Are you sure about using EMDR with pain? Exploring the latest evidence (March 2022)
This is an important question for EMDR therapists because so many people who have experienced trauma develop chronic pain symptoms. Then, many therapists, EMDR or others, don’t feel confident in dealing with pain. Interestingly, research tells us that when clients believe that their therapist is confident, pain relief is more marked than when they think the therapist is hesitant or unsure. Given this information, how can we become more confident? We are hoping that this article will help you gain greater confidence by explaining latest thinking on pain, how it works and why EMDR is a helpful intervention in alleviating it.
How a sceptic became a believer
On July 13, 2021, John Nash wrote an article about Dr Monty Lyman in The Times Newspaper entitled ‘Chronic pain – the doctor who says it’s in the brain’.
Nash recounted Lyman’s deep skepticism about the mind’s ability to cure the body until he tried hypnotherapy in an attempt to alleviate the chronic bouts of irritable bowel syndrome (IBS) that had plagued him all his life. As a medical doctor, Lyman had had been indoctrinated in the medical tradition of assuming that physical ailments have physical causes. He had tried hypnotherapy out of a sense of desperation and some degree of curiosity. To his astonishment, hypnotherapy has cured his IBS completely. From this experience, Lyman has gone on to question whether modern medicine has got it wrong about a problem that afflicts one in three Britons - that of chronic pain. He noted that western medicine doesn’t really talk about pain and certainly doesn’t understand it.
Startling discoveries
As a result of his hypnotherapy experience, Lyman has gone on to look into research about pain. He has discovered that rather than being just physical or mental, chronic pain results from complex interactions between body and mind. In his brilliant book entitled The Painful Truth: The new science of why we hurt and how we can heal, he explores the idea of an interactive mind-body system.
Some of his discoveries are startling, and helpful in understanding the role that psychological therapies can play in the relief of chronic pain. We draw on his writing in the piece below.
Does pain directly relate to injury?
Astonishingly, Lyman writes that injury is neither necessary nor sufficient for pain to be felt. This explains why the degree of pain experienced is not directly proportional to the extent of an injury. It also helps to explain why pain can persist long after tissue injury has healed. In fact, there are no pain signals or a simple one-way pain pathway travelling from the damaged tissue to the brain. Instead there are nociceptors or danger receptors and nociceptive signals and pathways. Together, the nociceptors and the nociceptor pathways convey messages of danger or damage in the tissue to the brain. In other words, pain is not created in the damaged tissue and it doesn’t travel up the nerves to the brain.
Instead, there is a complex network of intermediary neurons that can either let nociceptive signals through or block them. For instance, a non-painful nerve input such as touch could activate inhibitory neurons and stop danger signals from travelling up the spinal cord to the brain, thus closing the gate to nociceptive signals. Equally, if nociceptive signals pass through to the brain, pain can be experienced as acute. In other words, the degree of injury doesn’t necessarily equal the level of pain. Danger signals can be turned up or turned down.
How does pain work?
Lyman goes on to make some observations that are fundamental to this understanding of pain.
The first is that MRI scans show there is no single pain center in the brain. When someone experiences pain, different areas of the brain ‘light up’ representing all aspects of what it means to be human: the sensory, the emotional such as anxiety and stress, the cognitive including our thought, memories, beliefs and, importantly, our expectations.
Most fundament to this new understanding of pain is that the feeling of pain is not just ‘detected’ by the brain, nor is it created by tissue damage. The pain feeling is made in the brain. It follows a decision made by the brain – mainly outside our conscious control – to tell our conscious mind that we are in danger. In other words, pain is like an opinion on the body’s state of health rather than a mere reflective response to injury. Moreover, this ‘opinion’ is clearly going to be influenced by other, non-injury-related factors. Prior experience of pain, for instance may lead the body to become hyper-defensive. Similarly, the context in which pain is experienced such as family and genetic differences will influence expectations and the brain’s ‘opinion’ on the level of danger. Then damage to different parts of the brain such as the amygdala, insula and anterior cingulate may cause some people to feel pain without any emotional distress.
Moreover, whether or not the body is actually in danger or has actually been damaged is another matter altogether. For example, a trigger that brings up a memory of domestic violence may unleash feelings of danger and physical and emotional damage when none actually exists in the present.
Pain protects us
Counter-intuitive as it may seem, the conclusion from these discoveries is that pain is a protector, alerting us to danger and damage. It is both a sensory and an emotional experience. One part of the brain is crucial in unifying these different types of experience - the anterior cingulate cortex (ACC), which is activated not only by physical pain but also when we feel hurt by rejection.
This explains why:
Anxiety and fear worsen pain. They increase the sense of danger, damage or threat, which increases the brain’s need to protect the body i.e. to turn up the pain. Similarly, external threat coupled with a loss of control and helplessness worsen pain, as does low mood.
Chronic negative emotions and feelings – especially anxiety and stress - can facilitate the transition from short-term pain to long-term persistent pain in a process called Central Sensitization, when the brain becomes ‘re-wired’ to expect pain and suffering even when the initial injury has healed. In other words, pain has ceased to be a symptom and has become the disease. Persistent pain is a case of neuroplasticity – re-wiring - gone wrong and our brain has become hypersensitive. Examples of conditions thought to represent this include fibromyalgia, phantom limb pain and referred pain when we can be hurt in one part of our body but feel the pain in some other area.
There is also a strong link between adverse events in early life and chronic pain throughout late life. The underlying changes in the brain caused by trauma are also linked to pain.
What does this means for the treatment of pain?
The brain’s decision to hold the opinion that the body is in danger or risk of damage can be powerfully influenced by several therapeutic factors and interventions.
Attention and distraction
Almost all of our pain experiences are affected by attention and distraction. Even the most devastating injuries can feel painless in the heat of battle. Conversely, if our attention is focused on a potentially harmful or negative stimulus we feel more pain. Diversion is a powerful pain reliever, such as a memory task during a painful procedure. Similarly, the use of imagery and suggesting pleasant changes to painful images can help to reduce pain so that the perspective is changed from participant to observer of pain. These factors explain why hypnotherapy and HypnoVR can be so effective by using attention, distraction and imagination to change painful experiences.
Expectation and hope
Expectation and hope are key factors in pain relief. The brain is a predictive machine operating at incredible speed, mostly at an unconscious level, enabling us to see what it expects us to see, hear, feel, taste and smell. The mere expectation of pain relief is enough for the pain to release its own opioids i.e. a non-addictive morphine. The more dramatic the intervention the more meaning the patient gives to the treatment. Similarly, and the better rapport between patient and treatment giver, the higher the expectation of pain relief and the greater the actual pain relief. When a therapist gives a clear explanation of the process before treatment it can make a big difference, both positively and negatively. The latter comes about if negative expectations are triggered by comments such as, ‘How is your painful foot today?
Trauma and the brain
Trauma changes the brain and any treatment for pain that ignores this merely scratches the surface. Persistent pain is often worsened, and sometimes caused by post-traumatic experiences. Lyman’s book (p99) cites the use of EMDR to address underlying trauma in a client suffering from excruciating, long-term, whole-body pain. It was almost completely eliminated by the use of EMDR to address the underlying trauma.
The plasticity of our brains means that the brain is changed by experiences. Neurons that fire together, wire together. We can therefore strengthen and weaken brain circuits by the amount we use them. The more we activate them, the stronger the response to the same stimulus becomes. This explains why people with adverse childhoods are so sensitive to hyper-arousal and why people who have experienced pain can become hyper-sensitive to reoccurrence.
This is not to imply that addressing pain is ‘mind over matter’ or that pain is all in the mind! It’s more a recognition that mood, emotion and psychological outlook have an enormous influence on pain.
EMDR and Pain reduction
A systematic review of the literature linking EMDR to the treatment of chronic pain conducted by Tesarz et al in 2014, revealed a remarkable paucity of literature to review. All studies that used EMDR with chronic pain were eligible for inclusion in the review. This meant that the targets agreed by clients and therapists for EMDR reprocessing were disturbing pain-related or traumatic memories, current pain perceptions or future anticipated painful or stressful situations. The review noted that either the standard EMDR protocol or a pain-specific adaptation of the protocol was used in the literature they reviewed. During processing, the clients were asked to focus their attention on a disturbing pain-related or traumatic memory and the associated thoughts, feelings, and somatic perceptions while focusing on an external bilateral stimulus such as eye movements or tapping. In Grant’s pain protocol, painful feelings in the here and now were also used as targets.
CBT or EMDR?
In contrast to the CBT findings, the effects of EMDR seen in the review are mainly associated with some direct improvement in the pain intensity and only to a lesser extent with reduction of psychological distress such as anxiety or depression. The authors concluded that ‘this may indicate that EMDR has some direct impact on the underlying pain processing corticolimbic levels that finally results in an altered perception of the nociceptive information rather than being restricted merely to secondary “pain management effects” mediated by alterations of higher brain functions like cognition or coping behaviour’ (ibid p259). In other words, EMDR is connecting to a different part of the brain from CBT. This could well help to explain the difference in outcomes.
This idea that different parts of the brain are engaged during EMDR is in line with the theory underlying the adaptive information processing model (AIP). The AIP model posits that past traumatic experiences are involved in triggering the present pathology. This pathology would include psychological symptoms such as fear and distress as well as physical sensations such as pain. The underlying traumatic or painful memories my serve to increase the pain response to current stimuli even if the current stimuli are not actually painful. It has been hypothesised that EMDR desensitizes the limbically augmented portion of the pain experience.
Furthermore, EMDR might be effective in treating pain because it focuses specifically on the affective aspects of pain, which in turn interact with the client’s experience of pain. Affective distress can be an emotional component of pain just as pain can be a consequence of affective distress. Similarly, affective distress can be a comorbid disorder of pain. EMDR was developed originally to address the distress resulting from traumatic memories. It is probable that targeting the affective distress alongside the distressing events that are coupled with the pain, brings about amelioration of the pain.
Therapy and pain treatment
When there is a significant difference between incoming sensory information and what the brain expects, known as a prediction error, our brain is forced to revise its model of the world, updating our beliefs in the light of the new evidence. It’s now thought that when we experience pain relief, it’s not a direct consequence of healing in the body but the process of the brain recognizing that healing has taken place or that the danger of injury has been removed. Consequently the brain reduces the perception of pain, as its initial hypothesis that we were in danger or damage, is revised.
This is such good news for those who work therapeutically. It means that any information that can lead to the brain revising its view will affect perceptions of levels of pain. Such interventions might include direct verbal suggestions or even the rituals of a therapeutic environment. Just talking to a confident and caring therapist can make all the difference to a pain-sufferer. All these factors may prompt the brain into changing its view, thus minimizing the prediction error. As a consequence, the brain reduces the perception of pain.
In fact, anything that changes the brain’s context and increases a sense of safety reduces the need for the brain to increase protection by projecting pain onto the body.
One interesting finding was that treatment success varied with the length of treatment. In particular, studies with fewer than five sessions showed only small improvements in pain intensity and disability. When there wasn’t a pre-set number of sessions, the treatment seemed to average at six to eight sessions. This seems to suggest that six sessions or more is favourable when using EMDR for the treatment of chronic pain. Additionally, Wiensky noticed that the number of sessions needed for successful treatment was correlated with the time that had elapsed since the initial accident. He suggested that the sooner the pain was treated, the more quickly remission could be achieved.
EMDR interventions that might reduce pain
Stabilisation phase
Slow deep breathing (see Video 054 Four Elements Exercises for Stress Reduction). This kind of breathing stimulates the vagus nerve and activates the parasympathetic nervous system.
The container exercise or installation of a safe state can help as can the Light Stream exercise. (Demonstrated in Videos 051 and 052).
Enabling people to embrace ‘acceptance’ of what has happened to them reduces fear and stress and allows the brain to ‘relax’.
Ways to help people to have a restful sleep are also useful as are gentle exercises that push the limits of movement of a damaged part of the body.
Processing phase
Processing underlying trauma using the standard EMDR protocol.
The specially adapted pain protocol described by Grant, Video 017, which draws heavily on practices from Sensorimotor Psychotherapy. In Grant’s protocol there is a direct focus on the pain being experienced in the here iand now. This would be ideally applied to phantom limb pain, for instance. The pain intensity is described in terms of subjective units of pain and the use of EMDR processing aims to bring the intensity down.
Another intervention for pain relief that draws from sensorimotor psychotherapy is NAW (Notice, Acknowledge, Welcome). NAW alongside bilateral stimulation is demonstrated in Video 078 Part 1.4. Used this way, NAW is a way of incorporating somatic processing with dual attention.
When NAW is combined with EMDR bilateral stimulation to transform the pain experience, the client is asked to imagine the pain as a shape, a colour, a texture, a temperature, etc. The careful focus on the pain activates the neural pathways associated with the somatic aspects of the pain and the client’s emotional response the pain. The client is invited to stay with the physical and psychological sensations while attending to short sets of bilateral stimulation. Following each set, the client reports what, if any, changes have occurred. Clients typically report an increase in relaxation and a change in pain sensations alongside changing imagery that represents the embodied nature of the pain. Although the change in sensation is often a decrease in pain severity, it also may be a change in location, type, or quality of the pain, or a sense of relief or relaxation. When the client notices some change, they are asked to ‘welcome it’. This links to the role of prediction error and acceptance as ameliorating factors in the perception of pain.
Once changes have been noticed, the client is encouraged to cognitively integrate those changes through a series of interweaves such as ‘What does the final feeling remind you of?’ The new sensations and images can be installed and reinforced using bilateral stimulation.
In Summary
So what have we learned to make us more confident that we can use EMDR with chronic pain to good effect?
Pain is created in the brain and projected on to the body. Crucially it is independent of our physical body. This explains referred pain, where we are hurt in one part of our body but feel the pain in some other area. The brain has become hypersensitive through central sensitization. It has created a brain map that can spill over into other areas of the brain so other parts of the body are affected, not just the damaged part.
The therapist’s confidence is critical in helping the client to believe that pain relief is possible. The better the therapeutic relationship, the more likely EMDR is to work effectively. The therapist holds hope for the client’s recovery and enables the client to accept what has happened, so that they become more open to change. The mere expectation of pain relief is enough for the brain to release its own opioids.
The person providing treatment has a huge impact on the pain relief of the person receiving it. Giving a clear explanation prior to treatment makes a big difference too. The opposite is also true ‘I’m not sure this is going to work’ can trigger anxiety that releases neurotransmitters that can open the floodgates for pain.
Reduction of stress is important in reducing pain. Stress and anxiety increase inflammation. There is a strong link between adverse events in early life and both inflammation and chronic pain throughout later life. It’s like two danger systems working together – the nociceptors that indicate danger in the tissues and the flight/fight that perceive danger in the environment. Anticipation of future pain or memory of past pain contribute to stress and anxiety that open the gateways for nociceptive signals to the brain. It is important to address and process underlying trauma in order to help pain intensity in the here and now.
Relaxation calms down inflammation, which is why meditation and yoga are helpful for pain relief. Deep breathing stimulates the parasympathetic nervous system leading to rest and calm, and the reduction of stress. The calming visual imagery used in EMDR such as ‘safe /calm place’ and ‘Four Elements’ etc. help to bring calm, as does bilateral stimulation itself.
Repeated visualisation can rewire the brain, which can form a new body image map, not dominated by pain. This explains why approaches such as hypnotherapy, hypnoVR, and sensorimotor NAW help with pain reduction.
About the authors
References:
Nash, J. (2021) Chronic pain – the doctor who says it’s in the brain. The Times, Health, Tuesday July 13th.
Lyman, M. (2021) The Painful Truth: The new science of why we hurt and how we can heal. London. Penguin Morely, S. (2011) Efficacy and Effectiveness of Cognitive Behaviour Therapy on Chronic Pain: Progress and some challenges. Pain: 152 99-106
Grant, M. Pain control with EMDR. In: Luber M, ed. Eye Movement Desensitization and Reprocessing (EMDR)
Springer Publishing Co; 2010:517–36
Trsarz, J., Leisner, S., Gerhardt, J., Seidler, G., Eich, W. and Hartmann, H. (2014) Effects of Eye Movement Desensitization and Reprocessing (EMDR) Treatment in Chronic Pain Patients: A systematic Review. Pain Medicine: 15 247-263 Wiley Periodicals Inc.
Shapiro, F. (1995) Eye Movement Desensitization and Reprocessing: Basic Principles, Protocols and Procedures. New York: Guildford Press
Mazzola A, Calcagno ML, Goicochea MT, et al. (2009) EMDR in the treatment of chronic pain. J EMDR Pract Res 2009;3:66–79.
Ray P, Page AC. A single session of hypnosis and eye movement desensitisation and reprocessing (EMDR) in the treatment of chronic pain. Aust J Clin Exp Hypn 2002;30:170–8
Wilensky M. (2006) Eye movement desensitization and reprocessing (EMDR) as a treatment for phantom limb pain. J Brief Therapy: 5:31–44.
Grant, M., & Threlfo, C. (2002) EMDR in the Treatment of Chronic Pain. Journal of Clinical Psychology, Vol 58(12) 1505–1520 (www.interscience.wiley.com). DOI: 10.1002/jclp.1010
De Roos, C., Veenstra, A. C., de Jongh, A. Van der Wee, NJA, Zitman, Van Rood, N.J. (2010) Treatment of chronic phantom limb pain using a trauma-focused psychological approach. Pain Res Manage Vol 15 (2)
Seth A. (2021) Being You, A New Science of Consciousness. London. Faber & Faber Ltd
I have always loved the pastoral side of education, particularly the opportunities to see young people develop and flourish in whatever ways work for them. As a result of this interest, I completed a Masters in Guidance and Counselling in Education in 1998 followed by a PhD in 2002 that bridged the worlds of counselling and education.