EMDR Therapy Quarterly

In this evidence-based treatment manual, Mark Grant describes how to apply EMDR to the treatment of chronic pain and medically unexplained symptoms (MUS). Grant has been at the forefront of researching and developing this application of EMDR since the early days of the method. 

The manual begins by describing a trauma-informed model of pain, including physical and sexual abuse and attachment problems, and includes a review of the evolution of pain theories. Descartes’ famous dictum, “I think therefore I am,” leads to the question: is pain ‘mental’ or ‘physical’? It has stimulated periodic swings between mind and body-based theories and has trapped the field in a polarising conflict ever since. Grant reminds us that Janet and others recognised the connection between medically unexplained pain and trauma over a hundred years ago, but this was overlooked in the 20th century in favour of psychoanalytic and later behavioural models. The latter in particular fails to account for traumatic phenomena such as dissociation, which underlies so much medically unexplained pain. Grant integrates this information with polyvagal theory in terms of differentiating the psychophysiological effects of acute versus chronic trauma.

Associated with this, Grant reviews recent discoveries regarding the effects of trauma on the brain and the body, including an overview of brain structures and functioning associated with trauma and pain. Grant uses the vertical (‘top-down’ versus ‘bottom-up’) and horizontal divisions (left versus right) of the brain as a heuristic to provide a convincing rational for EMDR as a treatment for pain /MUS. For example, he proposes that new sensory information entering the brain via the brainstem and affective memory processing by the right hemisphere aligns with memory-based theories regarding how EMDR works. He also suggests this as a reason for the limited efficacy of traditional methods, such as CBT, in that they appeal to weak mechanisms of affective change.

Grant also explains the three broad categories of pain and the differences between them:

• Nociceptive pain (caused by tissue damage)
• Neuropathic pain (a combination of nerve and tissue damage)
• Functional pain (not explicable by organic pathology but may occur in addition to organic pathology).

Grant is thus offering a very basic introduction to how pain is categorised, which is useful for psychologists who may have limited medical knowledge. He also makes the point that while it’s generally difficult to ascertain precisely how much pain is of organic origin versus psychological origin, it can be assumed that there will be a psychological component to any pain that has persisted beyond normal healing timeframes.  

In Part 2 of the book, Grant’s EMDR protocol for the treatment of chronic pain/MUS is outlined. The protocol addresses the unique characteristics of chronic pain/MUS, including health issues, safety and stabilisation issues associated with inadequately managed pain. Different EMDR target options, for example, present pain/past trauma and resourcing/future template for patients with persistent pain, among others, are also included. The use of audio bilateral stimulation (BLS) when targeting present pain is included, along with various other modifications. Grant feels that audio BLS is more visceral and more adaptable for self-use for patients with persistent pain. He also notes that most sufferers of chronic pain/MUS are likely undiagnosed CPTSD sufferers, meaning that EMDR often has to incorporate extensive resourcing, titrated exposure and use of interweaves, as well as the incorporation of adjunctive strategies such as hypnosis, ego-state work and somatic therapies.

There is a chapter on hypnosis and EMDR, including many scripts that can be utilised regardless of whether you are trained in hypnosis. There is an emphasis on the importance of hypnosis as an adjunctive strategy because of its role in dissociation, which is ubiquitous in chronic pain/MUS. I found Grant’s normalisation of trance phenomena (dissociation) helpful in de-mystifying hypnosis and recognising how prevalent trance phenomena are in everyday trauma work.

Part 3 consists of a wealth of treatment resources for both therapist and client. For therapists, there are assessment and treatment planning tools. Also included are pain control scripts such as the ‘containing the pain with pendulation’ script, which I can highly recommend following application to my own clients. I used this with a low back pain sufferer recently, instructing him to focus on the pain in terms of its size, shape and intensity, then to focus on an area of his body that felt normal and free of discomfort, and how that felt, then to notice the pain again and so on. After four or five such ‘pendulations,’ I instructed him to “relax, take a deep breath and notice the pain again now.” He reported, with some surprise, that the pain now felt smaller and less bothersome than it had prior to the pendulation. I asked him what he felt he had learned and installed some positive beliefs about his ability to manage his pain. For clients, there are also various handouts and worksheets to help educate them on the nature of chronic pain, self-care and sleep strategies. I particularly like his “Pain Management Recipe,” a summary of all the possible necessary elements for resolving pain, with the added element of time, which again I have used many times with my own clients.

Overall, I found this to be an easy-to-follow yet highly informative manual that walks us through an innovative approach to treating chronic pain with a clearly defined but flexible EMDR protocol. Grant never loses sight of the fact that therapy should be an intersubjective, client-centred experience.

Despite Grant’s own research on this subject and numerous other randomised controlled trials, the quality and scope fall short of what is needed to qualify this application of EMDR as a gold standard or even sufficient to warrant a Cochrane review. Better and larger trials are needed. For some, this may be an impediment to embracing this application of EMDR, while for others, pragmatism will triumph. In the end, what’s most important is whatever works best for our patients. This is particularly true for a problem estimated to affect 1 in 5 people worldwide and for which effective treatments have proven elusive.

The manual is designed to accompany Grant’s EMDR training courses and is included in the online version (www.overcomingpain.com/workshops) or available for separate purchase from the usual online outlets.

Jane Eastwood is an EMDR Europe-accredited practitioner, specialising in chronic pain, based in Cheshire.