Mark GrantMA (Psych),Wyong Medical Centre,Margaret Street,Wyong NSW 2259,Australia.Tel.:/Fax: 612 9437 9219;E-mail:markgra@ozemail.com.au

EMDR: a new treatment fortrauma and chronic painMark Grant

EMDR (eyemovement desensitization and reprocessing) is a newpsychological treatmentfor trauma that is capable of facilitating rapid and permanent reduction in distressingthoughts and feelings (Carlson et al.1998,Wilson et al.1995). In addition to reduction ofpsychological distress, themethod leads tomore adaptive attitudes and functioning.The utility of themethod also appears to extendbeyond traumawith positive resultsreported in the treatment of addictions, phobias, andpain (Henry1996,Goldstein & Feske1994,Grant1986). As a treatment for pain EMDRoffers amethod of facilitating permanentchanges in howpain is experienced somatically and emotionally.Knowledge andunderstanding of the principles underlying EMDR can also provide a guide formoreeffective interventions by pain specialists.# 2000 Harcourt Publishers Ltd

INTRODUCTION

Eye movement desensitization and reprocessing

(EMDR) is a new psychological treatment which

can promote rapid and permanent resolution of

distressing thoughts and emotions. For example,

in the treatment of trauma, `cures' have been

reported after as little as three sessions with this

method, compared to up to 25 hours using

traditional approaches (McCann 1992, Wilson

et al. 1995, Carlson et al. 1998, Grant 1998).

EMDR's e�cacy with post traumatic stress

disorder has stimulated clinicians to apply it to

a range of problems including addictions, grief,

depression and pain (Shapiro 1995). There is also

some research to suggest EMDR can be e�ective

in relieving pain (McCann 1992, Hekmat et al.

1994, Grant 1986).

EMDR was identi®ed in the late 1980s by

Dr Francine Shapiro as a result of a chance

observation. Whilst walking in a park one day,

she noticed some distressing thoughts and

feelings she was experiencing about a particular

situation suddenly disappeared. Curious, she

reviewed what she was doing in the moments

prior to this and realized that her eyes had been

moving rapidly back and forth, in spontaneous

saccadic eye-movements. She then deliberately

repeated this process, of thinking of something

distressing and moving her eyes rapidly at the

same time and found when she did this the

intensity of the distressing thoughts was greatly

reduced (Shapiro 1995). After further experi-

ComplementaryTherapies in Nursing &Midwifery (2000) 6,91^94 # 2000 Harcourt Pu

mentation with traumatized Vietnam veterans,

and ®nding similar results, EMDR was born.

Professional acceptance of the method has come

relatively quickly for a new approach. In 1998

the American Psychological Association recog-

nized EMDR as `probably e�cacious' in the

treatment of trauma (Chambless et al. 1998).

EMDR is constructed around a set of proto-

cols which incorporates elements from many

di�erent treatment approaches. The therapeutic

elements of EMDR include meditative practices,

exposure, dual focus of attention, relaxation and

cognitive features (Shapiro 1998).

It is important to remember many of these

elements are common to more traditional meth-

ods of psychotherapy. For example, one of the

steps of EMDR involves instructing the client to

notice any negative feelings prior to attending to

the eye movement in the desensitization phase.

This `detached observer' stance has long been

a feature of meditative approaches (e.g. Kabat-

Zinn 1990). One of the unique features of

EMDR is the way these various therapeutic

elements are brought together.

For example, in cognitive therapies, thoughts

are typically used to change negative emotions.

In EMDR cognitive shifts are a manifestation

rather than the instrument of change.

During EMDR the therapist works with the

client to identify the problem or situation they

would like to feel better about. Negative feelings,

thoughts and sensations related to the problem

are noted. The client is then instructed to focus

blishers Ltd

EMDR seems to

change the

intensity of the

pain as well as

the way the pain

is remembered.

92 ComplementaryTherapies in Nursing &Midwifery

on the distressing images, feelings and thoughts

while simultaneously performing rapid eye-

movements, which are induced by instructing

the client to visually track bilateral movements

of the therapist's hand. Each period of eye

movement is termed a `set'. Following this the

client is instructed to relax and asked to notice if

they feel any di�erently. A signi®cant number of

people will report some change in how they feel

after just this. If not, the process is repeated until

the client reports feeling better. There are

additional protocols for what to do when the

client repeatedly fails to report any change.

Following EMDR treatment, clients frequently

report they are unable to recall the problem with

the same emotional intensity. For example,

following EMDR a pain su�erer reported their

pain `no longer seems as important'. EMDR

seems to change the intensity of the pain as well

as the way the pain is remembered.

EMDR is based on an `accelerated informa-

tion processing' model (Shapiro 1998). This

model posits that experience (i.e. feelings,

thoughts and sensations) is normally trans-

formed into adaptive learning. However, when

a trauma occurs, the information processing

system may not work properly causing informa-

tion to be stored maladaptively. An example of

this is when a victim of rape has, say, anxiety

attacks whenever she meets male acquaintances.

Although the danger is over, her nervous system

is still reacting as though she is in danger. The

theory is that the thoughts and feelings asso-

ciated with that experience do not get integrated

in the normal way, but remain `frozen' in the

nervous system. Consequently, that experience

may be constantly `re-played' in the form of

recurring anxiety, ¯ashbacks and negative feel-

ings (Van der Kolk 1994). The aim of treatment

is to bring the frozen information back into

conscious awareness where it is available for

processing and integration. There are as yet, only

theories and a little research (LeDoux 1993) as to

how this actually occurs. However, citing Le-

Doux's work, van der Kolk (1998) has suggested

EMDR facilitates the movement of information

from places in the brain where it may be `stuck',

such as the amygdala or emotional brain, into

the frontal cortex where it becomes accessible for

reprocessing.

It is important to approach psychological

treatment of chronic pain with an appreciation

of some of the special problems and di�culties

associated with its dual status as a medico-

psychological problem. These include wide-

spread medical mismanagement, mis-diagnosis

and inadequate pain control (Hitchcock 1994).

These problems have been found to exacerbate

the distress of patients with pain (Pither &

Nicholas 1991), and unless addressed can under-

mine psychological treatment. For example,

psychological approaches which focus on im-

proving coping without addressing the issue of

pain control have high relapse rates (Turk &

Rudy 1991). An often overlooked prerequisite of

psychological treatment of pain then, is to review

medical treatment and the adequacy of existing

pain management. The following case-studies

illustrate the application of EMDR to the

treatment of chronic pain.

Case1

`Tanya' (not her real name) presented complain-

ing of su�ering from severe pain in her jaw and

right shoulder for two years. She reported that

the pain made her unable to lift her arm and

severely restricted her ability to use her arm; for

example, she could not wash her hair. She

recalled that at one stage she had required her

daughter's assistance to get dressed. She had

been diagnosed as su�ering from Capsulitis and

told she would need surgery. She was basically

accepting of her medical diagnosis and had

resigned herself to the prospect of surgery. She

reported taking anti-in¯ammatories and mild

painkillers occasionally on an `as-needs' basis.

She had undergone numerous treatments for her

pain including acupuncture, physiotherapy and

massage, all without success.

She described her various pains in di�erent

ways, according to how each felt. For example,

she described the shoulder pain as a stabbing

sensation that vibrated all the way down to her

wrist and she pictured this pain as a dagger. She

described the pain in her jaw as a tight feeling,

and imagined it as a black spring that was stuck.

The desensitization and reprocessing involved

instructing her to focus on the pain sensations

and associated emotions and thoughts, whilst

simultaneously attending to the bilateral stimu-

lation. Following EMDR she reported less pain

and feeling as though something had released in

her neck. She got an image of a spray can of

lubricant that could make everything loose, and

practiced thinking of this whilst attending to

several sets of bilateral stimulation. Once she was

able to report a reasonably strong and stable

e�ect, she was instructed to continue practising

this at home. In the following session she

reported the pain relief had continued for several

days, and that when her pain eventually did

return it was not as severe or as disabling as

before the EMDR treatment. She reported she

had been able to wash her hair without assistance

for the ®rst time in over a year, and that she had

also been able to hang out a load of washing

without pain. In the following weeks she

continued to receive EMDR to facilitate further

pain reduction, and reinforce her anti-pain

imagery. By the end of treatment she reported

greatly reduced pain, increased use of her left

EMDR is

thought to

stimulate the

information

processing

resources of the

individual to

enable them cope

with the problem

in the most

adaptive way

possible.

EMDR: a new treatment for trauma and chronic pain 93

arm and feeling con®dent that she could control

her pain in future.

Case 2

A 40-year-old mother of two sought help to cope

with chronic leg pain following an industrial

accident two years earlier in which a pallet of

animal hides fell on her. `Sara' was depressed,

experiencing sleeping di�culties and restricted in

her physical capabilities. She was also su�ering

from posttraumatic stress disorder including

¯ashbacks and nightmares, as a result of the

accident.

I ®rst instructed her to focus on the memory of

the accident and follow my ®ngers. After several

sets, she reported that the memory of the

accident had become `fuzzy' and the distressing

emotions had decreased considerably. I then

asked her to focus on the pain in the same way.

After a few sets, she reported that the pain in her

leg and foot had virtually disappeared.

At the next session, Sara reported that the pain

relief had lasted over 12 hours and that the night

following the session she had been able to have

her best night's sleep in a long time. She also

stated that her post-traumatic anxiety (¯ash-

backs, panic attacks) had been much less. She

continued to work on some images that were still

troubling her, through EMDR, with more

progress made in reducing distressing memories

and emotions from the accident.

We then repeated the EMDR procedure with

her pain. After a few sets Sara again reported a

dramatic reduction in pain and a feeling of

numbness. This time I instructed her to `think of

something' that went with the feeling of relief she

was noticing. She likened it to `a block of ice'. I

instructed her to focus on that whilst attending

to the eye movement. This procedure was

repeated several times following which she

reported the imagery and the relief became

stronger. She was instructed to practice self-use

of the desensitization component of EMDR by

relaxing and thinking of the healing imagery

whilst listening to taped stereo audiotones at

home. After a few weeks of practicing with audio

taped bilateral stimulation, she was able to create

whole pain-free days for herself and sleep

virtually through the night.

These cases demonstrate how EMDR can help

clients learn to manage their pain in a relatively

short time through stimulating relaxation psy-

chologically and linking pain-relieving imagery to

the feelings of relaxation. In both cases EMDR

produced changes in pain perception as well as

positive changes in the clients' coping and self-

perception. Unlike in the case of more traditional

approaches, EMDR can help a client develop

pain-control imagery without the therapist ne-

cessarily having to `teach' them anything. Cogni-

tive interventions are used to interpret changes

rather than facilitate them. Developing pain-

relieving imagery out of the client's own feelings

is also more individual and hence more e�ective.

EMDR is thought to stimulate the informa-

tion processing resources of the individual to

enable them cope with the problem in the most

adaptive way possible. By the same token

EMDR cannot remove a negative emotional

response that is appropriate. For example, if a

person wanted to not feel anxious about giving

an important speech, but they had not done any

preparation, a certain amount of anxiety would

be appropriate. In a case like this, it is unlikely

EMDR could be helpful. Similarly, EMDR

cannot remove pain that is `ecological' such as

pain which is signaling injury.

Although apparently deceptively simple, the

therapeutic process can easily become complex,

depending on the type of problem being treated

and the history and personality of the client.

During EMDR reprocessing, clients experience a

kind of free association as present feelings

connect up with past memories ± sometimes

repressed trauma can emerge unexpectedly. If a

forgotten repressed memory emerges, clients may

unexpectedly experience highly distressing emo-

tions and the therapist must have the skills to

deal with these. For this reason, training in

EMDR so far has been restricted to licensed

mental health professionals such as psychiatrists

and psychologists.

In summary, EMDR is a new treatment which

works to reduce the distressing e�ect associated

with psychological problems such as trauma and

chronic pain. In the treatment of pain the

method can facilitate pain relief, and lead to

improved coping. Knowledge of EMDR is

important for two reasons: 1) As a possible

treatment option; 2) EMDR suggests several

principles for more e�ective treatment of chronic

pain su�erers: psychological pain management

must begin with adequate support; it must also

include procedures to dampen anxiety and

facilitate relaxation; desensitization can reduce

su�ering; cognitive interventions should be

derived from e�ective changes following relaxa-

tion/desensitization; pain imagery which is de-

veloped out of the clients' experience, as opposed

to being provided by the therapist, is more

e�ective. Any psychological intervention for pain

must also address the emotional aspects of pain.

Psychological treatment of pain with EMDR

must also be preceded by assessing the adequacy

of medical treatment. EMDR is unlikely to be

e�ective where pain is inadequately controlled or

intolerable, or where pain is signaling undiag-

nosed pathology.

Further information can be obtained from the

EMDR Institute web site at www.emdr.com or

www.overcomingpain.com

94 ComplementaryTherapies in Nursing &Midwifery

NB: The description of the EMDR procedure

in this article is abbreviated.

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