCD populations


Past

Present - Flash-forward

Future - Future Template


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o Flash-forward procedure is identical to the standard EMDR protocol, except that the target relates to a feared catastrophic future event rather than a past one

o The therapist may ask the client to say what they believe will happen if they are not able to avoid the fearful situation anymore

o Main characteristics of Flash-forwardo Primary focus - worst-case scenario

o A detailed and still picture

o Contains catastrophic elements of what might happen in the future

o Context specific and conceptually related to client’s symptoms

o Intrusive and disturbing

o “Death is not Enough”


Engelhard et al

…fear of future danger is common after a threatening event, and may take the form of future-oriented mental images. These may appear like ‘Flash-forwards’, echoing ‘flashbacks’ in posttraumatic stress disorder (PTSD) and possess sensory qualities, being vivid, compelling, and detailed. (Engelhard et al., 2011, p. 599).


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BLIND 2 THERAPIST PROTOCOLS IN EMDR THERAPYDr Derek Farrell CPsychol, PhD, Csci, AFBPsS


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Shame

Fear

Retribution

Secrecy

Disgust

Transference/ Counter-transference

Quasi Power and Control


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"Fundamentally, words can't integrate the disorganized sensations and action patterns that form the core imprint of the trauma…. To do effective therapy, we need to do things that change the way people regulate these core functions, which probably can't be done by words and language alone."


(FARRELL ET AL, 2016)

Kurdistan I Research Project 2: Blind 2 Therapist Protocol

Derek Farrell©Derek Farrell/July 2017

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High levels of Shame-Based Trauma within Yezidi survivors

In addition high levels of Shame-Based Trauma amongst Kurdish Population/ Participants

Research based on Shapiro (2001), Blore et al (2009; 2013) and slight modification by research team

“Where there are no words’

Cultural sensitivity and adaptability

Treatment versus No Treatment


First experimental design study using Blind 2 Therapist Protocol

Research took place during a intensive 6 day EMDR Therapy Level 2 Training (May 2016)

Participants – Jiyan Foundation Therapists during Self-experience Practicum

Each EMDR Therapy session supervised live by EMDR Europe Accredited Consultant

Control Group [N=59] – Standard Protocol

Experimental Group [N=39] – Blind 2 Therapist Protocol

Null Hypothesis


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Rape

Witnessing a murder

Recent Trauma

Sports injury

Bereavement

Road Traffic Collision

Bullying

War related conflicts & incidents

Torture

Dog attack

Imprisonment

Vicarious trauma

Gender-based violence


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Control Group - Standard Protocol [N=59] Experimental Group - B2T Protocol [N=39]

SUD (0-10) VOC (1-7)


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90% of the research participants would NOT have worked on their trauma experience without using the B2T protocol

95% Disclosed their trauma after EMDR Therapy

B2T Protocol was SAFE

Omission of C-, C+ and VOC still proved effective

Script of Protocol had to be adapted slightly to make more specific

Clear definition of what was meant by ‘CHANGE’ during processing


Modified Version of the Blind 2 Therapist ProtocolPhase 3: Modified Assessment of the Target Memory (B2T)

Target Word

- Memory

Current

Emotion

Subjective

Level of

Disturbance

(SUD)

Location of

Body

Sensation


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Chapter 7 EMDR Therapy and Head and Throat Cancer

Derek Farrell and Kate Reid


More complex the case – more important is the THERAPEUTIC RELATIONSHIP

Exposure and Response/ Ritual Prevention (ERP)

Anti-depressant Medication (SSRI’s)

Collaborative Partnerships

EMDR Therapy AIP Case Conceptualisation Trauma Stabilisation and Resourcing Trauma Processing & Confrontation

Standard Protocol – disclosed traumas Blind 2 Therapist – shame-based traumas Flash-Forward – future catastrophic scenarios


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Contact details:

Dr Derek FarrellUniversity of WorcesterEmail: [email protected]


mailto:[email protected]

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