EMDR Therapy Quarterly

Introduction

McKay et al. (2004) describe how individuals who receive a diagnosis of OCD may present with a diverse range of obsessions and compulsions. However, a common feature of the distressing thoughts reported by individuals with OCD is that they are ego-dystonic and inconsistent with the individual’s actual beliefs about themselves and others (Robbins et al., 2019). Compulsions may be performed overtly (e.g., ordering, cleaning, counting or reassurance seeking) or covertly (thought suppression, mental distraction or avoidance). The function of the compulsions and avoidance rituals is to alleviate anxiety and/or prevent a perceived risk of harm to themselves or others (American Psychological Association, 2013). Further research suggests there are four theme-based dimensions to OCD. These include contamination, responsibility for harm, unacceptable thoughts and symmetry (Abramowitz et al., 2010; McKay et al., 2004). 

Current evidence suggests that CBT incorporating exposure and response prevention (ERP) and/or pharmacological interventions are the most effective treatments for OCD (National Institute for Health and Care Excellence, 2005). However, around 25% of individuals with OCD refuse treatment or fail to benefit (Abramowitz, 2006). Despite much research being undertaken, there is still only a limited understanding of the aetiology and neuropsychology of OCD (Robbins et al., 2019).   

This study was initiated as a consequence of working with clients with OCD in private practice. Many of these clients had previous experience of CBT therapy but had struggled to undertake the ERP activities that are central to treatment. During ERP treatment, the individual is gradually exposed to situations that are designed to provoke their obsessions. As a result, they should become accustomed to experiencing a trigger and resisting their urge to undertake a compulsion (Hezel & Simpson, 2019). However, many clients described their difficulties with affect regulation and their inability to self-soothe when undertaking ERP, which made this process highly challenging and difficult to sustain in the long term.

There appeared to be several common themes in these clients’ narratives, with many reporting being subject to physical and/or verbal abuse during their early years. Gershuny et al. (2003) argue that OCD and PTSD are actually two disorders on the same continuum, with OCD symptoms initiated as a coping strategy undertaken to reduce and avoid trauma related symptoms and memories.   

There is some research to suggest that OCD may be a response that develops as a consequence of adverse events in childhood (e.g., Miller & Brock, 2017). This is compatible with research suggesting that parents who were emotionally abusive or neglectful may have hampered the child’s ability to self-regulate or self-soothe (Mate, 2012; Parnell, 2013; Perry et al., 2018; Schore & Schore, 2007), thus laying the foundations for OCD. 

Shapiro (2001) introduced the concept of large-T and small-t trauma in EMDR. She describes the way that small-t traumatic events such as rejections, humiliations and disappointments in childhood can have lasting adverse effects. While these small-t traumas may not lead to the intrusive imagery that is common in PTSD, these events can still generate emotions, beliefs and physical reactions that lead to unhappiness, anxiety and/or maladaptive behaviours in the present. 

In keeping with Shapiro’s concept of small-t trauma, Parnell (2013) developed an attachment-based modification to the EMDR approach. Parnell proposed that, while EMDR is a powerful resource that allows clients to challenge feelings and thoughts with reduced activation, it is less effective for clients who have developed an insecure attachment style stemming from relational trauma in childhood such as abuse, neglect, abandonment or mistreatment. She suggests that these individuals are more likely to struggle when navigating the intense emotions that arise during EMDR and require a strong bond with their therapist. Parnell describes how the primary difference between EMDR and AF-EMDR is the latter’s focus on the importance of the therapeutic relationship, with an emphasis on attunement and the adaptation of the work to the individual’s needs.   

Parnell describes how individuals whose parents were inconsistent, unavailable or overly intrusive may feel shame that ‘there is something wrong with me’ and emphasises the need for these clients to have tools to calm their anxiety and soothe their self-criticism and shame. Parnell proposes that when clients develop positive self-talk to counter their negative thoughts, it has a calming effect on the right brain hemisphere and new neural pathways may be created. This is compatible with neuropsychological research suggesting that the right brain systems are relevant for attachment, affect regulation and developmental change (Schore & Schore, 2007; Siegel, 2003). Brayne (2024) concurs with Parnell’s view, proposing that the clients’ attachment-informed survival response is adaptive, formed in their early years, and will have implications for their presentation in the here and now. 

In this research, the intent was to use AF-EMDR interventions to help participants with OCD improve their ability to self-soothe. AF-EMDR emphasises the use of bilateral stimulation (BLS) to ‘install’ resources prior to processing, which should help this population self-regulate. It was hoped that this would, in turn, facilitate them in undertaking ERP activities. 

Methods

This article describes treatment with three of the seven individuals who participated in a doctoral research study. The aim was to see whether AF-EMDR was a useful adjunct intervention to CBT for the treatment of OCD. The main criteria for inclusion were: being aged between 18 and 65, meeting the diagnostic criteria for OCD as assessed using the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) measure (with a cut-off of 16), having had symptoms of OCD for at least one year, having had CBT with ERP treatment but still presenting with OCD symptoms and having no previous experience of EMDR therapy. All participants who applied met the criteria, so the first applicants were recruited. Prior to commencing the study, all participants signed an informed consent form, which included consent to the publication of data.

The quantitative component of the study was a single-case experimental design (SCED), which is an approach that endeavours to bridge the gap between scientific research and clinical practice. The SCED has the potential to be useful in the early development phase as it relates the application of the research to each individual patient (Morley, 2018).   

In this study, the dependent variable was the participants’ subjective self-rating of the severity of their OCD, their mood and their ability to undertake ERP tasks. Participants completed subjective daily ratings of the severity of their OCD and their mood for 10 to 19 days prior to assessment (A¹) and continued to do so during the two-week assessment phase (A²). Having established these two baseline phases, each participant acted as their own control. From week three until the end of the study, participants continued with the two daily ratings along with a third rating of their subjective ability to undertake ERP tasks. The independent variable was the introduction of AF-EMDR interventions, with the CBT component (B¹) used for the evaluation of the AF-EMDR phase (B²). Normand (2016) describes how the power of the SCED paradigm comes from the number of repeated measures rather than the number of participants. 

A qualitative template analysis was also undertaken to provide further nuanced insights into participants’ experiences of the research process and the therapeutic interventions. 

Much of the clinical research for this study was undertaken within the context of the COVID-19 pandemic and subsequent lockdowns. As a consequence, all twelve sessions of therapy for each participant were undertaken online (via Zoom).  

Measures

As soon as a participant was accepted onto the study, they were asked to log their subjective rating of the severity of their OCD symptoms each day (1-100) with lower scores suggesting an improvement. At assessment, they also completed the Adverse Childhood Experiences (ACEs) questionnaire (Centers for Disease Control and Prevention, 2014), which helped form a trauma timeline, and the Experiences in Close Relationships-Revised (ECR-R) questionnaire (Fraley et al., 2000) to see whether the participants’ responses to AF-EMDR differed based on their attachment style.From week three, participants also provided their subjective daily rating of their ability to undertake ERP tasks. The Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) (Goodman et al., 1989) was completed at the start and end of treatment in order to ascertain whether there had been any improvement in the severity of the participants’ OCD. The template analysis (TA) interviews were also undertaken at the end of the study.   

Treatment and interventions

Sessions one and two (assessment)

Participants completed the assessment measures detailed above. In collaboration with the therapist, they also compiled an OCD hierarchy with subjective units of distress (SUD) ratings of their potential distress at being exposed to a task (e.g., not washing their hands). They also worked on a longitudinal formulation and a trauma timeline. They then collaboratively created an idiosyncratic formulation of their OCD (Steketee, 1993). 

Sessions three to six (the CBT component)

All participants had at least one session of CBT that included psychoeducation about OCD and ERP. They collaboratively agreed with their therapist on an idiosyncratic, low SUD, ERP exercise to be undertaken each day that week.  

In keeping with the SCED paradigm, John moved on to the AF-EMDR component of treatment after session three, while Sam and Susie continued following the CBT protocol for OCD treatment (Steketee, 1993). Sam moved to the AF-EMDR component in week five and Susie in week six.

Sessions four to twelve (the AF-EMDR component)

In their first AF-EMDR session, participants were given information about AF-EMDR, with OCD conceptualised as a protective behaviour to avoid more difficult feelings. Participants downloaded an EMDR app onto their phone (BSDR Player) for use in subsequent sessions. Participants also generated a safe place. 

In subsequent sessions, they continued to review the ERP tasks undertaken each week and devise another one for the upcoming week. After the first AF-EMDR session, participants were asked to create a resource team comprising of three nurturers, three protectors and a wise figure (real or fictional) that could be used in conjunction with their safe place as a grounding resource.

John and Susie were too agitated to begin processing at the start, and the work initially focused on grounding techniques, which included ‘creating an ideal mother’ (Parnell, 2013) and an adaptation of Knipe’s (2019) ‘loving eyes’ protocol. This was in keeping with Parnell’s emphasis on therapist attunement and the adaptation of the work to the individual’s needs. In subsequent AF-EMDR sessions, it was collaboratively agreed whether to start by processing more overt childhood traumas or taking an OCD behaviour and dropping that back in time. In keeping with Parnell’s AF-EMDR protocol, the focus was on the client’s more right-brain, emotive experience of trauma. The cognitive, more left-brain processes, such as rating the validity of cognition, are omitted from this process (Brayne, 2023). For example, in the case of Susie, who is described below, she was asked to give an example of feeling as if she was ‘too much’ and the emotions and physical sensations that accompanied this obsession. She was then asked to drop these sensations back in time without censoring anything that came up. This commonly leads the client back to a time when they were younger and had experienced some form of discomfort (often being shamed or very scared). 

Case illustrations

Prior to diagnosis, John and Sam had both believed that they were flawed individuals who may commit terrible acts if they did not remain vigilant regarding their behaviours. They both expressed a huge sense of relief when they were finally diagnosed with paedophile OCD (American Psychiatric Association, 2013). This did little, however, to alleviate their obsessive symptoms. Susie’s OCD emerged in her late teens when she had paedophile obsessive thoughts and other ‘inappropriate’ sexually intrusive thoughts. They all described the failure of health professionals to identify their symptoms as OCD, with some GPs and therapists appearing to only have awareness of the common OCD subtypes (e.g., washing or checking). 

John

John is a 36-year-old white British male who works in the financial sector. He quit his job three months prior to participating in the study, as his OCD was proving too debilitating for him to work. His primary obsession was that he was a paedophile, which evolved from a fear in his teenage years that he may be homosexual. Being gay would have been completely taboo in John’s family, whom he described as “racist, homophobic and aggressive.”  

John scored 5 on the ACE questionnaire, which was used to develop a trauma timeline. John’s father went to jail briefly after an altercation in a restaurant that ended in a physical fight. While his father was never formally diagnosed, John’s two previous therapists had both suggested that his father may have had borderline personality disorder. John’s mother would ignore these confrontations, which John now believes were an attempt to contain his father’s aggression. However, she never made reference to John’s father’s behaviour when they were alone together. John described a childhood where he felt very unloved by both parents. At the start of the study, John had been estranged from his parents for 10 years.

John described his OCD potentially developing as a coping strategy of ‘magical thinking’ in his childhood that was implemented to avoid sitting with distressing emotions: “I’d try and control my own thoughts and feelings, and then try and do this magical thing, like, where if I, you know, if I make this shot then I’m not gay. If I can throw this up in the air and catch it in my mouth, I’m not gay, loads of things like that.”

But as his OCD took hold, John described his exhaustion and times when he had experienced total overwhelm. His underlying beliefs appeared to be that he was ‘bad, mad or dangerous.’ At one time he related: “I was watching a film called Shutter Island, and the woman at the end says something like before she kills her own children. She said, “It feels like there’s something crawling across my brain.” And I just freaked out. I became so worried that was me and that I could do those things.” 

John’s previous treatment included two years of integrative therapy, where the focus was on his anxiety. He was diagnosed with OCD when he was 29, and he had been working with his private therapist for the past seven years implementing CBT with ERP exercises that he described as “hard-core” such as watching documentaries about real-life paedophile rings, which he found very distressing. When he commenced the study, he was highly anxious and described how he was undertaking ERP with little success for up to four hours each day. John described his previous experience of the rigid nature of ERP treatment as problematic, as he was not given any insights into the reasons he had these obsessive thoughts: “There was so much of the ERP that was just done on blind faith and “no, don’t…don’t try and understand it, whatever, just absorb it, accept it, let it be and carry on.”

Engagement with the study

While John was receptive to all the interventions in the AF-EMDR phase, he appeared to find the grounding exercises (safe place, resource team and ideal mother) at least as beneficial as the EMDR trauma processing.

Outcome

John’s subjective daily rating of the severity of his OCD reduced from 60 at baseline to 30 at the end of the 12-week intervention, and this corresponded with a subjective increase in his ability to undertake ERP tasks throughout the course of the study. These positive outcomes could not be solely attributed to the AF-EMDR, as John also showed improvements during the CBT phases. There was, however, a clear improvement in John’s condition. This is compatible with his outcome on the Y-BOCS measures (see Table 1).

Susie

Susie is a 30-year-old white British female who works in the healthcare industry. She had been off work for the four months prior to the study as she was finding her OCD overwhelming. Susie’s OCD emerged in her late teens. She believed: “I am a malicious person, and I cannot be trusted to behave responsibly.”

Prior to participating in this study, Susie had undertaken psychodynamic counselling and subsequently had 16 sessions of CBT to treat her OCD. Susie was also taking 60mg of Fluoxetine. She told me: “A lot of the time, I kind of felt like I was doing it [previous CBT/ERP] wrong, you know. And I think that impacted my ability to fully engage with it because I was constantly criticising myself… and I… felt worse in the end actually.”

Susie scored 6 on the ACE questionnaire. Susie said that her mother was depressed, her father was an alcoholic and they were both made redundant when she was very young. When her father was drunk, he would be verbally abusive to Susie and her mother. She described her childhood as “erratic.” Her parents were both full of love for their children, but “they did not have the capacity to be parents.” Her father had been sexually abused when he was younger, and when Susie was around 10, her parents were arguing and her father was shouting about his sexual abuse. Susie said his description was so graphic she could almost see it happening. 

Between the ages of 9 and 11, Susie’s father was arrested on several occasions and told to stay away from the family home. Her mother would tell Susie about the physical abuse she experienced at the hands of her father. Susie felt it was her job to “hold it together” and protect her younger brothers.  She described becoming hypervigilant when her parents were fighting in order to try to understand what the problem was.  

Engagement with the study

Susie commenced AF-EMDR in week six of the study. Relatively early in this phase, she had an emotive, visceral response to a touchstone memory where she was at nursery surrounded by a group of children. Her father came to collect her and described her loudly to the teacher as having “the face of an angel, but being such a bossy boots,” which had made her feel embarrassed, hurt and confused.  Creating a resource team appeared to have been a helpful grounding resource for Susie: “Thinking about my resource team and deciding on those individual people and whatever, actually was just a really comforting exercise that I think set me up to kind of engage in the work quite well.”

Susie was surprised at the somatic experience of AF-EMDR: “There was like a kind of very sort of direct parallel with the kind of ideas I’ve sort of embodied about myself from being really, really small to the present day. [including ideas of] I am just too bossy, too dominant, just too much and my OCD kind of was trying to sort of constantly watch out for the possibility of me becoming an intrusion.”

Outcome

Susie’s subjective daily rating of the severity of her OCD decreased from 65 at baseline to 31 at the end of the 12-week intervention and matched the increase in her ability to undertake ERP tasks throughout the course of the study. Again, these positive outcomes were compatible with the scores on Susie’s Y-BOCS measure (see Table 1).

Sam

Sam is a 32-year-old white British male who works in the healthcare sector. He described how he had bulimia and a sex addiction in his teenage years. When he was around 25 years old, he developed paedophile OCD, and for the following four years, he also had harm OCD (suicidal images of jumping off a building and a fear of knives). Sam also felt the need to confess, so he would tell his girlfriend when he was having sexual thoughts about her mother. For the past year, Sam has had OCD around cleanliness and cannot get into bed if it/he is dirty. At the start of the study, he had already benefitted from extensive therapy and was coping reasonably well with his OCD. 

Prior to participating in this study Sam had undertaken over 20 sessions of integrative counselling and 30 sessions of CBT, which he reported as finding helpful at the time. 

Sam scored 8 on the ACE questionnaire. He described how his mother was an alcoholic from the time of his birth and was very abusive with ‘push-pull’ emotions. “Just go and live with your fucking father,” and then she would cuddle him. When he was 6 years old, his father was beaten up very badly in front of Sam, his mother and his younger sister. There was a pool of blood, and Sam thought his father was dead. When he was 7 years old, Sam was sent to boarding school, where he was bullied, and he would cry himself to sleep at night. His parents divorced when he was eight, and when Sam was 12, his stepfather moved in. Sam described this man as physically and emotionally abusive and reported that his mother would always side with him rather than protect Sam or his sister. 

Engagement with the study

Sam commenced AF-EMDR in week five of the study, and he was receptive to the AF-EMDR conceptualisation of OCD as an adaptive process that helps individuals cope with adversity in their childhood. This contrasted with some CBT literature where OCD is described as the bully that has to be defeated. Sam said: “Thinking about the OCD in terms of a very powerful friend rather than a very powerful enemy… It’s actually quite sweet, in a way, to understand that this is that little child’s mechanism of protection.”

Sam showed a strong emotional and somatic affect when we processed his experience of isolation and confusion at boarding school and his deep sense of sadness. In a subsequent session, we processed his anger about his stepfather’s aggression. He said “It blew my mind actually how quickly you were able to get in touch with the raw feeling for me, like what was there that had maybe been unprocessed or untouched… rather than trying to articulate something that was a visualisation or a thought or a memory… it was genuinely a deep source of loneliness. I feel like I couldn’t have contacted that without the physical part.”

From a clinical perspective, it was apparent that he had processed some powerful touchstone memories, and this was confirmed by Sam’s report of diminished physical sensations in the aftermath of the AF-EMDR.

Whenever I’d think about that imagery, it was a full-body reaction, and I felt physically like I wanted to rip my skin off, and now when I think about it, it’s like a butterfly fluttering in my stomach and I think, “Ooh that was quite bad.”

Outcome

Sam showed a robust improvement during the AF-EMDR phase of the study, with his subjective daily rating of the severity of OCD decreasing from 55 at baseline to less than 20 after the 12-week intervention, suggesting that AF-EMDR was a useful adjunctive treatment. Sam went on holiday during the intervention and decided not to undertake ERP activities during that time (he still attended the session online). There was a marked improvement in Sam’s ability to undertake ERP activities in the AF-EMDR phase compared with the CBT phase. There was a major positive shift around day sixty, which correlates with the time he processed his isolation and humiliation at boarding school.   

As with the other two clients, these findings were further endorsed by Sam’s final outcome ratings (see Table 1 below).

		Y-BOCS (assessment)			Y-BOCS (end of 12 week treatment)
	Total	Obsessions	Compulsions	Total	Obsessions	Compulsions
John	18	10	8	12	6*	6
Susie	19	11	8	11	6*	5
Sam	12	8	4	6	3*	3

Discussion

This study explored the potential therapeutic benefits of using AF-EMDR interventions alongside a CBT/ERP protocol to improve treatment outcomes for individuals with treatment-resistant OCD. 

At assessment, John, Susie and Sam all reported higher rates of ACE than the norm and they all described frequent parental verbal abuse when they were young. This is compatible with research by Miller & Brock (2017), who propose that emotional abuse, neglect, violence and sexual abuse are all linked to OCD symptom severity. It also concurs with research by Mancini and Gangemi (2004), who found that individuals with OCD recalled being the target of hostile facial expressions more frequently than controls. While the ECR-R questionnaires (Fraley et al., 2000) suggested that all three presented with anxious and/or avoidant attachment styles, there did not appear to be a clear association between attachment style and treatment outcome.

John and Sam presented with ‘unacceptable thoughts,’ and Susie with ‘responsibility for harm’ OCD. This could feasibly be why they met the treatment-resistant criteria for this study. Research does suggest that unacceptable thoughts and fear of unfavourable judgement are more difficult to ameliorate with CBT/ERP (Mpavaenda, 2016).  

Did AF-EMDR interventions reduce OCD symptoms?

Susie and Sam both confirmed the hypotheses that AF-EMDR interventions would facilitate their ability to down-regulate their physiological arousal when facing stress and reduce their perception of the severity of their OCD symptoms. They also endorsed the hypothesis that AF-EMDR interventions would facilitate them in undertaking ERP tasks. While John also showed an improvement in the AF-EMDR phase, this could not be directly attributed to the AF-EMDR interventions as he also made progress during the CBT phase.

The qualitative interviews suggested that it was the AF-EMDR process overall, including the grounding exercises, that participants found beneficial. They were all receptive to the AF-EMDR conceptualisation of OCD, with the emphasis on childhood experiences and relationships. 

There was a high rate of engagement, with all participants finding the AF-EMDR treatment beneficial and asking to continue with treatment at the end of the study. This is interesting when considered in relation to the relatively high attrition rate for CBT treatment alone (Abramowitz, 2010).

 
[If I couldn’t see you] I would ask you: Who do you know that can work on trauma in the same way as you have, incorporating EMDR, ERP and sort of the psychodynamic work that we’ve done? Because I can’t just go down the route of just ERP, it doesn’t work for me.

John

I went from my rigid previous therapy to actually your OCD is complicated, and it’s linked in and knotted up with other stuff, and that other stuff is valid, and it’s okay to kind of get that out as well and think about it and feel it…that was a really, really valuable thing for me that, you know, that I took away from it.
 

Susie

Sam and Susie had both undertaken numerous therapeutic interventions over the past few years and described their surprise at the impact of this study:

From start to finish, this has been nothing but eye-opening for me… My management of my OCD was pretty good when we started working together, and it’s kind of, almost gone, which is a very, very strange feeling for someone that’s lived with crazy thoughts and horrible feelings attached to them for all these years… I thought this would be helpful, I didn’t expect this to be life changing.

Sam

To be able to say that it’s not the biggest pre… preoccupier in my life is quite an interesting thing. Actually, I hadn’t really said that before.

Susie

Sam gave his perspective on the relevance of both interventions in the study:

If I was to do it like a pie-chart, I’d say that 20% of the changes I’ve experienced are due to the ERP, the CBT and the outside EMDR parts. I’d say 80% was the EMDR, in particular the somatic stuff.

Sam

Limitations of this study

While all seven participants in the study appeared to benefit from treatment, the specific value of the AF-EMDR interventions was clear for these three participants. Further detail regarding the progress of the other participants can be found in Blake (2023). Two of the other participants continued in therapeutic work after the study concluded, and they also showed evidence of reliable change in their Y-BOCS scores over the next three months. It is possible that key childhood memories were processed during that additional time.

This research was undertaken within the context of the COVID-19 pandemic and the easing of lockdown restrictions. While we endeavoured to control for any identifiable confounding variables, some were less expected, such as the increase in participants’ anxiety when the lockdown eased. The lockdown restrictions also disrupted the ERP hierarchy for some participants, for example, when they were suddenly exposed to the triggers of going back into the office. 

The lack of fidelity checks in this study is acknowledged. It is common in SCED research for a Client Change Interview to be conducted by a second researcher in the follow-up to treatment (Elliott & Rodgers, 2008). It was agreed, however, that it would have been unethical to bring in a third party to ask participants to share their (often very personal) experiences of therapy and the difficult content of their obsessive thoughts, particularly for those participants with paedophile OCD. 

Avenues for further research and implications for clinical practice

This was a small study, using a novel approach, undertaken within the context of the COVID-19 pandemic. For this reason, suggestions regarding further research and the implications for clinical practice are only made tentatively. 

It would be interesting to conduct research into the impact of AF-EMDR with individuals grouped into the four themed-based dimensions of OCD proposed by Abramowitz et al. (2010).   

The small sample in this study was predominately white British, which does limit the potential to generalise findings across cultures that have the potential to express their OCD symptoms differently.

That said, both the quantitative and qualitative analysis and the low attrition rate did suggest that AF-EMDR has good potential for further research and may be effective as a stand-alone intervention or as a helpful augmentation to CBT for the treatment of OCD for some individuals.

Dr Joyce Blake is an accredited CBT psychotherapist and chartered psychologist who works in private practice. Positionality statement: "I am a middle-aged, straight, white-British, cisgender female. I come from a working-class background and I was the first person in my family to attend university. I have no lived-experience of OCD. Prior to training as a psychologist I worked as a journalist for many years and travelled extensively, which I believe this has been influential on both my worldview and my research. In keeping with my pragmatic approach, I acknowledge that there are many different ways of interpreting the world and I believe that research which combines a range of approaches has potential to provide a broader understanding of the phenomenon being studied."