treating resistance in ocd with emdr

Understanding and Treating resistance in OCD through EMDR:

Is OCD an Emotional Part?

Nick Crichton

EMDR Europe Consultant

BABCP Accredited Therapist

1

Broad aims of presentation

• To present EMDR with its broad and integrative theoretical base as an excellent way of being able to work effectively “in the OCD moment” with clients and modify responses.

• In particular to explore whether the theory of dissociation could be a helpful way of understanding OCD which will be conceptualised as an emotional part (EP).

• To enhance practitioner competence by presenting a way of forging a sound therapeutic alliance, while offering the client, insight, awareness of the authentic self, and through a variety of interweaves and metaphors to work with client resistance or looping.

• To explore briefly the use of positive psychology, compassionate mind and metaphors, and attentional focus, in helping the individual suffering from OCD to overcome fears of change within an EMDR context.

• This brief talk is hypothetical as strong empirical evidence for the methods as opposed to reported clinical experience does not yet exist. It is based mainly on clinical observations.

2

Understanding resistance in OCD • Exposure Response Prevention (Meyer 1966) – ERP is a behavioural method with about 50% success rate. (Previous

treatments did not work).

• Cognitive therapy approaches have relatively mixed research findings and seem to suit particular types of OCD. There is a review of research by Clark D.A. in “Cognitive Therapy for OCD” Guildford Press 2004 (pp.268 – 281).

• Clark concluded “It is clear CBT is an effective treatment for OCD, although it is unknown whether greater emphasis on cognition increases treatment potency beyond that achieved by an exclusive emphasis on exposure and response prevention. One thing is certain: ERP must continue to be the critical therapeutic ingredient in cognitive or behavioural interventions for OCD. One of the most promising avenues for CBT is the possibility it might improve our effectiveness in treating obsessional rumination.”

• David Veale suggested the various treatment approaches had a success rate of approximately 66% (Workshop April, 2014). If this is true, it suggests there are considerable areas of unmet need.

• It is argued in this brief presentation that an EMDR based protocol might have a specific role in meeting these needs.

• A discussion of existing CBT theories and approaches is out of the scope of this presentation.

• The presentation owes a great deal to John Marr (2012) and Robin Logie and Ad De Jongh (2014). A reading/reference list is available.

3

How can EMDR help in the treatment of OCD?

• CT approaches, while predominantly focussing on addressing the symptoms, also look at life history factors that might have contributed to the onset of OCD. It is recognised that such factors do not always manifest themselves, as OCD is a complex condition the causes of which are diverse and not fully understood. While OCD has broad themes, the meanings individuals form within these themes (e.g. checking) are highly idiosyncratic.

• The EMDR protocol takes a history of relevant experiences and offers, through discussion and through floatback, a way of locating earlier touchstone memories and events for which OCD might have been a response in certain clients (just as PTSD can be a response in some to overwhelming stress following a sudden life or integrity threatening event).

• The OCD can make it difficult for the client to be aware of and to connect with these earlier life experience factors – which then, sometimes out of the client’s awareness, might form the basis for an underlying resistance to any direct treatment of symptoms.

• A discussion of two anonymous clients in the following slides will seek to illustrate this. It must be emphasised that studies of links between trauma and OCD have been longstanding. However EMDR methods might offer cogency in identification, conceptualisation and treatment in individuals in whom such a relationship is apparent.

4

Possible unique advantages of EMDR in treating OCD

• One theory of why EMDR works is that the dual attention task taxes the working memory (Francine Shapiro New York Times Blog, 2012 ). It was proposed that “repeated checking causes memory distrust” (Van den Hout and Kindt, 2003). Repeated checking prioritised semantic processing at the expense of perceptual processing so while it increased familiarity it reduced the vividness and detail of a person’s recollection of situations leading to increased doubt and reduced confidence. EMDR taxes the working memory while the ems induce greater relaxation, less arousal and greater focus on perceptions of what had happened. The negative emotions underlying the memory are reduced and this helps the individual to make the required behavioural changes to ensure the OCD beliefs no longer hold sway. It is also possible helpfully to target physical sensations linked to anxiety over memory in EMDR.

• It is also possible that this could be combined with the theory that saccadic ems resemble R.E.M. sleep. The repeated ems can produce a feeling of relaxation in a safe environment, a shift in attentional focus, a reduction in unproductive attempts to tightly control thoughts, and, through increased associations, they can enable a greater focus on perceptions with a more mindful approach to intrusions which can then become normalised (Francine Shapiro, 2012 ).

• Views given in this presentation are hypothetical and would need to be refined and tested in RCTs and single case studies.

5

Phoebe (not real name) 1

• Phoebe is a lady in her 40s.

• She remembers being happy as a child. She also remembers being perfectionistic and having a strong wish to please others. She did well at school and achieved good results in her “A” levels – good enough for University acceptance.

• Her older sister had gone to university and Phoebe was also ambitious to do well. However owing to family financial circumstances she was not able to do this and had to obtain work. She eventually ended up working in a large organisation and was determined “to prove herself” by obtaining promotion. Her perfectionism drove her to work all hours she could, to be ahead of her colleagues in productivity and quality – even though this was placing her under increasing stress. The work was “never good enough” and the perceived risk and consequences of making a mistake was becoming more frightening for her.

6

Phoebe 2

• One day, over 20 years ago, she made a mistake. She remembers “feeling horrible” and thinking that she would pass out. She moved away from her desk into another room. Everything seemed black. She felt numb but very panicky in a way she had not felt previously. She returned to her desk but now felt very anxious and wanted to avoid being there.

• “I did not get that “right feeling”.”

• She thought at the time: “I’ve made this mistake. I’m going to get into trouble … serious trouble. I’m going to lose everything I’ve worked for”.

• She had feelings of sadness and dread. She recalls tension in her throat and stomach. From that moment she gave up thoughts of promotion and instead focused on survival. OCD came into her life. From the therapist’s perspective, it was as if this overwhelming feeling left a huge amount of energy locked inside as she sought to give meaning to this experience in this life transforming moment.

7

Phoebe 3

• From then on she developed OCD symptoms and major depression. • She had to check and reply to correspondence from customers. She performed

about 50% less well than her colleagues, her productivity being impaired by constant checking and rituals such as cursor/ mouse positioning, prayer, drinking water, looking out of the window, reassurance seeking, re-reading of the script several times, stroking her hair. The OCD “rule book” (which she mistook as her own “rule book”) was increasingly complex and changing. If she could not remember the correct order in which she did things, or she was interrupted, she had to start the process again. Paradoxically her fear about losing her job, with frightening images of imminent dismissal, increasingly placed her employment at risk owing to her slow productivity.

• In the float back to the onset of the OCD, she went back not to this incident, but to her exam success yet inability to go to university. With the OCD she tended to worry and develop a process of moral thought-action-fusion about the danger of making mistakes. This was moral as it reflected not only on her competency as a person but, as we were to test out, deliberate mistake making was also felt to be “morally wrong”. This seemed to be an early family value.

8

Phoebe 4

• The events she described might be an explanation for the endurance of the OCD which had proved initially resistant to ERP treatment.

• Robert Miller has developed the concept of positive feeling states. These occur when positive feelings become rigidly linked with specific objects and behaviour. Robert Miller has stated in a workshop that he has tried his protocol with OCD sufferers and it did not work. As a feeling state OCD symptoms are anything but positive, so this is perhaps not surprising.

• However with Phoebe in her pre-OCD state, success in her A levels seemed to meet profound Maslovian needs of esteem (which would be a positive feeling state). When these needs for esteem were subsequently not met (by the lack of opportunity to progress to university), she was strongly motivated to pursue these needs through a career in the large organisation which employed her in order to “to prove herself”.

• Her rigid perfectionism, according to Miller’s hypothesis, would be about seeking that original feeling state. This, rather than the objective rewards of promotion, would continue to drive her to the point of breakdown when OCD entered her life. Positive feeling states can be just as pervasively overwhelming, in a totally different way, as post traumatic stress, and are seen as linked to addictions, co-dependence, violent behaviour and obsessions

9

Phoebe 5

• Phoebe’s description of that moment in the office when she was overwhelmed and the OCD behaviour started seems to have characteristics of dissociation. It is possible that for some people OCD could be viewed as an emotional part (EP) which is cut off and capable of functioning in an relatively contained way from other parts of the personality.

• It would be powerful in that person’s life because the emotions which drive it (fear, dread, anger, disgust, guilt, shame) are powerful and disruptive enough often to trump reason. Moreover it could be activated through sensory triggers in a rapid, automatic and out of awareness way (as opposed to verbally accessible memories which have a sense of time and are autobiographical - Chris Brewin, 200).

• In this conceptualisation OCD in particular individuals could be seen as a response to distal life events as an EP. EPs are ego states or schemas resistant to reasoned change, the emotional brain undercutting and resisting cognitive structures. They are conditioned to be activated by environment stimuli, thoughts, physical sensations, feelings or actions in a powerful, and autonomic way. The reasoning would be emotionally driven dominated by images, threats and doubts rather than logic.

• In Phoebe’s case the function of the EP was harshly “protective”. During the EMDR processing, Phoebe expressed fear of change as her SUDs dropped. She had, as a perfectionist, low tolerance of future uncertainty and her OCD kept her in an anxious, complex world dominated by intrusions, which she interpreted as meaning she could be responsible for some serious mistake which would humiliatingly end her career and this would bring her insecurity and shame.

• Her response to this distressing feeling state was to engage in rituals and neutralising behaviour. This experiential avoidance, while it was deeply unpleasant, and negatively reinforced her harsh appraisal of the intrusion, also “protected” her as a perfectionist from facing an uncertain, menacing future. The nature and function of the EP which forms the OCD needs to be understood if it is not to remain another powerful basis for resistance during treatment.

10

Phoebe 6

• Conceptualising OCD in some individuals as an EP offers an explanation of resistance to change. Therapies that work with ego states (ego state therapy, schema therapy for example) see EPs as undercutting and potentially usurping the cognitive organising structures of the brain. In severe OCD the frontal lobes (in particular the orbital cortex) seem to interact via a fast superhighway of threat loaded images, doubts and beliefs with the limbic system, while the more rational cognitive structures can only respond more slowly and less forcefully via a long, winding footpath.

• In BLS reprocessing of that incident some 20 years previously Phoebe had an NC “I am stupid” with SUDs 9 to 10. The dominant emotions were sadness and dread (dread seems to go beyond fear as it suggests dread, awfulness, annihilation of the self – another reason for treatment resistance) and her physical feelings were tightness in the throat and stomach (this seems a common physical pattern in OCD sufferers). The initial VOC for the PC – “I’m OK just the way I am” was 3/7.

• The sense of self in OCD can be deprived of its autobiographical and rational context and essence and is conceived as vulnerable, as needing to be highly vigilant about current threat. Hence it is validated by a “felt sense” and is experienced as highly fragile. In that respect it is perhaps not dissimilar to the damaged sense of self in many sufferers from PTSD.

11

Phoebe 7

• AIP perhaps makes EMDR a preferred basis to treating OCD. The client can be in the moment of OCD yet also viewing these events on an imaginary screen while noticing the changing images and the sensations in his or her body. Effectively the observing part of that client, after preparation and resource installation, can view and mindfully, compassionately notice this distress, and also how it changes after sets of BLS.

• In this scenario the client can actively communicate with the OCD part through the observing self. Interweaves are frequently necessary during reprocessing. In the above mentioned reprocessing, Phoebe’s “observing self” was able, during BLS, to float back to her self at the onset of OCD and communicate with that part of her through her own words, before returning to the present. This intra-psychic approach appeared effective (more effective perhaps than an attempt through the therapist to modify rationally the OCD beliefs) and enabled the SUDs to drop gradually to zero with reduction of bodily tension before successfully installing the PC (which remained unrevised). Phoebe described this as “a burden being lifted”.

• It seemed then that Phoebe became able to loosen the grip of the OCD in the office setting which, unlike OCD in her out of work life, had been strongly resistant to chance.

12

Amy (1)

• Amy, not real name, who also allowed me to give this anonymised presentation, is, like Phoebe, a current client (at the time of writing) in her early twenties.

• She came to see me over an issue of co-dependency. She had seen me previously and had found the EMDR had been the only therapy to have helped her (out of a long list of therapies through childhood and adolescence).

• The issue was that she was trying to end a relationship with an abusive partner and kept finding herself being drawn back in, notwithstanding her current involvement in a another relationship which was not seen as abusive.

13

Amy (2)

• She was asked to identify a time which she remembered as intense and positive with the abusive partner. She identified the state of mind underlying this feeling state as “being connected”. On floating back to when she had experienced this state of mind for the first time, she remembered as a child being with her grandfather, who had died suddenly when she was thirteen.

• As a child aged about five she stated she had had traumatic ordeals with a dentist who drilled her teeth before the anaesthetic had began to work causing immense, and, for a tiny child, overwhelming pain. Current memories of that episode were described as vivid and intrusive.

• As a young child she experienced considerable anxiety (the full causes of which are obscure as there were some identity issues for her in her upbringing) and her grandfather, himself a dentist, was a major source of comfort to her and acted at times as her principal carer. When he died she remembered feeling numb, without tears, and did not have a full grief reaction. She recalls not having been able to say goodbye and in the years following his death she had felt numb, lost and abandoned. She asked herself if she had omitted to do things that might have prevented his death. She attended the funeral but was distraught and had no memory of it.

14

Amy (3)

• As a child and teenager she appeared to go through a difficult time. At one time as a teenager she was self-harming, then using drugs to escape her pain. She experienced an eating disorder. She was psychologically bullied at school.

• She became perfectionistic. When she wrote a sentence in her English, this sentence had to be 100% perfect. If not, she had a strong feeling of letting her grandfather down. Constantly she would ask herself: “Would he like me to do this?” This let to a lack of an internal locus of control for her self esteem. With such harsh yardsticks for performance, perhaps not surprisingly, she abandoned her English degree. She castigated herself. “I’ve let him down because I’ve not finished.” “He would be ashamed of me doing that … he would be disappointed.”

• She developed a yearning for the presence of her late grandfather. “I would like him to manifest … to tell me..” She has embarked on a nurse training course. “I need to do nursing in order not to let him down.”

15

Amy (4)

• The positive feeling state associated with the presence of her late grandfather seemed to be at the heart of her co-dependency issues. However the drive for connectedness, following his sudden death, seemed to give rise to a host of problems including OCD. Reprocessing of the PFS seemed to reduce the co-dependency issues while helping to see the connectedness of this with her OCD, which also left her feeling very vulnerable in her own identity.

• For her some OCD rituals involved checking the door handle five times. The number five represented the number of family members before the death of her grandfather.

• She also spent 20 minutes after meals excessively brushing her teeth after each meal. She would inspect each tooth in the mirror and also her gums for infection. If her gum seemed inflamed she stated she would become paranoid and seek reassurance from her dentist. She had a dread of “her teeth being wrong” She would obsess not just about her own teeth but also about other people’s teeth. She stated she had never had a filling (since the early episode with the careless dentist) and believed that if this were to become necessary it would mean that she had betrayed her grandfather. This would be catastrophic. It would be unthinkably awful.

16

Amy (5)

• Amy was also left a locket by her grandfather. She had magical thinking surrounding this believing if she did not wear (if she had forgotten to put it on) something bad would happen to her.

• Her description of her state of mind following this bereavement suggests dissociation, and from then an intense need for connectedness dominated and still dominates her life with disastrous consequences. At that point her OCD developed. As with Phoebe her OCD seems to function like an emotional part (EP) and the earlier life factors of trauma and grief need first to be addressed before ERP can take place successfully. Positive feeling states might also need to be identified and reprocessed

• EMDR uses a three pronged approach. It would make sense after adequate preparation to reprocess her sense of abandonment and

difficulty in completing the tasks of grieving following her grandfather’s sudden death. It would be important to reprocess the image of her mother’s face when her mother received the news on the phone which appeared overwhelming. The reprocessing of the earlier traumas when receiving dental treatment as a five year old might also be indicated. The OCD has seemed to encroach on her sense of identity and influenced her greatly in making major life decisions.

• This direct work could activate the OCD which would make such treatment difficult, and in this contingency work with the OCD might be indicated. Work within the moment of OCD during BLS might ask her compassionate mind part what her dentist grandfather might advise if he could communicate to her about her overbrushing, and whether she might find healthier grieving by embracing a more compassionate figure for her grandfather than the OCD archetype. The therapist might need to work with the OCD in order to clear the way for Amy to grieve. The therapist would have to be flexible in treatment prongs in order to work with the experiential avoidance which fuels the OCD while recognising the function of the OCD for Amy.

• In floating back to an earlier time when her grandfather was alive she was asked how he would react to the fact that she had found it necessary to have a filling. She stated that his approach, given her fear of dental treatment, would be sympathetic and encouraging (the opposite of the approach she imagined in the moment of OCD).

• A flashforward technique would also be helpful in order for her to ascertain what would be the worst aspect of her feeling of having let down her grandfather. If she did have to go and have a filling, what would be the worst things for her in that image – the fear of dental work triggering images of the earlier experiences; the fear of the internalised “voice” of her grandfather having “let him down” or the fear of facing the pain inside. The flashforward technique could also help unpick the areas of resistance.

17

Why OCD as an EP?

• OCD has varying degrees of severity and in many instances individuals can respond to an ERP or CT programme. However research suggests that many people suffer from a more severe OCD that seems resistant to these treatments according to research evidence. While EMDR could work with OCD at various levels of severity, it seems also effective with clients who cannot respond to ERP. (John Marr, 2012)

• An EP is a set of rigidly and powerfully interrelated parts which seem in the moments of OCD to be sealed off from the rest of the personality. An analogy could be made in qualitatively different circumstances from the EP in a person suffering from PTSD. It is suggested that just as EMDR can work effectively with the EP in PTSD, so it can work effectively with the EP in OCD.

• David A. Clark has suggested a Cognitive Control Theory of Obsessions which attempts to integrate various theories of OCD. His book is mentioned in the suggested reading list so that practitioners who need to can acquaint themselves with existing theories and research. Time does not permit a discussion in this presentation (Clark, 2004).

18

Integration

• A theory of dissociation would imply integration as goal. In the treatment of PTSD the emotional memory is reprocessed so that it is no longer dominant in the personality. In the EMDR treatment of OCD, the appraisal of threat from the unwanted intrusions and the secondary appraisals of control are worked with so that these are no longer dominant in the personality.

• For the treatment of OCD, education about the condition and how it can be treated needs to be followed by a careful understanding and analysis of the conditioning triggers, experiential avoidance, appraisals, emotions, behaviours, physical feelings and the function of the EP for that individual.

• This understanding can be on-going during treatment. For example during an EMDR session when Phoebe appeared to be responding successfully, she began to express concern that without the OCD she felt vulnerable and afraid. The earlier fears of making mistakes, of failing, of an uncertain future re-emerged. While being in the grip of the OCD was unpleasant, its rules conferred a certain predictability on her actions and she admitted seeing the OCD as a “friend” even though it was a “false friend” which caused her stress in many areas of her life. This made it necessary for other channels to be explored. EMDR seems to offer an ability to reveal otherwise covert issues and to address them in the moment of OCD during the BLS.

19

Preparation and resource installation

• Not all clients with OCD can identify historical factors which appear linked with the disorder. Some will say they have suffered from OCD for as long as they can remember in early childhood, and that OCD has tended to dominate their waking hours.

• When asked about their authentic, non-OCD self, some adult clients will say words to the effect that they are not sure who they are. For all clients an understanding of the costs and benefits of the OCD, and being able to conceptualise the problem in a way that allows the therapist to work collaboratively alongside, and offer hope to the client is paramount. Hopefully a sense of the authentic self will start to emerge during treatment as the client becomes both exhilarated and calmer during treatment.

• Joint conceptualisation is an important part of EMDR and very good models of this can be found in the literature.

20

Preparation and Resource Installation 2

• Schwarz’s “Brainlock” theory (see reading list) attracts controversy in its statement that OCD is a biochemical problem in the brain which can be altered by carrying out a behaviourally based CBT. He bases this on PET scans which record high (“cortisol bound”) activities between the orbital cortex and constituents of the limbic system when the person is suffering from OCD. By contrast, when people heal, through a four step CBT process, the PET scans no longer record this activity.

• Many theoreticians reject this biologically based theory stating that the scans correlate with OCD symptoms rather than indicate a cause. These theoreticians argue that there is no evidence for an organic basis for OCD and that it is unhelpful to sufferers to indicate that their condition is a “brain thing” rather than a variant of normal patterns of thinking.

• However just as it is helpful to sufferers from PTSD to explain reactions in the brain which can be changed during treatment (owing to neuroplasticity), and this can reassure people who believed they were losing their sanity, similar explanations might be empowering for the same reasons for OCD sufferers. Clients who had already read “Brainlock” have informed me of their sense of relief and newly gained hope afterwards. From an EMDR perspective it can lead to a discussion on AIP. To understand something is a first step towards changing it.

• As EMDR targets bodily feelings (that feel threatening and constricting) these preliminary discussions of neural pathways could also later be empowering to the client during BLS. This also helps the person to stay with the frightening obsessions (rather than engage in overt or covert avoidance or neutralisation) so that as the SUDS gradually reduce, the fog of threat and doubt begins to clear.

21

OCD makes sense from the inside

• Mark Freeston (Presentation: Nov. 2013) comments that searching for causal/longitudinal explanations for an individual’s OCD can be at times very helpful, even essential, at others very unhelpful, or neutral.

• In most initial meetings the client sees what is happening now as the main priority. Owing to the strong emotional arousal, things which do not otherwise make sense seem very real in the moment of OCD.

• Each client is different and the therapist’s first task is not to challenge or explain OCD but to suspend his or her own beliefs and try to enter the world of the client. Being curious about how the OCD works for this client, what are its rules, can build trust and help the therapist to be seen as working along side the client. This should be a priority before working with other protocol tasks.

• “Better to push on a door with a chink of light than a door firmly held shut.” (Mark Freeston). The client is likely to be frightened, uncertain, even guilty about change, and without trust and understanding this change will not take place. Forming a joint conceptualisation is one way of achieving this.

22

A possible conceptualisation

Scanning for triggers

Intrusions /urges (normal thinking)

Appraisal - OCD obsessions

Strong Emotions

Thought –Action /Event/Object Fusion

Catastrophic Images

Compulsions - neutralising or threat reducing activities

Waiting till it “feels” right

Life events

23

Inflated responsibility Controllability of thoughts Perfectionism Overestimation of threat Intolerance of uncertainty Overimportance of thoughts (six belief domains of OCD proposed by OCCWG 1995)

1.Intrusive nature 2.Unacceptable 3.Urge to resist

4.Sense of lack of control

5.Inconsistent with, even threatening to, core values of

self

Phoebe’s OCD conceptualisation External triggers (pen aligned in

certain place; cursor in bottom right hand corner of screen glass of

water on right hand side; read note first.) Internal triggers (eyes down

to desk, deep intake of breath, silent phrase “Come on”

Intrusions /urges (normal thinking)

Have I done this right?

(If Phoebe were to notice this thought as an event in the mind

she would join the approximately 97% of the population who did not

have OCD)

Appraisal - OCD obsessions: I am incompetent. I must not make mistakes. I could have made a serious mistake and missed it.

I could lose my job.

Strong Emotions (fear, dread)

Thought –Action Fusion

“This thought frightens me so it must be true”

Images (losing job after disciplinary; self as failure)

Attempts to suppress appraisal only to have it rebound.

Compulsions - neutralising or threat reducing activities .

”I feel awful unless I do something about this thought”;

Check by reading through written notes and typing on screen. After approximately four checks (starting again if interrupted) with

prayers in between and drinks of water) she will say to herself “Come on – last time” before

carrying out a further check. It then “feels right” to stop.

Life events

24

Amy’s conceptualisation Vigilance about teeth. Having

objects around sink in a certain order with glass half full of

mouthwash.

I could need a filling or something might be wrong

with my teeth

I would be letting my grandfather down.

I would be letting my grandfather down and so be

unworthy, abandoned and bad. Frightening image of dental

cavity or diseased gum

Cleaning teeth gums with inspection of each tooth taking

about 20 minutes after food until it feels just right. Seeking

reassurance from dentist

Life

events

25

Phoebe - theory 1 and theory 2 • Theory 1 (for finding NCs)

• OCD says:

• The problem is I am incompetent. A mistake would be catastrophic as I would loose my job and be a failure.

• Evidence: My performance makes me anxious. It’s slow.

• If this is true, what do I need to do?

• To avoid making a (catastrophic) mistake and losing my job, I must read each document several times sticking to the OCD rules until I feel comfortable.

• What does this say about the future?

• Work will be a constant worry and grim struggle.

Theory 2 (for finding PCs and interweaves)

• OCD is:

• The problem is am a person with high standards who worries about my job and about making mistakes but who is competent.

• Evidence: The quality of my work is good. I am asked to mentor new staff.


• Make the odd small mistake deliberately to test out beliefs. Let go of control and trust myself. Let the thoughts go without doing anything about them.


• It looks OK.

26

Amy - theory 1 and theory 2 • Theory 1 (for finding NCs)

• OCD says:

• The problem is I must not have a filling or any blemish with my teeth. If I did it would be catastrophic as I would let my late grandfather down. I would be abandoned.

• Evidence: I have a strong feeling and conviction about this in the moment of OCD


• Clean mornings and evenings each time for 20 minutes inspecting each tooth with other cleans of lesser duration during the day.

• I do not know what a tooth needing a filling looks like, so I panic at anomalies and seek re-assurance from anyone (including the dentist). I can only stop the cleaning when “it feels right”.


• This will dominate much of my life causing anxiety.

Theory 2 (for finding PCs and interweave material)

• OCD is: The problem is am a person with high standards who worries about my teeth and have formed a link between my teeth and my deceased grandfather.

• Evidence: There are times when I realise too much brushing can damage my teeth which is not what my grandfather would have wanted.


• Brush as recommended – maximum 2 minutes.

• What would my grandfather advise me now?

• Express acceptance of the death of my grandfather and gratitude for his legacy to me of a compassionate inner voice (things that cannot be taken away). Having a filling, like any one else, would not be a big deal in these circumstances.

• Realise how his voice lives in me.


• It looks OK.

27

Resource installation and interweaves

• If a person is going to make the arduous changes in ERP, it is necessary to cultivate a vision of what is right about this person to motivate him or her. Some of many possibilities are listed below. Need for a compassionate observing part in BLS.

• Character strengths: “Via Survey of Character Strengths (Adult)” in www.authentichappiness. org / 100th Birthday (21st birthday for child) – values for living.

• Light source and Compassionate imagery (compassion and humour is toxic to OCD)

• Mindfulness including ACT metaphors (drop the rope, chess board, bus) – possible interweaves. Foreign bazaar metaphor. Defusing thoughts – especially obsessions.

• Spoofing catastrophic thoughts and images (humour to offset thought-action-fusion). Stories. Eminem. Mountain Lion. (Weg A.H. –reading list). Flashforwards.

• “Worry Hill” for child (Pinto Wagner – see reading list)

• Nickname for the OCD EP. Preferably humorous and distancing rather than aggressive.

• Cost benefit analysis or motivational grid.

• Cognitive Attentional Style and Attention Training Technique, Tiger, Detached Mindfulness (Wells, 2007).

• Level of urge reduction.

28

The biggest cause of resistance

• OCD has been called “the doubting disease”. Fear of uncertainty and inflated feelings of responsibility bring about negative core beliefs about the self (e.g. vulnerable, flawed, unworthy), others (e.g. superior) and the world (e.g. dismal) and this gradually erodes the sense of self and meaning in life. Unless the client develops an authentic sense of him- or her self, and moves towards a sense of meaning in life (towards something bigger than the OCD), attempts purely at symptom removal are likely to meet with huge resistance and longer term progress might be more precarious. It is no coincidence that OCD is often co-morbid with depression or learned hopelessness.

• “Doubts are more cruel than the worst of truths” Molière

• Jeff Bell (see reading list) a sufferer from OCD who has turned his condition around offers a far more eloquent guide to this transition than I could hope to replicate in this short talk. Basically belief is the opposite of doubt and by definition is about future uncertainty. His strongly recommended book explains to sufferers how they can “make belief” while drawing on the wisdom of others. While some might not entirely accept his theoretical underpinnings or personal beliefs there is considerable wisdom and practical experience in this book to help sufferers plan their own escape route from OCD. Acceptance and Commitment Therapy (ACT) appears to offer a similar approach.

29

How can EMDR help here?

• Choose to adopt a reverence towards self, others and the world. Affirm your potential..

• Visualise goals based on passion, valued living and finding personal meaning using mindfulness, compassionate mind training and positive psychology within EMDR. Even if OCD does not completely disappear it would in time be managed and the positive values would predominate.

• Resolve to fully complete ERP by facing fully the fear of uncertainty and inflated responsibility through EMDR protocol. Put commitments above comfort. Keep sight of the bigger picture, your valued life. Noting neutralising or avoiding and bring the person back to the fear till SUDS reduce.

• Acceptance not white flag to OCD but choosing mindful awareness of thoughts (not suppression).

• Deliberately switch attention from themes based on fear and doubt to those based on purpose and service. EMDR with focus on thoughts, feelings and bodily sensations can greatly assist with exposure particularly with issues of memory. EMDR can offer template for graduated in vivo exposure. Use of theratapper or other bls provided these help client to approach rather than avoid threat. However OCD can quickly convert threat approaching behaviours into rituals - so caution.

• Invest by making deliberate choices based on abundance of possibilities based on purpose and service, transforming OCD suggestions based on fear and doubt – hence scarcity of choices.

• Future template visualising possibilities and “acting as if” at first.

• Serenity prayer. Pain is given; suffering is optional.

30

Treating the OCD through EMDR

• There are various theories about OCD each with treatment successes. However it is a condition with diverse manifestations and so some flexibility of approach is indicated. The associative nature of BLS is helpful in understanding and working with the EP. EMDR is a suitable platform for helping to integrate an EP as AIP synchronises treatment at different interrelated points.

• Treating OCD as an EP could be integrative and flexible not just from the theoretical point of view but also for the sufferer from OCD. For example, if a person becomes stuck, asking the compassionate observing self to float back to the part in the grip of the OCD on the screen and communicate its own wisdom to this part might be more effective than, say, a guided discovery approach by the therapist.

• A key skill for the therapist would be to create and help maintain a mindful boundary between the compassionate observing self focused in the present (which feels the distress and physical tension) and the EP (on the screen) in the moment of OCD. The interaction across the boundary will assist integration.

• These integrative exercises might be effective in helping the sufferer to better understand the boundaries between the compassionate observing self and the OCD EP, and so help the client to overcome resistance to change.

31

A simple way of eliciting specific OCD and anti-OCD thinking (Mrs Horrid was a child’s nickname for OCD) 1 – useful for interweaves

• Some thoughts Mrs. Horrid wants you to have (tick which apply to you): • • If I didn't resist these thoughts, it means I'm being irresponsible • • I could be responsible for serious harm • • I cannot take the risk of this thought coming true • • If I don't act now then something terrible will happen and it would be my fault • • I need to be certain something awful won't happen • • I shouldn't be thinking this type of thing • • It would be irresponsible to ignore these thoughts • • I feel awful unless I do something about this thought • • Because I have thought about bad things happening, I must act to prevent them • • Since I have thought of this, I must want it to happen • • Now I have thought of things which could go wrong, I have a responsibility to make sure I don't let them happen • • Thinking this could make it happen • • I must gain control of my thoughts • • This could be an omen • • It is wrong to ignore these thoughts • • Because these thoughts come from my own mind, I must want to have them

32

A simple way of eliciting OCD and anti-OCD thinking (Mrs Horrid was a child’s nickname for OCD) 2

• Some thoughts that Mrs Horrid strongly discourages • • Thoughts CANNOT make things happen • • This is just a thought so it doesn't matter • • Thinking of something happening doesn't make me responsible for

whether it happens • • There's nothing wrong with letting such thoughts come and go naturally • • Everybody has horrible thoughts sometimes, so I don't need to worry

about this one • • Having this thought doesn't mean I have to do anything about it

33

Summary

• Hypothesis that the EMDR protocol offers a platform for treatment of OCD based on evidence based research as to efficacy of BLS because:

• It is holistic in its approach (as opposed to protocols which focus more directly on symptomatology);

• It is found acceptable by clients who reject, or are not suited to, more direct exposure techniques;

• It is integrative with other theories; • It offers specific protocols which are helpful; • It is effective; • It works with emotions such as disgust – not always amenable to exposure methods; • It works well when the obsessions have no overt compulsions; • And it assists personal growth.

• However there is a need for more research (RCTs, single case studies) to establish

EMDR as a mainstream treatment for OCD. • EMDR needs a refined yet flexible protocol which can also lend itself to empirical

research.

34

Email/brief reading list (not comprehensive) 1

• [email protected]

• Journal of EMDR Practice and Research articles:

• The “Flashforward Procedure”: Confronting the Catastrophe. Logie, Robin David Julian; De Jongh, Ad. Volume 8, Number 1, 2014, pp. 25-32(8)

•

• EMDR Treatment of Obsessive-Compulsive Disorder: Preliminary Research. Marr, John

• Volume 6, Number 1, 2012, pp. 2-15(14)

•

• Using Compassionate Mind Training as a Resource in EMDR: A Case Study. Beaumont, Elaine; Hollins Martin, Caroline J. Volume 7, Number 4, 2013, pp. 186-199(14)

• Treatment of Behavioral Addictions Utilizing the Feeling-State Addiction Protocol: A Multiple Baseline Study. Miller, Robert. Volume 6, Number 4, 2012, pp. 159-169(11)

•

•

35

mailto:[email protected]

Reading list and acknowledgements

• Cognitive Behavioural Therapy for OCD. Clark, David A. 2007 Guilford Press.

• Break Free from OCD: Overcoming Obsessive Compulsive Disorder with CBT . Challacoombe F., Oldfield V.B. and Salkovskis P.M.

• Metacognitive Therapy for Anxiety and Depression. Wells A. 2009 Guilford Press.

• Overcoming Obsessive Compulsive Disorder. Veale D and Willson R. 2005 Robinson.

• OCD Treatment through Storytelling. Weg A. H. 2011. Oxford.

• The Imp of the Mind. Baer L. 2002 Plume.

• When in Doubt Make Belief . Bell J. 2009 New World Library.

• Shapiro F. Blog. New York Times.

• The Compassionate Mind. Gilbert P. 2009. Constable.

• The Haunted Self. Van der Hart O., Nijenhuis E.R.S. and Steele K. 2006 W.W. Norton & Co.

• Brain Lock: Free Yourself from Obsessive-Compulsive Behavior . Schwartz J.M>.1996 ReganBooks.

• Up and Down the Worry Hill: A Children's Book about Obsessive-Compulsive Disorder and Its Treatment . Wagner A.P. 2000. Lighthouse Press

• Meyer V. (1966) Modifications of expectations in cases with obsessional rituals” Behaviour Research and Therapy, 4, 273-280.

• Van den Hout. M. and Kindt M. (2003) Repeated checking causes memory distrust. Behaviour Research and Therapy, 41, 301-316.

• Posttraumatic Stress Disorder: Malady or Myth? (Current Perspectives in Psychology). Brewin C. (2007)

36

treating resistance in ocd with emdr

Documents