Sometimes the original VoC is not longer a good fit. Ask; “Is there another positive statement or cognition that fits better now? If so, what would it be?”

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Instruct the client to “just think of your pain now and that thought and just notice..” 
Perform 8 slow bilateral eye movements. Check again.
 “So how does that feel now?”
 

Body Scan
 

 “So if I ask you to think of your original pain (or distress) now, how does it feel in your body?”

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You should have already done this but if any significant discomfort is still reported restimulate with bls or create antidote resources if you haven't already.

 “OK, do you have any idea about what’s stopping the pain from changing?” 

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When the client reports no pain or it is apparent that the client cannot improve any further, 
“Close your eyes and keep in mind the original memory/image and the positive cognition. Then bring your attention to the different parts of your body, starting with your head and working downward. Any place you find any tension, tightness or unusual sensation, tell me.”

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 Closure
 

“Now that you are feeling better you are probably wondering how long the effects will last. Experience suggests that these changes can last anywhere from a few hours to being permanent. Even if the pain comes back, it is often weaker because of the way EMDR effects memory. The  most important thing is to just have an open mind and pay attention to what you are feeling in the present. Many people find that EMDR helps them feel more in touch with their feelings and this can lead to increased self-care and reduced stress and pain flare-ups.

You can also use the antidote imagery we created or bilateral stimulation by yourself to control your pain. I am going to give you a recording of this sound. Whenever you need relief from pain (or stress, or even insomnia) just play this app/audio download/CD etc (whatever applies). and concentrate on the negative feelings you want relief from, just like you did here 
today. The more you practice the more you will succeed. Of course if your pain persists beyond 
what you feel you can cope with you should always seek medical help ”

Clients with on-going pain, will need resources to help control that pain. See the client resources section at the end of the manual for various ideas about how clients with unresolved pain can cope.

Re-evaluation

 Reviewing the clients experience of their pain since the last session.

 “So what have you noticed about your pain since our last session?”

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 If the client says nothing, ask more direct questions.
 

“Have you noticed any changes in your sleeping pattern?”

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“Have you noticed any changes in your activity levels since last time?”

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“Have you done anything different or unusual?

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 Have you noticed any changes in your mood since last time?”

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Inquire about specific areas of the client’s life that they have identified as problematical or affected by their stress, trauma or pain, such as sleep, relationships, activity levels etc.

 “Tell me about _______(state problem areas) since the last session. What have you noticed?”

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It is not uncommon for clients to fail to notice changes because of depression, alexithymia or negative thinking. Asking detailed, change-oriented questions helps the client recognize those important changes, exceptions and new trends. The therapist needs to check with clients for any changes in how they have been feeling in terms of the material that was processed at the previous session and use this as a basis for constructing new targets for EMDR reprocessing. It is not uncommon for the image of the pain to change between sessions, as the clients experience changes, particularly if progress is being made.

EMDR treatment of chronic pain is often less ‘successful’ in terms of the kinds of dramatic treatment gains that can be expected from EMDR treatment of simple PTSD. This is not  surprising; chronic pain is maintained by injury processes which are not as amenable to change as mental or emotional phenomena. Where the client is left with residual pain to any significant degree, EMDR may need to be supplemented by adjunctive pain management strategies such as sleep management strategies, exercise, resilience building etc. Chapter 11 covers some of these strategies, plus the client handouts from the client resources chapter. 
 

This protocol is based on the original EMDR trauma protocol, as developed by Francine Shapiro Phd.1

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 Desensitization case example

Here is an example of what processing pain with EMDR can look like. June suffered from chronic low back pain after falling down some stairs. Although June was facing significant other stressors (attachment issues associated with being raised in a cult, financial stress, single motherhood), it was apparent that she was a very resourced, emotionally stable person.  By the second session it was possible to isolate her current pain among a number of unresolved stressors and target it with bls (based on June electing her present pain as the thing she wanted to work on first). The session went something like this;
 

Therapist: “So can you describe your pain as you feel it right now, including how intense it feels on a scale of 1 to 10.”
June: “The pain feels like a dark solid ball at the lower end of my spine. It’s about 6/10 which is a bit above average.”
Therapist: “Okay, so can you focus on your pain the way you’ve just described it, and the bilateral stimulation, and just let whatever happens happen?”
Bls (30-40 seconds)
Therapist: “Okay, take a break and when you’re ready tell me, what do you notice now?”
June: “Hmmmm, (sounding surprised and confused) it feels smaller.”
Therapist: “(without giving her too much time to think about it) “Great, just go with that...”
Bls: (30 seconds)
Therapist: “...and what do you notice now June?”
June: (sounding even more incredulous) “Its shrunk to like a small pea.”
Therapist: (after pausing to let June notice the changes in her pain and setting her up for a positive cognition/resource installation). “Wow, isn’t that amazing - see what you are capable of?”
June: “Yes.”
Therapist: “And how would you rate the level of the pain right now?”
June: “About a 2.”
Therapist: (running low on time) “Good, and do you think you can have less or does that feel okay for you at the moment?”
June: “I can easily live with a  2 for now.”
Therapist (trying to make changes conscious) “Okay, so can you describe how it feels now where the pain was before?”
June: (takes a moment to think) “It feels empty, blank.”
Therapist: “Good, and what image goes with those feelings?”
June: “It just feels like an empty space.”
Therapist: “Okay, just think of that and just notice.”
Bls/DAS: (20-30 seconds)
Therapist: “and what do you notice now?”
June: “I got an image of my favorite holiday place, a snow-field in the mountains.”
Therapist: “and how does the memory of that place make you feel?”
June: “Peaceful, free - all that white empty space just makes me feel soooo relaxed.”
Therapist: “Good, and is there a word that goes with those feelings?”
June: “okay, I feel okay.”
Therapist: “Just think of that.”
Bls/DAS (30 seconds)
Therapist: “And what do you notice now?” 
June: “My whole body feels relaxed, and the pain is hardly noticeable.”
Therapist: “Excellent. The changes you have experienced may last anything from a few hours to a few days. You should practice thinking of that image and the words that do with it every day. It may help of you do that whilst listening to the audio bilateral stimulation recording I provided you.”

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Pain Protocol variations 
 

Different problems often require variations to the standard EMDR protocol, and pain is no exception. Below is a summary of the variations to the basic protocol for working with pain, together with the rational for each variation and any precedents or other applications.
 

1. Present pain’ as a target
If pain is viewed as a kind of affect-management problem, then the option of targeting the pain first helps with client stabilization (sense of mastery) and preparation for trauma work. This option is offered when the pain is assessed as the primary presenting problem, whether trauma is present or not, but the client should be offered the choice.
Caution: To avoid triggering trauma prematurely, use the pain target option in the protocol and keep the client focused on present affect, (ie; OFF the trauma processing track) and track physical changes closely.

2. Substituting Sensations for emotions (TICE/S)
When pain is the predominant affect you may use that in place of emotional distress when setting up target prior to commencing bls/desensitization
 

3. Tracking and facilitating effects of bls
Rationale: Continuous Bls keeps the client “on the track”- this is important for Be aware of the full range of possible effects of bls and take an active role in helping clients recognize the positive (increased relaxation, connectedness) and negative (decreased pain, distress) effects of bls. See ‘effects of bls menu’.
 

4. Continuous Bls
Continuous bls keeps the client “on the track” and gives intellectualized or anxious clients more time to attune to bls and experience its effects. You can check in with clients in the usual way (“what do you notice now?”) without interrupting the bls. Cease bls when you feel some changes have occurred and or client appears tired. If you are not sure just ask.
 

5. Auditory Bls
Auditory bls may have a more visceral effect than Ems. EMDR expert Sandra Paulson feels that sounds or tapping are more subcortical, subliminal, affective. A study involving 11 chronic pain sufferers found that recipients obtained similar levels of relief from trauma, pain and distress when this option was employed to those report ed using visual bls (Grant, 2014). Auditory bls can also be used by clients’ in-between sessions as a self-soothing device (see below).
 

6.Negative Positive cognition themes
Shapiro has categorized EMDR negative cognitions into different themes. Lack of safety/vulnerability, control/power, responsibility/feeling defective. When working with pain look for themes of responsibility and feeling defective in addition to control/power.

• Negative trauma-related cognitions; Lack of safety/vulnerability, control/power

• Negative pain-related cognitions; Responsibility/feeling defective, control/power
   

7. Expectations
Chronic pain sufferers often have low expectations of treatment so it is important to do thorough body-scans and highlight even small somatic changes following bls. You may need to reinforce physical effects of bls to help the client integrate them.
 

8. Self-use of Bls
For appropriate clients with on-going pain, self-use of Bls gives them a safe, effective tool for alleviating pain, stress and insomnia which often persists in-between treatment sessions. Self-use should be introduced as a self-soothing strategy, (not DIY 
EMDR) AFTER the client has experienced positive effects of Bls (e.g. relaxation etc) in session. Self-use of bls is not recommended for severely dissociative clients. Always advise clients to discontinue self-use if they experience any adverse side effects.
 

The author’s apps (Anxiety Release based on EMDR and Sleep Restore based on EMDR) both contain bls tracks. Alternatively, there are various audio downloads.

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