1. 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

2. 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

3. 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

4. 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

5. The personal experience of pain

6. 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)

7. 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

8. ‘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

9. 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 )

10. 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

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

12. Effective intervention:
Decreased affect
Reducing image vividness

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

14. 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?

15. 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

16. 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

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

18. 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

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

20. 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

21. 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

22. 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

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

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

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

26. 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

27. 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

28. Developments in EMDR practice
Thank you
Any Questions?
Helen Macdonald 2011

29. References
Grant, M and Thelfro, C., (2002) EMDR in the treatment of chronic pain, in J. Clin. Psychol, Dec;58(12):
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),
Hekmat, H., Groth, S. & Rogers, D. (1994) Pain ameliorating effect of eye movement desensitization. Journal of Behavior Therapy and Experimental Psychiatry, 25,
Lister, D (2003) Correcting the Cognitive Map with EMDR: A Possible Neurobiological Mechanism,
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
Van der Kolk, B, (1994) The body keeps the score.
Vanderlaan, L. (2000). The resolution of phantom limb pain in a 15-year old girl using eye movement desensitization and reprocessing. EMDR Clinician