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Helen Macdonald Durham 7 th October 2011

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

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Helen Macdonald Durham 7 th October 2011

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  1. Developments in EMDR practiceMarbles 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)

  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 • 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 • 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 h.macdonald@sheffield.ac.uk

  29. 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

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