EMDR pain protocol Mark Grant. MA, MAPs.

EMDR pain protocol Mark Grant. MA, MAPs

Goals of treatment Resolve or reduce pain Develop pain control skills
Resolve trauma Reduce associated emotional distress Address identity issues Alleviate health fears Stimulate improved adjustment and functioning Medications- lot of people = anxious – important to validate, reassure – never judge Cycle of dependancy – usage often plateaus then decreases Mark Grant. MA, MAPs

Goals of treatment “ EMDR treatment of chronic pain includes the processing and desensitization of both; the automatic emotional response to the pain sensation and, the automatic components of the stored memories related to the etiology of pain.” - Mazzola et al, 2009 Mark Grant. MA, MAPs

Elements of treatment History Medical diagnosis 2. Preparation
Safety, Medical issues AIP model for pain Assessment Target: Traumatic memory, present pain, effects of pain Desensitization Continuous auditory Bls “Incomplete processing” Self-use of DAS/Bls Dealing with blockages ‘ Medications- lot of people = anxious – important to validate, reassure – never judge Cycle of dependancy – usage often plateaus then decreases Mark Grant. MA, MAPs

Elements of treatment +’ve cognition and/or antidote imagery
5. Installation +’ve cognition and/or antidote imagery 6. Body Scan addressing persistent pain 7. Closure Educating client about how to notice and integrate changes Resources for living with pain 8. Re-evaluation Physical vs mental changes Medications- lot of people = anxious – important to validate, reassure – never judge Cycle of dependancy – usage often plateaus then decreases Mark Grant. MA, MAPs

Stage 1. History 1 History 2. Preparation 3 Assessment
4. Desensitization 5 Installation 6. Body Scan 7. Closure 8. Re-evaluation Mark Grant. MA, MAPs

History Medical diagnosis Trauma? Family background Cormobid problems
Narrative (how, when, where, what) Medications? Suitability for EMDR Target sequencing Medications- lot of people = anxious – important to validate, reassure – never judge Cycle of dependancy – usage often plateaus then decreases Mark Grant. MA, MAPs

Mark Grant. MA, MAPs

Medical diagnosis What is the client’s medical diagnosis?
Implications of medical diagnosis To what degree does client accept/understand it? What treatments? Outcomes? How long in pain? Prognosis? Chronic pain is unique as a psychological problem because of involvement of physical factors Medical diagnosis is important for many reasons; - The problem and its effects are more than just mental (which is not to diminish severity or complexity of MDD, PTSD, anxiety etc) but these problems do not normally involve disabling pathology. But if you havea a bbroken leg its accepted you can’t run. For therapist it places limitations on what can be achieved(compared with ‘psychological’ pain. For client it places limitation on expectations ‘how can psychology help – my pain is real’ Lack of clarity causes lot of uncertainty, anxiety. Mark Grant. MA, MAPs

Trauma History Sexual abuse Accident (auto, work, other) Injury
Diagnosis of life-threatening illness Surgery Combat trauma Complicated bereavement Abortion Assault Torture Rape Note; many women develop chronic pain after childbirth Mark Grant. MA, MAPs

Developmental trauma “unless there is solid evidence to the contrary, clinicians would be wise to assume that virtually all clients carry with them some degree of developmental fixation or stuckness.” - Kitchur, 2005 Developmental trauma is ubiquitious Mark Grant. MA, MAPs

Developmental trauma. Abuse, neglect, instability
Early childhood illness Family breakup Family dynamics Intergeneration physical and mental health problems Mark Grant. MA, MAPs

Effects of developmental trauma.
Co-morbid cluster C symptoms Avoidant, Dependant, Borderline Emotional regulation problems More likely to dissociate Relationship problems Identity issues (defective schema) Mark Grant. MA, MAPs

Co-morbid problems. Depression Anxiety Personality disorder Insomnia
Substance abuse Other health/medical problems Life circumstances Adjustment problems I ALWAYS ask about sleep, sleeping problems = fatigue = increased pain, depression etc. Mark Grant. MA, MAPs

Narrative (client’s story).
Problem: What is client’s definition of presenting problem? How well does it fit the facts? Client: What does way client talks about problem indicate about their coping style/capacity? Goals/expectations: What do they really want? Or need Resources: What resources are discernible? Entry point: Where might you begin? Preparation: What inputs might be necessary prior to desensitization? Mark Grant. MA, MAPs

EMDR ‘targets’ PAST TRAUMA: Car accident I can’t cope
Event NC PAST TRAUMA: Car accident I can’t cope Having to live with abusive ex-wife while recovering from injuries Needing breathing apparatus Failed marriage I’m trapped I’m helpless I’m a failure PRESENT STRESS: Freeway phobia I’m out of control Mark Grant MA

Narrative (client’s story).
Problem: What is client’s definition of presenting problem? How well does it fit the facts? Client: What does way client talks about problem indicate about their coping style/capacity? Goals/expectations: What do they really want? Need Resources: What resources are discernible? Entry point: Where might you begin? Preparation: What inputs might be necessary prior to desensitization? Mark Grant. MA, MAPs

Psychology of Workers Insurance.
Loss of; control Privacy Freedom/choices (feels trapped needs the benefits and treatment but) Health/physical integrity Future Safety Mark Grant. MA, MAPs

How much history? “ask for only the most basic facts, the bare minimum that will allow us to proceed with the case formulation.” - Greenwald, 2007 Need for history has to be weighed against urgency of clients current presenting problem and their readiness for therapy and the development of rapport (not necessary prior to commencing EMDR) Mark Grant. MA, MAPs

History-taking. A process of both gathering and uncovering information about the client Includes verbal and non-verbal information A function of the therapeutic relationship (eg; safety) Also part of therapy (eg; developing a narrative) Not necessary to complete prior to reprocessing May continue well into therapy Pacing is important Goal-oriented Mark Grant. MA, MAPs

Case conceptualization.
Physical pain + injury/illness Trauma Family problems, Neglect Comorbid problems (anxiety, depression) Current stressors Personality factors Resources Its more than just taking a history – you’re also assessing things like ego-strength, affect, concentration and attention, relationship between narrative and feelings, style (wall of words vs someone who has spaces in their narrative. (Ric Woods vs.. Grief case) I look for clients with a reasonably intact ego who wear their heart on their sleeve Mark Grant. MA, MAPs

The Pain Pyramid. Pain Stress, trauma Illness, injury,disability
Abuse, neglect, abandonment, deprivation, genetic factors Pain is often tip of iceberg of unresolved trauma, chronic stress, adverse experiences stemming right back to childhood. Sometimes there is a very direct connection between stress, trauma and pain, and EMDR, through its ability to facilitate rapid resolution of these problems, can significantly reduce their contribution to pain. Sometimes the contribution of physical injury may be the overriding factor and a significantly modified version of the trauma protocol is necessary. Mark Grant. MA, MAPs

Assessing personality
Ego Strength Defence Mechanisms Neuroticism Borderline Hemispheric Dominance Mark Grant. MA, MAPs

Ego strength Ability to; engage in satisfying relationships,
experience a relatively full range of age-expected feelings and thoughts, function relatively flexibly when stressed by external forces or internal conflict, have a clear sense of personal identity, are well adapted to their life circumstances, neither experience significant distress nor impose it on others. - Psychodynamic Diagnostic Manual Its more than just taking a history – you’re also assessing things like ego-strength, affect, concentration and attention, relationship between narrative and feelings, style (wall of words vs someone who has spaces in their narrative. (Ric Woods vs.. Grief case) Also; my five secret assessment criteria for deciding who EMDR will work with I look for clients with a reasonably intact ego who wear their heart on their sleeve Mark Grant. MA, MAPs

Defence mechanisms. Denial ‘Primitive’ Dissociation Projection
Somatization Masochism Repression Sublimation (Hyperactivity - manic defence) Intellectualization Humour ‘Sophisticated’ Its more than just taking a history – you’re also assessing things like ego-strength, affect, concentration and attention, relationship between narrative and feelings, style (wall of words vs someone who has spaces in their narrative. (Ric Woods vs.. Grief case) Also; my five secret assessment criteria for deciding who EMDR will work with I look for clients with a reasonably intact ego who wear their heart on their sleeve Mark Grant. MA, MAPs

Personality disorders and pain.
Avoidant Control issues * Trust and safety issues * Hypervigilance * Borderline Affect regulation problems * Propensity to dissociate * Fear of abandonment Lack of support * Identity issues * Histrionic High emotionality * Attention-seeking behavior Dependant Submissive * Needing to cared for by others Fear of separation Mark Grant. MA, MAPs

Trauma related symptoms
PTSD symptoms (increased physiological arousal etc) Dissociative symptoms Affect regulation problems Somatization Depression Relationship problems Identity issues - van der Kolk (1996) Mark Grant. MA, MAPs

Brain Hemispheric Differences
LH RH “what?” “How?” Inflexible Flexible Narrow focus attention open, sustained attention Prefers known Likes novelty - Never fully known Emotionally - Anger Emotionally - Depression Self= act of will Self in relation to others Denotative language metaphors, symbols Competitive , exploitative Empathic Sequential processing Parallel processing Decontextualized world “Lived world” Acknowledgement: Ian McGilchrist (2009) RH sees whole pic via pattern recognition Mark Grant

Problem of pain Pain: A stressful, often traumatic event
Exacerbates pre-existing trauma Overwhelms coping mechanisms (medical model): “not my problem – the doctor should fix me” Mark Grant. MA, MAPs

The medical model: Mark Grant. MA, MAPs

Traumatic pain vs medical pain
A memory (‘past’) “Stored memories related to etiology of pain” Emotional distress with or without injury Pain = maintained by memory Medical pain: An event (‘present’) “Automatic emotional response to pain” Pain = maintained by physical injury Mark Grant. MA, MAPs

Goals of treatment “ EMDR treatment of chronic pain includes the processing and desensitization of both; the automatic emotional response to the pain sensation and, the automatic components of the stored memories related to the etiology of pain.” - Mazzola et al, 2009 Mark Grant. MA, MAPs

Pain + trauma Mutually exacerbating problems, comprising physical and emotional factors, past and present experiences, which involve; - Intrusive thoughts and feelings, avoidance, numbing - Autonomic dysregulation, (sleeping problems, fatigue) - Emotional dysregulation, (depression, hyper-sensitivity, mood swings) Oth trauma and pain = overwhelming events that cannot easily be integrated into persons whole sense of self – NB body image vs injured self. Alteration to AIP model idea that rx is about reprocessing dysfunctionally stored past memories Whether or not client has suffered abuse or neglect, if they have a rupture disc or nerve damage, they you are dealing with more than just memory You are dealing with a present internal physical stressor which may be refractory to medical treatment. Result: Complex processing, rarely straightforward, often, Incomplete, Different targets, Future Template =more important Mark Grant. MA, MAPs

Pain + injury Pain + Effects of pain: on physical functioning
(‘work, love and play’) sleep mood relationships coping identity Mark Grant. MA, MAPs

My 5 “secret” assessment criteria
What is client’s affect range/capacity What is client’s medical diagnosis? (if applicable) How much is person able to distance themselves consciously from their problem? Personality (strong, stable?) Life circumstances (stable?) How do we know when a client is suitable and ready for EMDR? In EMDR u are supposed to have; Adult perspective, present orientation, Present safety and positive resources. These are my main criteria for determining whether a client is suitable for EMDR 1 Is affect congruent with presenting problem? Mark Grant. MA, MAPs

Pain Tests. Impact of Event Scale (Horowitz, et al, 1979)
Pain Disability Index (Chibnall & Tait, 1994) Beck Depression Inventory Beck Anxiety Inventory Pain Catastrophizing Scale (Sullivan et al, 1995) SFMPQ, VAS Pain Self-Efficacy Questionnaire (Nicholas, 1989) Its more than just taking a history – you’re also assessing things like ego-strength, affect, concentration and attention, relationship between narrative and feelings, style (wall of words vs someone who has spaces in their narrative. (Ric Woods vs.. Grief case) I look for clients with a reasonably intact ego who wear their heart on their sleeve Mark Grant. MA, MAPs

PPI vs affect in SFMPQ Mark Grant. MA, MAPs

Stage 2. Preparation 1 History 2. Preparation 3 Assessment
4. Desensitization 5 Installation 6. Body Scan 7. Closure 8. Re-evlaluation Mark Grant. MA, MAPs

Preparation Therapeutic relationship
Transference & counter transference Safety and containment issues Pain control Safe place (if necessary) Medical issues Explanation of EMDR Dissociative screening – normally everybody, but with non-trauma pop this is not necessary Gen Health includes anything that may impact on response Bls – eg guy with brain stint, hypersensitive to stimuli Th alliance – trust – demonstrate u Mark Grant. MA, MAPs

Transference -Nicholas, (1996).
" A person seeking help for chronic pain could be said to be inactive with secondary physical deconditioning, to hold unhelpful beliefs, to be overly passive or reliant on others for resolution of his/her problems.." -Nicholas, (1996). Eg; my ‘rescuer’ gets triggered by older female pain sufferers – my mother is a chronic pain sufferer My need for omnipotence is met when clients feel better – after coming in with very low expectations – stiles video? Mark Grant. MA, MAPs

Transference and countertransference
Therapists are always influenced by their patients: “We hope for the best; we are saddened by their [patients] failures, gladdened by their accomplishments; and we suffer real losses when they complete therapy” - Beitman (1983) Eg; my ‘rescuer’ gets triggered by older female pain sufferers – my mother is a chronic pain sufferer My need for omnipotence is met when clients feel better – after coming in with very low expectations – stiles video? Mark Grant. MA, MAPs

How to recognize your transference
1. Emotional reactions: Frustration, Anger, Guilt, Shock, Pity, Sadness. 2. Ego states: ‘Helpless child’, ‘Incompetent Failure’, ‘Rescuer’, ‘Omnipotent fixer’, ‘Critic’ Eg; my ‘rescuer’ gets triggered by older female pain sufferers – my mother is a chronic pain sufferer My need for omnipotence is met when clients feel better – after coming in with very low expectations – stiles video? Mark Grant. MA, MAPs

Uses of Transference Assessment tool
Facilitates therapeutic relationship Facilitates clients exploration of feelings Client safety Therapy more likely to be aligned with clients capabilities Professional development Self-protection (avoiding burn-out) Eg; my ‘rescuer’ gets triggered by older female pain sufferers – my mother is a chronic pain sufferer My need for omnipotence is met when clients feel better – after coming in with very low expectations – stiles video? Mark Grant. MA, MAPs

Uses of Transference T: I’d like you to think about some place that feels calm or safe. C: I’m on the beach. It’s a sunny day. The sand is warm and the ocean is calm. T: Bring up the image of that calm place, concentrate on the pleasant sensations in your body and follow my fingers… How do you feel now? C: I am not a good swimmer, I feel anxious T: Feeling compassionate and hoping something else will work. Think of another place. (Client can’t find anything) T: Do you ever feel safe anywhere? C: Not really, no. Mark Grant. MA, MAPs

Uses of Transference T: I just noticed that I went numb all over my body. I’m wondering if you are feeling something similar. C: Yes as a matter of fact I am. Finding a safe place is such a simple thing, Why can’t I do it? T: It seems like the memory feels safe at first, but then an unpleasant memory intrudes and destroys the safety. C: I am beginning to realize that I don’t know what safety feels like. I don’t think I have every felt safe anywhere, with anybody. Does this mean I can never feel safe.. can’t do EMDR? T: We are doing EMDR right now…for people who don’t have a safe place we can work to develop that. Mark Grant. MA, MAPs

Therapeutic relationship.
“The heart of the preparation stage is the feeling of trust that comes from knowing we’re engaged in the same task...” - Mark Dworkin, 2008 I’d say its more than this, the client often comes in with very little hope – until after their first round of DAS/Bls Type of Bls – all research = eye movements – own research with auditory Bls (in press) =?? Mark Grant. MA, MAPs

Safety. Adequate control over pain/affect Freedom from threat
Secure living conditions Psychological safety (safe place) Access to support Affect regulation includes reasonably adequate means of controlling pain Spectrum from person is suicidal as result of feeling tormented by inescapable pain to person who through pacing and medication is able to have some quality of life. Mark Grant. MA, MAPs

Explanation of EMDR AIP model and pain
“Pain can occur for many reasons. We generally understand pain as a signal that something is wrong physically. However, sometimes pain can continue longer than expected, despite medical treatment. Pain can persist because of fatigue, stress, and biochemical changes. As a result of these changes, the pain becomes “locked” in the nervous system… Client willingness; would it be okay if we do something that might help you have more control over your pain instead of havin to rely on medication? Mark Grant. MA, MAPs

Explanation of EMDR AIP model and pain
You are not meant to suffer from pain indefinitely. Your nervous system is actually designed to process experience, including physical and emotional pain, so that once the injury that caused the pain is healed, everything returns to normal. EMDR is a way of stimulating the nervous system to facilitate healing. Even though we might not be able to completely eliminate your pain, EMDR often stimulates feelings of relaxation, which will help.” Client willingness; would it be okay if we do something that might help you have more control over your pain instead of havin to rely on medication? Mark Grant. MA, MAPs

Stage 3. Assessment. 1 History 2. Preparation 3 Assessment
4. Desensitization 5 Installation 6. Body Scan 7. Closu 8. Re-evaluation Mark Grant. MA, MAPs

Creating a ‘pain target’
1 What targets appear to have set groundwork for clients presenting issue? 2. What negative reactions does the client possess in the present that can be traced to experiences in the past? 3 Which of these targets appear to have potential to fill in deficits in the clients life and optimize a healthier level of functioning? 4. Is the client able to access these identified experiences and process them to successful resolution? - Hensley, (2009) What present physical discomfort is the client seeking relief from? - Grant, (1998) This slide has been moved up 1 Mark Grant. MA

Creating a pain ‘target’
Key question: Where to begin..past, present or future? (Based on client’s needs and readiness) Either: Traumatic pain; targeting past memory Or: Medical pain; targeting present pain Where to begin – past or present? Mark Grant. MA, MAPs

Creating a pain target Traumatic Pain: - Image + pain 2. Medical pain
3. Symptom-related memory - pain-related traumatic experiences (de-Roos & Veenstra) Plus; NC, PC, SUD’s etc Note: Not all pain is associated with trauma or part of a traumatic memory But, pain and its effects are often quite traumatic = present pain target SUD’s may be used to measure trauma or pain Mark Grant. MA, MAPs

Creating a pain target Trauma or; Pain Mark Grant. MA, MAPs

Trauma target (picture)
Memory: “What incident or event comes to mind when you feel pain?” Sensory: “What does the pain feel like - how would you describe it?” When working with traumatic pain, the picture is generally associated with the event that triggered the pain Eg; Rosa, MVA case, Mark Grant. MA, MAPs

Medical pain target (picture)
Sensory: If the pain had a size, shape colour… how would you describe it? Imaginal: What does the pain feel like, what does it remind you of? Can you draw a picture? Sensory – people are rarely asked to describe their pain – powerful thing Imaginal – free association based on memory – whats it LIKE; knife hot poker, red ball, electricity Picture – last resort rarely necessary - value of all this is to CONNECT client with pain (so u can work with it) in a tolerable (detached awareness) way Mark Grant. MA, MAPs

Trauma ‘Target’ Image (based on memory) Negative Cognition
PC & VoC Emotion & SUD Bodily sensations Normal targeting sequence based on trauma-based focus Mark Grant

(based on present feelings)
Pain ‘Target’ Bodily sensations Image (based on present feelings) Negative Cognition PC & VoC Emotion & SUD For present non-traumatic pain (present pain is the event, not directly connected to touchstone memory) Person may have developmental trauma, but it is not emotionally connected to current pain Image is constructed Mark Grant

Negative cognitions (trauma and pain).
Lack of safety/vulnerability: I’m helpless I’m going to die Lack of control/power*: I‘m trapped I’m helpless’ ‘I can’t control it (the pain)’ Responsibility/being defective*: ‘I’m weak’ ‘‘There’s something wrong with me’ Pain-related NC’s are more based on the experience of pain Mark Grant. MA, MAPs

Negative cognitions (effects of pain).
‘I’m worthless/useless’ ‘I’m unloveable ‘I deserve to suffer’ ‘I’m a burden’ I’m a failure Moved up 1 Mark Grant. MA, MAPs

Positive cognition. Trauma and pain (lack of safety/vulnerability) ;
‘Its over, I’m okay’ “I’m alright” ‘I survived’ Managing on-going pain (lack of control/power) ; “I can cope” “I can control my pain” ‘I will survive’ Effects of pain (responsibility/being defective) ; I’m okay/I’m alright I can still be useful Mark Grant. MA, MAPs

Partial positive cognitions
“Based on what happened today, what is the most positive statement that you can make about yourself?” - Lazarov, 1996 “What is the most positive thing you have learned about yourself today regarding your ability to control the pain?” - de Roos, 2009 Mark Grant. MA, MAPs

MVA victim (traumatic pain)
Trapped in car NC: ‘I’m gonna die’ PC: I survived (2/7) “Terror” 9/10 Heart palpitations Leg pain Normal targeting sequence based on trauma-based focus Mark Grant

Injured worker (present pain)
Burning sensation 3/10 “A Red ball” NC: I’m defeated PC: I’ve won (2/7) Sad angry (5/10) Note that the present pain is the main target For present non-traumatic pain (present pain is the event, not directly connected to touchstone memory) Person may have developmental trauma, but it is not emotionally connected to current pain Image is constructed Mark Grant

Stage 4. Desensitization
1 History 2. Preparation 3 Assessment 4. Desensitization 5 Installation 6. Body Scan 7. Closure 8. Re-evaluation Mark Grant. MA, MAPs

Desensitization checklist
Is the client mindfully present? Is the client experiencing affect? Is the client able to adopt detached observer stance (distance) Informed consent (AIP rationale, ensuring client understands what is happening) Mark Grant. MA, MAPs

Set-up “Okay, so now we are ready to see if we can help you to have less pain. So I’m going to ask you to listen to these tones whilst simultaneously focusing on your pain. We can’t predict how your nervous system will respond to the EMDR stimulation, so try and adopt an open mind and just notice the sensations of your pain and let whatever happens happen. Most people find it harder to concentrate on their pain, and start to feel more relaxed, but there is no right or wrong, just let whatever happens happen. Very rarely the pain can increase. In the unlikely event that this happens, just raise your hand like this (show stop signal) and I will stop.” This is raelly about setting up detached awareness and getting client into an observing sensing mode. Mark Grant. MA, MAPs

Focusing/Dual Attention
“So just focus on the pain [or image] now, how you see it and where you feel it in your body And the negative thought And just notice.. Just let whatever happens happen..” Commence DAS/Bls Mark Grant. MA, MAPs

Desensitization Bls/DAS; auditory bilateral tones (recommended),
(with eyes closed or open & fixated) eye-movements tapping. 2. Pause (optional) cease bls; “take a breathe” 3. Refocus attention; “what do you notice now?” “what seemed to happen then?” “What do you get now?” Nb; prefer auditory because more ‘visceral’ and suitability for self-use – mention CD’s Other benefits – facilitate sleep, relaxation, stress-management Length: needs to be long enough to stimulate change, but shorten it up if have concerns (health probs, dissoc’n) Mark Grant. MA, MAPs

Types of responses to DAS/Bls
sensory changes (reduced intensity) perceptual changes (distancing effect) “The pain seems smaller, further away” cognitive changes (decreased worry, conc’n) “it just doesn’t seem so important..” Don’t just rely on client self-report; also look for; physiological changes ▼ pain & tension (postural changes), changes in breathing rate / facial expression Changed – added sensory Mark Grant. MA, MAPs

Grounding questions As you’re telling me that what do you notice is happening in your body? Where do you notice the sensations in your body? How would you describe those sensations? (tight, hard, stiff, heavy etc) What feelings go with those sensations? Mark Grant MA

Continue with bls stimulation until complete, had enough or plateaux

Target within target NB: SUD’s of 0 is not always possible with chronic pain Normally you only return to target after end of channel has been reached, but with pain ret to target when client ceases to progress anymore or appears tired Mark Grant. MA, MAPs

Blockages. “Nothing” or “no change” responses Intellectualization
Increased pain Unconscious fears Medication Dissociation Other psychopathology Strong Left Hemisphere Dominance Pain increases; Louise R – shoulder injury, not well understood, lot of other present stressors, changed focus. Same with guy with brain stint – hypersensitive to noise – its as though their nervous system cannot take ANY stimulation and/or that it overreacts to normally innocuous stimulation Mark Grant. MA, MAPs

“Nothing” or “No change”
“What do you mean by nothing?” “what were you feeling in your body whilst you were listening to the tones?” “Where was the pain while you were listening to the tones?” “What do you notice about how the rest of your body feels? “Some people notice feelings of distance, relaxation lightness, do you notice anything like that?” How does the pain feel now compared with how it felt before (present vs past dichotomy) Reconnect client with experience Mark Grant. MA, MAPs

Pain increases If pain increases; stop
check with client, review diagnosis continue or - Change treatment modality Pain increases; Louise R – shoulder injury, not well understood, lot of other present stressors, changed focus. Same with guy with brain stint – hypersensitive to noise – its as though their nervous system cannot take ANY stimulation and/or that it overreacts to normally innocuous stimulation Mark Grant. MA, MAPs

Unconscious fears “Is there any part of you that might need this pain?” “is there anything that might be stopping the pain from getting better?” "If there was an emotional contributor to this pain, what might it be?" “Is there something else your body needs in order to feel better?” Benoir actually says would – too direct for Australians and many clients just couldn’t answer Mark Grant. MA, MAPs

Dissociation. Use grounding techniques to bring client back into present. Teach client how to self-soothe instead of self-injure/not feel Teach client how to attend to their pain by showing appropriate care and concern Challenge feelings of unworthiness Develop self-soothing strategies Mark Grant. MA, MAPs

Other psychopathology
Dissociative Identity Disorder Bipolar Disorder Schizophrenia Autism Mark Grant. MA, MAPs

Strong Left hemisphere dominance

Hemispheric Dominance Inventory
Study skills page, Middle Tennessee State University Mark Grant. MA, MAPs

Stage 5. Installation 1 History 2. Preparation 3 Assessment

Positive cognition. Trauma and pain (lack of safety/vulnerability) ;
‘Its over, I’m okay’ “I’m alright” ‘I survived’ Managing on-going pain(lack of control/power) ; “I can cope” “I can control my pain” ‘I will survive’ Effects of pain (responsibility/being defective) ; I’m okay/I’m alright I can still be useful Mark Grant. MA, MAPs

Partial positive cognitions
“Based on what happened today, what is the most positive statement that you can make about yourself?” - Lazarov, 1996 “What is the most positive thing you have learned about yourself today regarding your ability to control the pain?” - de Roos, 2009 Mark Grant. MA, MAPs

Resource installation
Focus on the image of the resource and the positive emotions and sensations that accompany that image (top-down) Focus on strengthening the positive sensations that clients have when thinking about a friendship, safe place, etc. (Shapiro, 1995, Leeds, Kiessling 2005) Focus on an image based on positive sensations client noticed following DAS/Bls. (Grant, 1998, 2009) Mark Grant. MA, MAPs

Resource imagery/strategies
Healing light/light-stream Anesthetic mist Breathing techniques Strengthening pre-existing resources: Skills Friendships Experiences Linking pre-injury values with present functioning Mark Grant. MA, MAPs

Stage 6. Body Scan 1 History 2. Preparation 3 Assessment
4. Desensitization 5 Installation 6. Body Scan 7. Closure 8. Reassessment Mark Grant. MA, MAPs

Body Scan. Look for changes in affective states associated with trauma but not directly targeted Accept there may be residual pain when treating medical pain Accept pain may return following successful ‘reprocessing’ of medical pain Mark Grant. MA, MAPs

Body scan. If I ask you to mentally scan your body for pain or discomfort, what do you notice now? How do you feel in your body now? Whats there now where the pain was before? Review SUD’s – emotional distress - physical pain Mark Grant. MA, MAPs

Stage 7. Closure 1 History 2. Preparation 3 Assessment

Closure. Stabilizing client Expectations Homework
Reinforcing possibility of change Mark Grant. MA, MAPs

Stabilizing client. Completed session:
You’ve done well, see, you can learn how to feel different, you have learned something very important about yourself Incomplete session: You’ve made a good start, obviously it takes time to learn to feel different, but judging by the way you have responded today, I am sure you will continue to make progress If you have any problems with your pain or trauma, you can always use your calm place, or the self-help CD. Mark Grant. MA, MAPs

Expectations. Traumatic pain;
Because your pain is associated with a trauma, processing the trauma often leads to a reduction if not a complete resolution of the pain. We have no way of knowing. The important for you is to just have an open mind and let whatever happens happen. Medical pain; The work we have done today should have a permanent effect on your pain memories. In other words even though the pain might return, it will probably return in a less severe way so keep an open mind for changes in how you experience your pain. Mark Grant. MA, MAPs

Reinforcing possibility of change.
You might find that hard to believe, but you probably didn’t come here expecting anything much right? So its important to just have an open mind and try and observe your pain each time as if for the first time, and try and be aware of any subtle changes. When you’ve been in pain for a long time it seems like it can never change, but pain can change … it just has … so have an open mind let whatever happens happen. Mark Grant. MA, MAPs

Re-evaluation 1 History 2. Preparation 3 Assessment 4. Desensitization
5 Installation 6. Body Scan 7. Closure 8. Re-evaluation Mark Grant. MA, MAPs

Re-evaluation. Reviewing changes since last session;
Have you noticed anything different about your pain and how you experience it? Have you noticed any other differences in how you live your everyday life? Reviewing previous work; How do you feel now when you think of what we worked on last time? Resuming reprocessing; Mark Grant. MA, MAPs

Target within target NB: SUD’s of 0 is not always possible with chronic pain Normally you only return to target after end of channel has been reached, but with pain ret to target when client ceases to progress anymore or appears tired Mark Grant. MA, MAPs

Cognitive Interweaves for pain.
New Information: Do notice a feeling of distance.. or lightness.. Whose responsibility is it?; Did you ask to be in pain? Do you like feeling like a burden? “I’m confused”; If you’re really so worthless how come…. Stories of survival; We all have the ability to overcome bad things Socratic method; Mark Grant. MA, MAPs

Resource installation
Image (of a resource) + positive emotions and sensations that accompany that image (‘top-down’) Strengthening positive sensations that clients have when thinking about a friendship, safe place, etc. Pleasant bodily sensations (“some part of your body that feels okay, calm, comfortable”) + image (Shapiro, 1995, Leeds, Kiessling 2005) 4. Developing imagery based on positive sensations client noticed following DAS/Bls (‘bottom-up’) (Grant, 1998, 2009) Mark Grant MA MAPS

Somatic resource installation
‘The more capable the body is of being affected in many ways.. the more capable of thinking is the mind.’ Spinoza, 1650 Mark Grant MA MAPS

Key assumptions Usual AIP precepts
DAS/Bls is de-arousing for most people You should expect clients to feel more relaxed, decreased pain, more distance from pain following DAS/Bls If client fails to report positive changes, it indicates; Not set up right (problem with ‘target’) Problem with clients ability to process sensory input You are dealing with pure pain (nociception) Mark Grant MA MAPS

Somatic Resourcing Steps
Help clients identify and label positive changes in sensation following DAS/Bls Utilize affective changes following DAS/Bls to create resource/antidote imagery for coping with future pain Install and reinforce clients ability to utilize resources/antidote imagery Mark Grant MA MAPS

Accessing questions (resources)
Whats there now where the pain was before? Can you describe that feeling? What does that feeling remind you of? What image would go with that? What word best summarizes that feeling? Mark Grant MA

Comfort words Cool (vs Hot) Dull (vs Sharp) Soft (vs hard) Loose (vs tight) Light (vs heavy) Ebbing (vs pulsing) Flowing (vs stuck) Tingling (vs stinging) Easing (vs worsening) New slide Mark Grant MA MAPS

Accessing words “Safe” “Comfort” “Relief” “Healing” Mark Grant MA MAPS

Hypnotic installation
“you will notice that your head has gone quiet, that the usual thoughts and preoccupations are absent for the moment… just notice that … and how different it feels .. because things are usually so busy up there... just sitting in the chair, with nothing particular to think about. And physically you’ll notice a feeling of calmness.. or emptiness.. maybe a feeling of lightness.. and that your breathing has slowed down.. just notice that. Mark Grant MA MAPS

Hypnotic installation
You probably haven’t felt this way for a long time because of everything you’ve had to deal with… but that’s normal. You’re not actually supposed to feel anxious and tense all the time. You are supposed to feel relaxed and carefree sometimes…. Imagine what life would be like if you felt like this all the time?” Mark Grant MA MAPS

Self-use of DAS/Bls Affect management tool rather than relaxation
Not reprocessing – so no need for PC, NC etc Effective for stress, pain, insomnia, Training effect from in-session work Can also be used without audio equipment Usual precautions apply Self-use – story of traumatized bus driver (rock in face) who used it without audio equipment to alleviate anxiety when kids fighting on back of bus (pinnington) Mark Grant MA

Self-use of DAS/Bls Pain control Alleviating anxiety Reducing worry
Alleviating insomnia Stress management Mark Grant MA MAPS

Accessing questions (for resources)
What’s there now where the pain was before? Can you describe that feeling in terms of a size, shape etc? What does that feeling remind you of? (Suggest some possibilities if client is having trouble finding words to describe) What image would go with that memory/description? What word best summarizes that feeling/image Mark Grant MA MAPS

Stories of hope Mark Grant. MA, MAPs

Summary of pain protocol differences
History - Preparation: - attention to medical history/diagnosis - safety as freedom from pain/physical disability - modified version of AIP Assessment (Targeting): - traumatic memory or present pain - NC/PC; 3 x possibilities - trauma, pain and coping Desensitization: - reliance on auditory DAS/Bls - partial positive cognitions, incomplete processing Installation: - addition of antidote imagery - self-use of DAS/Bls Mark Grant. MA, MAPs

Pain management Resources based on EMDR

EMDR pain protocol Mark Grant. MA, MAPs.

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EMDR pain protocol Mark Grant. MA, MAPs.

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