As we have seen, while there is much overlap between trauma and pain, there are also significant differences (eg; organic pathology, nociplastic pain, medical trauma) which require variations to the basic trauma protocol. These differences have necessitated variations to the standard trauma protocol. These are briefly summarized below. 

1. Pain history
As with PTSD, EMDR history-taking with chronic pain requires screening for trauma. While trauma is a well-known risk factor for chronic pain, it should not be assumed that trauma is the only factor relevant to present pain or that physical pathology has been completely ruled out as a cause of pain/MUS. Many clients with pain/MUS have experienced some combination of trauma, neglect, health problems and extensive medical investigations and interventions. The latter can be an additional unique source of trauma, depending on the nature of their condition and other pre-existing vulnerabilities. For example, recipients of surgery are up to 5 times more likely to develop PTSD than people in general.1 

History-taking should thus include a medical history, including childhood illness and hospitalizations, medical trauma and current health concerns. The latter can have implications for their readiness for EMDR. If for example, the client truly believes that their pain signals an undiagnosed physical illness, EMDR would fail because the pain is ‘ecological’. If the pain involves a significant neuropathic (eg, post-herpetic neuralgia, post-surgical neuropathy) component, then EMDR processing of emotional aspects alone may be insufficient. 

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2. Health status
EMDR is based on the AIP model, which assumes “an inherent system in all of us that is physiologically geared to process information to a state of mental health”. But because of the presence of injury or illness, often chronic, it cannot be assumed that sufferers of pain/MUS have ready access to innate healing capacities or that they are sufficiently well enough to participate in what can be an energy-intensive therapy. It is therefore important to assess the client’s general health status in terms of whether they have the capacity to engage with traumatic memories in the way that EMDR therapy requires. This is an additional dimension of phase two.

3. Resourcing
While resourcing is an element of most applications of EMDR, the increased somatic dimension of pain/MUS, together with the likelihood that clients with chronic health issues may continue to suffer from persistent pain requires the creation of resources with a more somatic focus. These typically include pain-ameliorating imagery, accessing positive memories of comfort and well-being and distraction and avoidance. 

Additional pain-focused resources include future-template and hypnotic inductions aimed at stimulating healing and increased coping and functioning. Clients with persistent pain may need to practice these strategies regularly as part of their self-care.

4. EMDR targeting
EMDR targets can range from past trauma to present pain, to the effects of pain. Although pain/MUS sufferers frequently have other trauma in their background, which may or may not be directly related to their current pain, the impact of present pain is often of primary concern. For the patient, uncontrolled pain is a safety issue, a kind of threat from within, which makes them feel unsafe in their own body. It must be neutralized or brought under adequate control to permit focusing on other issues. Facilitating pain reduction by targeting present pain helps with client stabilization (sense of mastery) and preparation for trauma work. Targeting present pain involves changes to the TICES which are further discussed below.
When targeting present pain the image may be constructed on the basis of sensory descriptors (‘if your pain had a size/shape/color what would it be?’) and associated imagery (‘is there an image that goes with that?’) where there is no direct trauma. Additionally, clients who have never addressed their trauma (and may not be ready to) may even find it safer to focus on physical pain/MUS rather than painful dissociated memories. Where pain is part of an unresolved traumatic memory (e.g., whiplash pain), or where there is unrelated trauma, and it is unclear where to begin with EMDR, ask the patient which problem they want to focus on first, the trauma or the pain. 

5. Substituting Sensations for emotions (TICE/S)
When targeting present pain, the pain sensations may be used instead of the emotion in the target set-up. In terms of the ‘E’ in TICES, the pain is the negative affect including how and where it is felt in the body. While there is inevitably negative emotion associated with the pain, this is not generally the focus when targeting present pain. It would be if targeting how the pain makes the patient feel about themselves, which is a different problem involving a more standard application of the TICES. It is the author’s experience that asking the client to identify their pain sensations after asking them how the pain makes them feel is unnecessary and can be confusing. This variation aims to facilitate a more client-centred affect-laden target which is sufficient for reprocessing.

6. Negative and Positive cognition.
Shapiro has categorized EMDR negative cognitions into different themes. Lack of safety/vulnerability, control/power, responsibility/feeling defective (Shapiro, 2012 p 84). Trauma survivors tend to endorse NC’s with themes of lack of safety/vulnerability and control/power while pain sufferers typically endorse NC’s with themes of responsibility and feeling defective. While any client-centered NC is adequate, and there are always issues of safety and control, it is the author’s experience that the negative cognition only needs to be proximate to how the pain makes the client feels about themselves and/or their ability to control it.

Chronic pain sufferers who have struggled with pain for many years may find it difficult to endorse a PC with any degree of believability (VoC). It is more efficient and effective to dispense with the PC in the set-up stage and ‘backload’ it after successful reprocessing. Following successful processing, once the client has achieved some degree of relief and control, they generally find it much easier to endorse PC’s such as ‘I can cope’, and ‘I can control the pain.’

7. Continuous audio BLS
Normally BLS is ceased during check-ins. While these pauses can give traumatized clients a necessary break during trauma processing, they may serve to take chronic pain clients “off the track” in terms of engagement with BLS. Because of the entrenched, chronic nature of symptoms in complex pain, changes may be subtle and slow in coming. Continuous BLS allows for the gradual accumulation of minor sensory changes and gives dissociated or alexithymic clients more time to attune to BLS and experience its effects. 

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Check-ins should be conducted every 30 – 60 seconds or when non-verbal changes are noticed or if you feel unsure about what is happening. BLS should be ceased when there are noticeable changes, or the client appears tired. This can be after anywhere from 5 – 10 minutes or more. If you are not sure just ask the client ‘have you had enough or would you like a little more?.’ Following BLS review and reinforce changes (see below).

Auditory BLS may be an effective alternative to eye movements when targeting present pain. The speed of the BLS should be sufficient to attract and hold attention but not too rapid as to be overstimulating. An additional advantage of auditory BLS is that it can readily be used as a self-soothing aid in-between sessions for patients with persistent pain (see below). 

9. Tracking and facilitating effects of BLS
The success of EMDR therapy depends upon the client’s ability to notice changes in the sensory-emotional elements of their problem following BLS. Because of dissociation and alexithymia, it should not be assumed that clients are sufficiently self-aware to notice any and all changes. Close attention should be paid to both the client’s self-report and non-verbal signs during EMDR check-ins. Observe changes in facial expression, decreased respiration, posture etc in addition to the client’s feedback. Questions that direct awareness to the body (‘what do you notice now?’) and hold it there (‘just notice that’) are useful. Failure to detect such changes represents a lost opportunity in the sense that it can appear as though nothing is changing when in fact it is.

Positive effects of BLS can also be installed by pairing them with BLS or hypnotically or both. The author typically uses the following hypnotic phrasing to reinforce the effects of BLS,
‘so you’re sitting in the chair, feeling relaxed, feeling more comfortable, feeling more connected with yourself, more whole, more together, mind and body as one… all together now … that’s it… because you are learning how to feel more integrated … that you can be safe… that you can heal. And I want you to take a moment and really notice what this feels like … a new way of being in your body that can become part of your experience of yourself more and more every day, in many ways… something you will enjoy noticing … just taking a few quiet moments to notice that for yourself now … that’s right.’ 
This verbal refreshing of post-BLS changes gives the patient an added opportunity to consolidate their new learnings.

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10. Self-use of BLS
In patients with persistent pain, self-use of audio BLS ‘at home’ may offer a safe and effective means of self-soothing. BLS is known to stimulate physiological changes associated with relaxation, decreased worry, distancing effects and even sleepiness. For appropriate clients with ongoing 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 (eg; relaxation etc) in session. 

The author has created several apps incorporating audio (and visual) BLS (Grant, 2025).

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References
Grant, Mark, Lau, Richard Ck, DiNardo, Jeff (2025). Feasibility and potential efficacy of mobile app series based on EMDR: A Pilot Randomized Control Trial with PTSD and co-morbid problems. In press Jnl EMDR Practice and Research