Helen Macdonald Durham 7th October 2011 Developments in EMDR practice Marbles in the elbow and other stories: Using EMDR in the treatment of persistent pain Helen Macdonald Durham 7th October 2011

Developments in EMDR practice: Treatment of persistent pain Background and context Impact of persistent pain Why using EMDR can help Putting it into practice Choosing targets for change Using imagery Case example Where losing your marbles can help

Background and context Why do EMDR clinicians and researchers take an interest in persistent pain Impact of treating trauma on pain experience How many people we see who have persistent pain Impact of persistent pain on quality of life Effectiveness of current treatments

The impact of pain: statistics Between 10-50% of chronic pain patients meet criteria for PTSD (Sharp 2004) 7.8 million people in the UK have a chronic pain problem - all ages 70% of sufferers are <60. 25% lose their jobs 22% develop depression (Chronic Pain Coalition 2007) Mistaken assumption that anyone exp. a traumatic event will develop PTSD Far from true Results of studies vary but in general confirm that 20% of folks will develop PTSD. AND IN GENERAL POPULATION 7-12% HAVE PTSD Factors that mediate traumatic stress include Preparation for the expected stress Age Belief system - it was my fault, Prior exp with trauma Internal resources - coping skills Support - high level of family dysfx, were they believed, was abuse reported, have they even talked about it Degree of violation-sexual vs. nonsexual Level of threat & fear involved - weapon, aggression

The personal experience of pain

What do we know about persistent pain? Pain: “An unpleasant sensory and emotional experience which is due to actual or potential tissue damage, or which is described in terms of such damage” Mersky and Bogduk (1994) Chronic pain ….duration longer than six months (DSM (iv), 1994) Usually refers to non-life-threatening conditions (Cole, Macdonald & Carus 2005)

Acute pain: ‘Good’ pain Designed to protect the body from harm or minimise damage Survival It hurts..... You stop doing it It stops hurting You don’t do it again

‘Bad’ Pain It hurts ?Not helping survival E.g. The story of You stop doing it It doesn’t stop hurting It doesn’t get better ?Not helping survival E.g. The story of Phantom Limb pain

Proposed Role of Memory in persistent pain Pain encoded as traumatic experience Pre-morbid traumas may be memory-linked to the pain (Grant, 2002) ‘Cognitive map’-body image and somatic experience (Lister, 2003 )

Information processing somatic memory of traumatic experience (pain) chronic pain (Wilensky, 2006) Reprocessing the sensory experiences/ traumatic events facilitate resolution i.e. Re-consolidate memory as less distressing

Pain and memory Pain memory isolated from any potential adaptive information Unresolved material easily triggered during similar experiences Intrusive thoughts Emotions Somatic response

Effective intervention: Decreased affect Reducing image vividness

Evidence Best evidence: Phantom Limb pain Aborting Migraine attacks Also: Aborting Migraine attacks Headache Medically Unexplained Symptoms (subjective health complaints) Fibromyalgia

Putting it into practice Own experience: Current or past referral with persistent pain as an issue Impact on functioning Potential targets- past, present, future? What imagery?

Putting it into practice Usual assessment Medication Belief in person’s experience of pain Education on the role of stress in experience of physical symptoms Appropriate management of other issues: Substance misuse Depression Risk

Factors to consider Investigations ( and what they mean) Optimum management of the condition ? E.g. Pain relief medication Exercise/physiotherapy ‘Compliance’ with recommendations? Is the person waiting for more medical input? What does the person believe is happening? The digestive biscuit story

Giving rationale for EMDR Increased coping Changed attitude to the pain Reducing stress/ Relaxation Decreased intensity caution about offering pain reduction as goal

Choosing a Target for EMDR: Past situations ‘What best represents this for you?’ Specific image or memory Trauma Pain related targets Personal and physical constraints Impact on life Medical interventions Pain memories Location of sensation(s) Responses of others

Choosing a Target for EMDR: Present situations Personal circumstances Having needs met Impact on daily life

Choosing a Target for EMDR: Future situations Thoughts and feelings about pain and future Impact of pain on: Family Social life Occupation Economic circumstances Medical

Specific Antidote imagery: targeting the pain itself deRoos and Veenstra (2009) Image of current pain sensation Think of something that could take the pain away or make it better – ‘antidote fantasy’ Imagery of healing Using ‘antidote imagery’ Hoping for change in sensation Evidence that there are changes in image and sensation

Case example 47-year old man, involved in an RTA near to his workplace Severe damage to his arm, resulting in: scarring reduced function persistent pain Occupational and relationship changes

Case example: Marbles in the elbow ‘Bag of marbles’ Image of current pain sensation

What could take the pain away? Medical treatment to make the elbow as it was before Antidote ‘fantasy’ Image: X-ray

Case example continued EMDR using the antidote image Resources Reduction in pain Acceptance Increased functioning

Developments in EMDR practice for Pain High level of unmet need: people in pain EMDR can facilitate changes in how pain is experienced somatically and emotionally. Specifically working with imagery and developing an ‘antidote’ can add to EMDR interventions with pain targets

Developments in EMDR practice: Limitations: Need for greater sample sizes in research More consistent rigour in research Need for better explanations of mechanism Pain can get worse, particularly at first

Developments in EMDR practice Thank you Any Questions? Helen Macdonald 2011 h.macdonald@sheffield.ac.uk

References Grant, M and Thelfro, C., (2002) EMDR in the treatment of chronic pain, in J. Clin. Psychol, Dec;58(12):1505-20 Grant, M ( 2001) Pain control with EMDR; a practitioner’s manual, New Hope Hassard, A. (1995). Investigation of eye movement desensitization in pain clinic clients. Behavioral & Cognitive Psychotherapy, 23 (2), 177-185. Hekmat, H., Groth, S. & Rogers, D. (1994) Pain ameliorating effect of eye movement desensitization. Journal of Behavior Therapy and Experimental Psychiatry, 25, 121-130 Lister, D (2003) Correcting the Cognitive Map with EMDR: A Possible Neurobiological Mechanism, www.EMDR-practitioner.net O’Keefe, J and Nadel L. (1978). The Hippocampus as a Cognitive Map. Oxford University Press Rothschild, B ( 2000) The Body Remembers Van den Hout et al (2010) Counting during recall: Taxing of working memory and reduced vividness and emotionality of negative memories in: Applied Cognitive Psychology 24 no 3 303-311 Van der Kolk, B, (1994) The body keeps the score. http://www.trauma-pages.com/vanderk4.htm Vanderlaan, L. (2000). The resolution of phantom limb pain in a 15-year old girl using eye movement desensitization and reprocessing. EMDR Clinician