EMDR (Eye Movement Desensitisation and Reprocessing) therapy is a NICE and World Health Organisation recommended treatment for psychological trauma. It was developed in the 1980’s by Francine Shapiro, and has a robust evidence base generated over several decades. Multiple randomised controlled trials have been carried out which demonstrate its effectiveness.
What happens in EMDR therapy?
EMDR is an 8 phase psychotherapeutic approach. It begins with history taking of the trauma(s) and piecing together the puzzle of an individual’s difficult experiences and coping strategies. We know that people who are traumatised can find it hard to stay in the ‘window of tolerance’ (see image below), so it is really important that we help our clients feel safe and stable prior to starting trauma processing. This may be through teaching various skills to regulate their nervous system, such as visualisations, breathing exercises or movement. We often use lots of education in this phase too, to help clients understand that they have responded in a perfectly adapted way to protect themselves from trauma. They are not weak, and have not done anything wrong.
During an EMDR processing session, we will select a memory to work on and ask some specific questions about the memory, to activate it in the working memory. We talk about the image, beliefs, emotions and sensations, as well as a ‘gut level’ rating of how distressing the memory is currently (rated out of 10).
We then use bilateral stimulation, either eye movements left to right, tactile sensation or auditory stimulation, whilst focussing on the target memory.
How does EMDR therapy work?
Imagine you fall and graze your knee. Your body inherently knows how to heal, without instruction, from the inside out. EMDR therapy assumes the brain has an innate ability to heal from trauma. However, sometimes that process gets a little stuck, and EMDR therapy can speed up the process, much like what happens during REM sleep. There are a few theories offered as to how EMDR therapy works. It is thought that the rhythm of bilateral stimulation reduces activity in the brain’s areas associated with fear and allows reappraisal (new information or beliefs) and integration (appropriate storage) and consolidation of the trauma memory. The left and right sides of the brain are able to work together because of the bilateral stimulation. It is also thought that by distracting your brain with another task (bilateral stimulation) the memory being worked on becomes less vivid and distressing.
By putting a memory in working memory and then making your working memory work hard (the taxing theory) we can integrate that memory in order to store it away. Trauma memories tend to be fragmented, poorly organised, lacking time stamps and not updated with new information. I like to think of EMDR as sweeping up the fragments of broken glass together in to a whole, so that the brain can properly store it away.
So how is this relevant for clients with persistent pain?
Firstly, we know there is a huge overlap between trauma and pain. People with persistent pain are more likely to have a history of trauma than individuals without persistent pain (Nicol et al, 2016). The pain may have been caused by a traumatic incident or injury, which may in itself continue to carry distress. Persistent pain is known to be a combined effort from sensory, cognitive, emotional and neurological processes.
So if we identify an individual with persistent pain has experienced trauma, we may first decide to work on processing that trauma, to store old memories away so that trauma memory is not constantly activated. This in itself can sometimes help reduce activation in the nervous system and reduce, or even resolve an individual’s pain.
We know ‘the body keeps the score’. Pain, particularly in presentations such as phantom limb pain, is hypothesised to involve inappropriately stored or chronically activated memories. Following EMDR therapy, memories involving pain, whether through an accident, injury or traumatic experience of pain, are appropriately stored, thus meaning less activating of old ‘body memories’.
Individuals with trauma histories are more vulnerable to developing pain, and people with pain (and therefore, likely anxiety) are more vulnerable to developing trauma reactions. Distress following trauma influences pain. Pain and other difficulties such as anxiety, avoidance and cognitive bias can mutually maintain one another. Previous experiences of pain can lead to fear avoidance, further exacerbating pain. Without experience of movement, expectations, predictions and cognitive bias cannot be challenged.
All of these factors are important to consider and help us understand how EMDR might help persistent pain.
What does the evidence base suggest?
As previously mentioned, the evidence base for EMDR for trauma presentations is robust. If we are treating an individual with trauma and pain, EMDR is a good treatment choice, evidenced by our gold standard of research, Randomised Controlled Trials (RCTs).
Although studies have been relatively small, there is good emerging evidence for EMDR for phantom limb pain (de Roos et al, 2010), migraine (Marcus, 2008) and fibromyalgia. Pain can be seen as just another type of hyperalert state to help protect us, an overdeveloped survival response to keep us safe. With that in mind, it makes sense why EMDR would help people with pain.
If you would like further help with your clients with pain, say hello at firstname.lastname@example.org