Transcript EMDR-PAIN-PROTOCOL

EMDR pain protocol
Mark Grant. MA, MAPs
Goals of treatment
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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
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
1 History
Medical diagnosis
2. Preparation
Safety, Medical issues
AIP model for pain
3 Assessment
Target: Traumatic memory, present pain, effects of pain
4. Desensitization
Continuous auditory Bls
“Incomplete processing”
Self-use of DAS/Bls
Dealing with blockages
‘
Mark Grant. MA, MAPs
Elements of treatment
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
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
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Medical diagnosis
Trauma?
Family background
Cormobid problems
Narrative (how, when, where, what)
Medications?
Suitability for EMDR
Target sequencing
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?
Mark Grant. MA, MAPs
Mark Grant. MA, MAPs
Trauma History
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Sexual abuse
Accident (auto, work, other)
Injury
Diagnosis of life-threatening illness
Surgery
Combat trauma
Complicated bereavement
Abortion
Assault
Torture
Rape
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
Mark Grant. MA, MAPs
Developmental trauma.
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Abuse, neglect, instability
Early childhood illness
Family breakup
Family dynamics
Intergeneration physical and mental health
problems
Mark Grant. MA, MAPs
Effects of developmental trauma.
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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.
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Depression
Anxiety
Personality disorder
Insomnia
Substance abuse
Other health/medical problems
Life circumstances
Adjustment problems
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:
Event
NC
Car accident
I can’t cope
Having to live with abusive exwife while recovering from
injuries
Needing breathing apparatus
Failed marriage
PRESENT
STRESS:
Freeway phobia
Mark Grant MA
I’m trapped
I’m helpless
I’m a failure
I’m out of control
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.
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Loss of;
control
Privacy
Freedom/choices (feels trapped needs the benefits
and treatment but)
Health/physical integrity
Future
Safety
Mark Grant. MA, MAPs
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
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
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– injury/illness
– Trauma
– Family problems, Neglect
– Comorbid problems (anxiety, depression)
– Current stressors
– Personality factors
– Resources
Mark Grant. MA, MAPs
The Pain Pyramid.
Pain
Stress, trauma
Illness, injury,disability
Abuse, neglect, abandonment,
deprivation, genetic factors
Mark Grant. MA, MAPs
Assessing personality
Ego Strength
Defence
Mechanisms
Borderline
Neuroticism
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
Mark Grant. MA, MAPs
Defence mechanisms.
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Denial
‘Primitive’
Dissociation
Projection
Somatization
Masochism
Repression
Sublimation (Hyperactivity - manic defence)
Intellectualization
Humour
‘Sophisticated’
Mark Grant. MA, MAPs
Personality disorders and pain.
Avoidant
Borderline
Histrionic
Dependant
Control issues *
Trust and safety issues *
Hypervigilance *
Affect regulation problems *
Propensity to dissociate *
Fear of abandonment
Lack of support *
Identity issues *
High emotionality *
Attention-seeking behavior
Submissive *
Needing to cared for by others
Fear of separation
Mark Grant. MA, MAPs
Trauma related symptoms
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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
“what?”
Inflexible
Narrow focus attention
Prefers known
Emotionally - Anger
Self= act of will
Denotative language
Competitive , exploitative
Sequential processing
Decontextualized world
RH
“How?”
Flexible
open, sustained attention
Likes novelty - Never fully known
Emotionally - Depression
Self in relation to others
metaphors, symbols
Empathic
Parallel processing
“Lived world”
Acknowledgement: Ian McGilchrist (2009)
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
• Traumatic 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)
Mark Grant. MA, MAPs
Pain + injury
Pain
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Effects of pain:
on physical functioning
(‘work, love and play’)
sleep
mood
relationships
coping
identity
Mark Grant. MA, MAPs
Mark Grant. MA, MAPs
My 5 “secret” assessment criteria
1. What is client’s affect range/capacity
2. What is client’s medical diagnosis? (if
applicable)
3. How much is person able to distance
themselves consciously from their problem?
4. Personality (strong, stable?)
5. Life circumstances (stable?)
Mark Grant. MA, MAPs
Pain Tests.
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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)
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
Mark Grant. MA, MAPs
Transference
" 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).
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)
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’
Mark Grant. MA, MAPs
Uses of Transference
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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)
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
Mark Grant. MA, MAPs
Safety.
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Adequate control over pain/affect
Freedom from threat
Secure living conditions
Psychological safety (safe place)
Access to support
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…
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.”
Mark Grant. MA, MAPs
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)
5. What present physical discomfort is the client
seeking relief from?
Mark Grant. MA
- Grant, (1998)
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
Mark Grant. MA, MAPs
Creating a pain target
1. Traumatic Pain:
- Image + pain
2. Medical pain
- Pain + image
3. Symptom-related memory
- pain-related traumatic experiences
(de-Roos & Veenstra)
Plus; NC, PC, SUD’s etc
Mark Grant. MA, MAPs
Creating a pain target
Trauma
or;
Mark Grant. MA, MAPs
Pain
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?”
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?
Mark Grant. MA, MAPs
Trauma ‘Target’
Image
(based on memory)
Negative
Cognition
Bodily sensations
Emotion & SUD
PC & VoC
Mark Grant
Pain ‘Target’
Bodily
sensations
Image
Emotion & SUD
(based on present feelings)
Negative
PC & VoC
Cognition
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’
Mark Grant. MA, MAPs
Negative cognitions (effects of pain).
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‘I’m worthless/useless’
‘I’m unloveable
‘I deserve to suffer’
‘I’m a burden’
I’m a failure
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
Heart palpitations
NC: ‘I’m gonna die’
Leg pain
PC: I survived
(2/7)
“Terror” 9/10
Mark Grant
Injured worker (present pain)
Burning
sensation 3/10
“A Red ball”
Sad angry (5/10)
PC: I’ve won (2/7)
Mark Grant
NC: I’m defeated
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
1. Is the client mindfully present?
2. Is the client experiencing affect?
3. Is the client able to adopt detached observer
stance (distance)
4. 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.”
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
1. 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?”
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
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
Mark Grant. MA, MAPs
Target within target
Mark Grant. MA, MAPs
Blockages.
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“Nothing” or “no change” responses
Intellectualization
Increased pain
Unconscious fears
Medication
Dissociation
Other psychopathology
Strong Left Hemisphere
Dominance
Mark Grant. MA, MAPs
“Nothing” or “No change”
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“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)
Mark Grant. MA, MAPs
Pain increases
If pain increases;
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stop
check with client, review diagnosis
continue or Change treatment modality
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?”
Mark Grant. MA, MAPs
Dissociation.
I.
II.
III.
IV.
V.
Use grounding techniques to bring client back into
present.
Teach client how to self-soothe instead of selfinjure/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
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Dissociative Identity Disorder
Bipolar Disorder
Schizophrenia
Autism
Mark Grant. MA, MAPs
Strong Left hemisphere dominance
Mark Grant. MA, MAPs
Hemispheric Dominance Inventory
Study skills page,
Middle Tennessee State University
http://frank.mtsu.edu/~studskl/hd/hemispheric
_dominance.html
Mark Grant. MA, MAPs
Stage 5. Installation
1 History
2. Preparation
3 Assessment
4. Desensitization
5 Installation
6. Body Scan
7. Closure
8. Re-evaluation
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
Resource installation
1. Focus on the image of the resource and the positive
emotions and sensations that accompany that
image (top-down)
2. Focus on strengthening the positive sensations that
clients have when thinking about a friendship, safe
place, etc. (Shapiro, 1995, Leeds, Kiessling 2005)
3. 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
4. Desensitization
5 Installation
6. Body Scan
7. Closure
8. Re-evaluation
Mark Grant. MA, MAPs
Closure.
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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
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
1. Image (of a resource) + positive emotions and
sensations that accompany that image (‘top-down’)
2. Strengthening positive sensations that clients have
when thinking about a friendship, safe place, etc.
3. 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;
1. Not set up right (problem with ‘target’)
2. Problem with clients ability to process sensory
input
3. You are dealing with pure pain (nociception)
Mark Grant MA MAPS
Somatic Resourcing Steps
1. Help clients identify and label positive
changes in sensation following DAS/Bls
2. Utilize affective changes following DAS/Bls to
create resource/antidote imagery for coping
with future pain
3. Install and reinforce clients ability to utilize
resources/antidote imagery
Mark Grant MA MAPS
Accessing questions (resources)
Can you describe that
feeling?
What does that feeling
remind you of?
Whats there now
where the pain
was before?
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)
Mark Grant MA MAPS
Accessing words
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“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
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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
Mark Grant MA
Self-use of DAS/Bls
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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
Mark Grant. MA, MAPs