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EMDR Therapy for Obsessions and Compulsions: A Guide for Therapists

Updated: Jul 10

Eye Movement Desensitization and Reprocessing (EMDR) therapy has proven to be an effective method for addressing a range of psychological issues, including obsessions and compulsions. This therapeutic approach can be particularly beneficial for individuals struggling with Obsessive-Compulsive Disorder (OCD), Compulsive Hoarding, Disordered Eating, and Body Dysmorphia. This article outlines a EMDR approach tailored for working with obsessions and compulsions specifically, providing practical steps and techniques for each phase of treatment.

Disclaimer: Working with acute moderate to severe OCD and eating disorder presentations requires an integrative, caring, and skillful multidisciplinary approach. This article is only focused on addressing obsessions and compulsions in clients who are stable and not at high risk. It does not cover all the complexities of these disorders. It is important to also note that EMDR therapists who are not trained in handling acute and severe cases of ED, OCD, and related disorders may risk moving too quickly into trauma processing, and must consider spending the necessary time in stabilization, preparation, resources phase to proceed. based on Robin Shapiro's and others work, the effectiveness of EMDR for clients who tend toward dissociation and avoidance of disturbing emotions is achieved through the stabilization phase. It is crucial to build a strong therapeutic relationship with Therapist holding Self-energy and to provide a safe and supportive environment for the client to begin to reprocess traumatic experiences.


In the article, we will also explore how Marr's (2012) work on adapting the EMDR protocol and the Distancing Technique by Krentzel and Tattersall can enhance the therapy process.

Healing Obsession and Compulsions
Wisdom in EMDR for Healing

Phase 1: EMDR History Taking for Obsessions & Compulsions

The initial phase of EMDR therapy involves thorough history taking to capture critical incidents, traumatic experiences, and current triggers. This step is essential for target selection and helps the therapist understand the client's background and resources. Key elements to capture include:


  • Critical Incident(s): Significant events that have impacted the client.

  • Traumatic Experiences: Past traumas that contribute to current symptoms.

  • Clients’ Resources: Strengths and coping mechanisms the client already has.

  • Sensitive or Disturbing Moments: Specific moments from experiences that are particularly distressing.

  • First Memory: The earliest memory related to the issue.

  • Worst Memory: The most disturbing memory related to the issue.

  • Recent Activating Events: Recent events that have triggered symptoms.

  • Current Triggers: A list of situations, thoughts, or images that trigger obsessive thoughts or compulsions.

  • New Triggers: Any new triggers that emerge during therapy.


Target Identification

Encourage clients to narrate the story of critical incidents, focusing on identifying sensitive or disturbing moments, which will become the targets for EMDR processing.


Phase 2: EMDR Preparation for Obsessions & Compulsions

In this phase, therapists use resource-building exercises to prepare clients for EMDR processing. Effective protocols and exercises include:


  • Grounding & Pendulation: Techniques to help clients oscillate between distressing and resourceful states.

  • Distancing Technique: Developed by Krentzel and Tattersall, this technique helps clients create psychological distance from distressing memories. It involves visualizing the memory as if it is happening to someone else or on a screen, thereby reducing emotional intensity.

  • Resource Development Installation: Installing positive resources to counteract negative emotions.

  • Safe/Calm Place: Creating a mental space where clients feel safe and calm.

  • Light Stream Technique: Using visualization to reduce stress and negative emotions.

  • Four Elements: Integrating earth, water, fire, and air elements for grounding.

  • Back of the Head Scale: Constantly orienting clients to present safety.


Phase 3: EMDR Assessment for Obsessions & Compulsions

During assessment, the adapted EMDR Phobia Protocol setup is used:


  1. Picture/Image of the Targeted Event: Ask the client to imagine rewinding the picture or image of the targeted event.

  2. Negative Emotion Identification: Identify the negative emotion associated with the event.

  3. SUD Scale: Measure the Subjective Units of Distress (SUD) for the negative emotion on a scale from 0 to 10.

  4. Negative & Positive Cognitions: Identify negative and positive beliefs related to the event.

  5. Body Sensation: Determine where the negative emotion is felt in the body.


Common Distortions and Example Targets

  1. The Rejected Self: Address feelings of rejection, shame, and appearance-related concerns.

    1. Target: Disturbing memories related to rejection and shame.

  2. Contamination: Overestimation of germ danger and underestimation of immune system capability.

    1. Target: Belief that touching doorknobs causes severe illness.

  3. Checking Compulsion: Fear of fires due to not checking the stove repeatedly.

    1. Target: Belief that not checking the stove will result in a house fire.

  4. Fear of Harm: Overestimation of control over external events.

    1. Target: Belief that not performing rituals will lead to harm.

  5. Symmetry Compulsion: Overemphasis on order to prevent negative outcomes.

    1. Target: Belief that misaligned objects will cause harm.

  6. Fear of Weight Gain: Overestimation of the impact of specific foods on weight.

    1. Target: Belief that any carbohydrate intake leads to weight gain.

  7. Body Image Distortion: Misperception of body size and health.

    1. Target: Belief in being overweight despite being underweight.

  8. Perfectionism in Eating: Overemphasis on perfect eating habits.

    1. Target: Belief that imperfect eating leads to failure.

  9. Fear of Judgment: Overestimation of others' focus on appearance.

    1. Target: Belief that others constantly judge based on body size and shape.


Common Obsessions List

Identify specific obsessions in the client's words, which can include thoughts, fears, or images related to:


  • OCD: Fear of contamination, causing harm, violence, imperfection, symmetry, unwanted sexual thoughts, religious obsessions, and excessive doubt.

  • Compulsive Hoarding: Fear of losing items, distress at discarding items, sentimental attachment, and fear of being wasteful.

  • Eating Disorders: Obsession with body weight, fear of gaining weight, preoccupation with food, distorted body image, and ritualistic eating behaviors.

  • Body Dysmorphia: Preoccupation with perceived physical flaws, excessive grooming, and seeking cosmetic procedures without satisfaction.



Phase 3: EMDR Desensitization for Obsessions & Compulsions


Marr's Adaptations for OCD

Marr's (2012) research on adapting EMDR protocols for OCD provides valuable insights for tailoring treatment. Marr emphasizes the importance of addressing the specific nature of obsessions and compulsions, focusing on both the cognitive and emotional aspects. This approach involves:


  • Customized Target Selection: Identifying specific obsessions and compulsions as targets for EMDR processing.

  • Cognitive Interweaves: Integrating cognitive interweaves to challenge distorted beliefs and reinforce adaptive thinking.

  • Gradual Exposure: Using a step-by-step approach to gradually expose clients to distressing thoughts and images, reducing their emotional impact over time.


In this phase, the adapted EMDR Phobia protocol focuses on desensitizing clients to their most disturbing triggers. Begin by identifying an image of the current trigger, the associated emotion, and any corresponding body sensations. For example, an image might be touching a doorknob (the most disturbing part), with emotions of anxiety and sensations of a racing heart. Have the client focus on the image, the emotion, and the bodily sensation while you perform bilateral stimulation (BLS) at a slow to moderate pace of 6-15 passes. Continue this process until the level of distress reduces to zero or as low as possible.


Following this, install a future template where the client envisions successfully managing similar situations without distress. Additionally, process past associated memories, including the first, worst, and most recent instances. This approach is particularly useful for clients whose obsessions overpower them, with a concern for potential destabilization. The primary goal is to desensitize these triggers to reduce the client’s engagement in obsessions and compulsions, thereby improving their overall stability and well-being.

Meditation
Mindful Internal Attention

Mental Video Playback Adaptation

To further adapt the desensitization process, use the mental video playback technique. This method allows the client to mentally replay a recent trigger, experiencing the associated emotions and bodily sensations within a safe and controlled environment. For clients with complex OCD, involving multiple activities, the mental video playback breaks down the anxiety into smaller, manageable pieces.

This way, the client only has to focus on one small step at a time, making the overwhelming nature of their obsessions and compulsions more approachable. By playing back the video in their mind, the client can achieve detailed desensitization of every aspect of the OCD event, gradually eliminating their fears and empowering them to handle similar situations in the future. Although this technique shows promise, further research is needed to investigate these hypotheses and validate the effectiveness of this approach in clinical settings.


The Distancing Technique by Krentzel and Tattersall

The Distancing Technique developed by Krentzel and Tattersall is particularly useful for clients with high levels of distress. This technique helps clients create psychological distance from distressing memories by:


  • Visualization: Encouraging clients to visualize the memory as if it is happening to someone else or on a screen.

  • Reduced Emotional Intensity: By viewing the memory from a detached perspective, clients can reduce the emotional intensity and process the memory more effectively.

  • Enhanced Coping: This technique enhances clients' ability to cope with distressing memories and reduces the likelihood of re-traumatization.


3 Core Distancing Approach Elements with Obsessions and Compulsions

  1. Marr’s adapted EMDR Phobia Protocol

  2. Distancing Technique: creation of Adaptive Coping Statements (ACS)

  3. Future Rehearsal (EMDR methods with CBT’s exposure response prevention to desensitize OCD triggers)


Key Elements of the Distancing Approach:

Creation of Adaptive Coping Statements

  • Adaptive Cognitive Statements (ACSs) are positive self-statements that serve to correct the client’s maladaptive stance. These statements are designed to increase insight and create a sense of distance from OCD symptoms. Examples of ACSs include, “A thought is just a thought,” “I don’t have to respond to this feeling,” and “I don’t need to listen to what my brain says.” These statements help clients reframe their thoughts, recognizing them as mere thoughts rather than reality. By doing so, ACSs broaden the client’s resources and build their capacity to access these resources effectively. Additionally, these statements can serve as effective interweaves during the EMDR process, aiding in the therapeutic intervention by reinforcing positive cognitions and perspectives.


Desensitization and Reprocessing:

  • The core of the EMDR process is used to target and reprocess the specific obsessions and compulsions characteristic of OCD. This includes addressing the over-importance of thoughts, the need to control thoughts, and the thought-action fusion often seen in OCD patients. In the distancing Approach Marr's Adaptive EMDR Phobia Protocol is used.


Future Rehearsal:

  • This technique involves visualizing and mentally rehearsing future scenarios where OCD triggers might occur. The client practices responding to these triggers without engaging in compulsive behaviors. This method integrates the EMDR Phobia Protocol, which helps in processing and desensitizing these feared future events.


Benefits of the Distancing Approach:

  • Enhanced Insight: Clients develop a better understanding of their OCD symptoms and learn to distinguish between thoughts and reality.

  • Reduced Symptom Severity: Through desensitization and the development of coping strategies, clients experience a reduction in the severity of their OCD symptoms.

  • Improved Quality of Life: With effective management of OCD symptoms, clients can lead more fulfilling lives, experiencing less distress and more positive emotions.


Conclusion

EMDR therapy offers a structured and effective approach for addressing obsessions and compulsions. By carefully selecting targets, preparing clients with resource-building exercises, and utilizing compassionate protocols like the Loving Eyes Protocol, therapists can help clients process traumatic memories and reduce distressing symptoms. Integrating Marr's adaptations and the Distancing Technique by Krentzel and Tattersall further enhances the therapy process, providing a comprehensive framework for treating various obsessive-compulsive and related disorders. This guide provides a foundation for therapists to effectively use EMDR in treating obsessions and compulsions, helping clients achieve lasting relief and improved quality of life.


With love, AGLOW


Stacy Ruse, LPC, RYI, EMDR & IFS Consultant


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AGLOW is a global hub for therapists and the world. Led by trauma expert Stacy Ruse, LPC, providing courses, consultation, and counseling services. Specializing in EMDR, IFS, Yoga, & Transpersonal therapies to inspire therapists and individuals alike.


Stacy Ruse, LPC, is an esteemed Evergreen EMDR & IFS-Institute Consultant, Registered Yoga Teacher (RYT), and founder of Aglow Counseling. Stacy teaches a therapeutic style that is characterized by the art of EMDR & IFS therapies with a transpersonal twist, transcending the conventional boundaries of traditional therapy. Her holistic approach acknowledges the interconnectedness of mind, body, and spirit allowing individuals to tap into their innate resilience and ignite their personal transformation journey. As a trauma expert, national and international trainer, and clinical consultant, Stacy's approach is deeply rooted in trauma-informed methodologies.


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