EMDR pain protocol

1. EMDR pain protocol Mark Grant. MA, MAPs

2. 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 Mark Grant. MA, MAPs

3. 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.” - Mazzolaet al, 2009 Mark Grant. MA, MAPs

4. Elements of treatment • History Medical diagnosis 2. Preparation Safety, Medical issues AIP model for pain • Assessment Target: Traumatic memory, present pain, effects of pain • Desensitization Continuous auditory Bls “Incomplete processing” Self-use of DAS/Bls Dealing with blockages ‘ Mark Grant. MA, MAPs

5. Elements of treatment 5. Installation +’ve cognition and/or antidote imagery 6. Body Scan addressing persistent pain 7. Closure Educating client about how to notice and integrate changes Resources for living with pain 8. Re-evaluation Physical vs mental changes Mark Grant. MA, MAPs

6. Stage 1. History 1 History 2. Preparation 3 Assessment 4. Desensitization 5 Installation 6. Body Scan 7. Closure 8. Re-evaluation Mark Grant. MA, MAPs

7. History • Medical diagnosis • Trauma? • Family background • Cormobid problems • Narrative (how, when, where, what) • Medications? • Suitability for EMDR • Target sequencing Mark Grant. MA, MAPs

8. Mark Grant. MA, MAPs

9. 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? Mark Grant. MA, MAPs

10. Mark Grant. MA, MAPs

11. Trauma History • Sexual abuse • Accident (auto, work, other) • Injury • Diagnosis of life-threatening illness • Surgery • Combat trauma • Complicated bereavement • Abortion • Assault • Torture • Rape Mark Grant. MA, MAPs

12. 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 Mark Grant. MA, MAPs

13. Developmental trauma. • Abuse, neglect, instability • Early childhood illness • Family breakup • Family dynamics • Intergeneration physical and mental health problems Mark Grant. MA, MAPs

14. 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) Mark Grant. MA, MAPs

15. Co-morbid problems. • Depression • Anxiety • Personality disorder • Insomnia • Substance abuse • Other health/medical problems • Life circumstances • Adjustment problems Mark Grant. MA, MAPs

16. 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? Mark Grant. MA, MAPs

17. EMDR ‘targets’ Mark Grant MA

18. 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? Mark Grant. MA, MAPs

19. Psychology of Workers Insurance. Loss of; • control • Privacy • Freedom/choices (feels trapped needs the benefits and treatment but) • Health/physical integrity • Future • Safety Mark Grant. MA, MAPs

20. Mark Grant. MA, MAPs

21. 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 Mark Grant. MA, MAPs

22. 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 Mark Grant. MA, MAPs

23. Case conceptualization. Physical pain + • injury/illness • Trauma • Family problems, Neglect • Comorbid problems (anxiety, depression) • Current stressors • Personality factors • Resources Mark Grant. MA, MAPs

24. The Pain Pyramid. Mark Grant. MA, MAPs

25. Assessing personality Mark Grant. MA, MAPs

26. 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 Mark Grant. MA, MAPs

27. Defence mechanisms. • Denial ‘Primitive’ • Dissociation • Projection • Somatization • Masochism • Repression • Sublimation (Hyperactivity - manic defence) • Intellectualization • Humour ‘Sophisticated’ Mark Grant. MA, MAPs

28. Personality disorders and pain. Mark Grant. MA, MAPs

29. Trauma related symptoms • PTSD symptoms (increased physiological arousal etc) • Dissociative symptoms • Affect regulation problems • Somatization • Depression • Relationship problems • Identity issues - van der Kolk (1996) Mark Grant. MA, MAPs

30. Brain Hemispheric Differences LH RH “what?”“How?” Inflexible Flexible Narrow focus attention open, sustained attention Prefers known Likes novelty - Never fully known Emotionally - Anger Emotionally - Depression Self= act of will Self in relation to others Denotative language metaphors, symbols Competitive , exploitative Empathic Sequential processing Parallel processing Decontextualized world “Lived world” Acknowledgement: Ian McGilchrist (2009) Mark Grant

31. Problem of pain Pain: • A stressful, often traumatic event • Exacerbates pre-existing trauma • Overwhelms coping mechanisms (medical model): “not my problem – the doctor should fix me” Mark Grant. MA, MAPs

32. The medical model: Mark Grant. MA, MAPs

33. 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 Mark Grant. MA, MAPs

34. 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.” - Mazzolaet al, 2009 Mark Grant. MA, MAPs

35. 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) Mark Grant. MA, MAPs

36. Pain + injury Pain + Effects of pain: on physical functioning (‘work, love and play’) sleep mood relationships coping identity Mark Grant. MA, MAPs

37. Mark Grant. MA, MAPs

38. My 5 “secret” assessment criteria • What is client’s affect range/capacity • What is client’s medical diagnosis? (if applicable) • How much is person able to distance themselves consciously from their problem? • Personality (strong, stable?) • Life circumstances (stable?) Mark Grant. MA, MAPs

39. 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, 1989) Mark Grant. MA, MAPs

40. PPI vs affect in SFMPQ Mark Grant. MA, MAPs

41. Stage 2. Preparation 1 History 2. Preparation 3 Assessment 4. Desensitization 5 Installation 6. Body Scan 7. Closure 8. Re-evlaluation Mark Grant. MA, MAPs

42. Preparation • Therapeutic relationship Transference & counter transference • Safety and containment issues Pain control Safe place (if necessary) • Medical issues • Explanation of EMDR Mark Grant. MA, MAPs

43. 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). Mark Grant. MA, MAPs

44. 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) Mark Grant. MA, MAPs

45. 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’ Mark Grant. MA, MAPs

46. 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) Mark Grant. MA, MAPs

47. Uses of Transference 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 anxious T: 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. Mark Grant. MA, MAPs

48. Uses of Transference 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. Mark Grant. MA, MAPs

49. 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 Mark Grant. MA, MAPs

50. Safety. • Adequate control over pain/affect • Freedom from threat • Secure living conditions • Psychological safety (safe place) • Access to support Mark Grant. MA, MAPs