Transcript Bag of marbles

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)
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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
– 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
– 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
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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
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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:
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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
[email protected]
References
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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.traumapages.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