Treating Obsessive Compulsive Disorder (OCD)

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PAUL KEENAN, DEREK FARRELL, LYNN KEENAN & CLAIRE INGHAM

Treating Obsessive Compulsive Disorder (OCD) using Eye Movement Desensitisation and Reprocessing (EMDR) Therapy: An Ethno-Phenomenological Case Series Paul Keenan, Derek Farrell, Lynn Keenan & Claire Ingham

Abstract Obsessive Compulsive Disorder (OCD) is a bio-psycho-socio-cultural disorder that includes genetic, neural brain anomalies, traumatic experiences, and development of dysfunctional beliefs frequently learnt from others and from the environment. Current empirical research supports Cognitive Behavioural Therapy (Exposure and Response Prevention) as the ‘gold-standard’ psychological treatment intervention. However, clients with OCD often describe their anxieties as the result of an exposure to earlier adverse life experiences (past), or as a worst fear (future) related to their symptomatology, by onset or maintenance features. This case-series design study explored the impact of EMDR Therapy with eight clients diagnosed with OCD, yet despite having received previous treatment – CBT (ERP) – were still OCD symptomatic. The research methodology was that of Ethno-Phenomenology. Psychometric results highlighted a promising treatment effect of EMDR Therapy by reducing anxiety, depression, obsessions, compulsions and subjective levels of disturbance. Despite promising initial results with a small survey, more conducted research with this important clinical population is essential. Keywords: OCD, EMDR, CBT, Obsessions, Compulsions, Trauma _____________________ Introduction Obsessive Compulsive Disorder (OCD) is an anxiety mental health condition in which people experience unwanted and repeated thoughts, ideas, feelings, sensations or behaviours. These compel the person to act upon them, either by actions to rid the obsessive thought, neutralising behaviour to bring on short-term symptom relief, or by not performing an obsessive ritual, which can then generate significant anxiety (Leahy, 2017). Current US estimates some 2.2 million adults suffer the condition with OCD being the fourth most prevalent psychiatric condition, striking men and women equally (Weaton & van Meter, 2014). Faulty appraisals and confrontational control strategies correlate to both distress and frequency of intrusions (Clarke & Radomsky, 2014). Salkovskis & Kobori (2015) consider International Journal of Psychotherapy: Nov. 2018, Vol. 22, No. 3, pp. 74-91: ISSN 1356-9082 © Author and European Association of Psychotherapy (IJP): Reprints and permissions: www.ijp.org.uk Submitted Nov. 2017; peer-reviewed twice (March, 2018), reformatted May/June 2018; revised July 2018.

TREATING OBSESSIVE COMPULSIVE DISORDER (OCD) USING EYE MOVEMENT 75 the characteristics of obsessions to be intrusive, unacceptable, uncontrollable, subjectively resistant and ego-dystonic. Table 1 outlines the key aspects of OCD contained within the ICD-10 diagnostic classification. Ostensibly, OCD is a bio-psycho-socio-cultural disorder that includes genetic, structural brain changes, adverse life experiences and environmental factors. It is still mostly unknown as to what actually causes OCD, or ‘triggers’ it, however, researchers consider that the discovery of a genetic marker on chromosome 9 – near a gene called ‘protein tyrosine phosphokinase’ (PTPRD) – may lead to a better understanding of the condition and provide more insight into effective treatment interventions (Goddard et al., 2008). Obsessive-compulsive disorder, F42: Anxiety disorder characterized by recurrent, persistent obsessions or compulsions: obsessions are the intrusive ideas, thoughts, or images that are experienced as senseless or repugnant; compulsions are repetitive and seemingly purposeful behaviour which the individual generally recognizes as senseless and from which the individual does not derive pleasure although it may provide a release from tension. Table 1: The ICD-10 classification of mental and behavioural disorder (WHO, 1993) There is increasing evidence of genetic contributions to the aetiology of OCD, although the condition probably has quite a complex pattern of inheritance (Nestadt et al., 2000). The medical- biological basis of OCD explores three distinct components: 1. Medical Conditions: Evidence of obsessions and compulsions in certain medical disorders, such as: Schizophrenia, Parkinson’s Disease, Huntington’s Chorea, Tourette Disorder, Traumatic Brain Injury and Tumours (Grados et al., 2001; Stein, 2000). 2. Pharmacology: The impact that anti-depressant medication (SSRI’s / SNRI’s) has made in controlling both compulsions and obsessions suggests strong evidence for a neuropharmacological hypothesis that serotonergic systems can modulate OCD symptomatology. It is also suggested that dopaminergic mechanisms are affected by neuroleptic medications, especially when used in conjunction with anti-depressant medication, and this can also have a beneficial impact also in the treatment of OCD (Micallef & Blin, 2001). 3. Brain Imagery and Biology: Although Functional Magnetic Resonance Imaging (fMRI) demonstrates increased metabolic activity in certain brain areas, however a primary pathological process that underlies any core OCD symptoms has not been identified to date. Functional imaging studies have established that metabolic or perfusion in the cortico-striatal-thalamocortical Circuit (CSTC) pathways are affected. However, despite these important elements, there is still uncertainty surrounding the genetic and environmental bases of OCD. One can conclude therefore that the biological underpinnings of the disorder are not as yet properly established. The identification of genetic and environmental causes of OCD requires more research to raise expectations that more rationale treatments will become more available and preventative measures more possible (Nestadt, Grados & Samuels, 2010). Social learning theory considers that clients with OCD may have ‘learnt’ to be anxious through prior contact with others, predominantly through primary caregivers, albeit through actions, perceived dangers or evidence of avoidance behaviour. The family provides a socially constructed environment, which provides a rich opportunity for learning; however, larger cultural factors also influence social learning. Still, these influences may play a significant role in the aetiology of OCD.

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Cognitive models consider anxious people, particularly those who worry excessively, are more likely to be more intolerant of uncertainty. Intolerance of Uncertainty (IU) is defined as a dispositional characteristic that results from a negative set of beliefs about uncertainty and its implications and involves the tendency to react negatively on an emotional, cognitive and behavioural level to uncertain situations and events (Tolin et al., 2003). How these tendencies manifest in OCD is that clients wish to know the outcome – with absolute certainty – before engaging in any ‘risky or aversive behaviour’. Individuals with IU experience this uncertainty as: upsetting and stressful; something to be avoided; and thus they often have trouble functioning in uncertain situations (Buhr & Dugas, 2002). This IU model potentially explains some of the development and maintenance factors within OCD, where symptoms are perpetuated by an imagined ‘worst fear’ scenario (Tolin et al., 2003). These worst fears can often be catastrophic in nature, extremely detailed in content, and subjectively disturbing in the present. Currently the main psychological treatment intervention for OCD – for both adults and children – is Cognitive Behavioural Therapy [CBT] (Barton, 2013; Clarke, 2011; Eddy et al., 2004; Gyani, 2012; NICE, 2005; Veale & Roberts, 2014). Although CBT extols itself as the ‘gold standard’ for OCD related disorders, the behavioural component of the treatment - Exposure and Response Prevention (ERP) targets cessation of repetitive behaviours (Hofmann et al., 2012; Olatunji, Cisler & Deacon, 2010), whereas the cognitive element focuses upon four areas: irrational beliefs, distorted cognitions, psychoeducation and improving motivation. Despite strong empiricism supporting CBT (ERP) as an effective treatment intervention for OCD, not all clients respond well to the intervention, with recovery rates varying significantly (Roth & Fonagy, 2013). Current treatment interventions view OCD as a ‘stand-alone’ psychiatric disorder. However, there is an increasing evidence-base that is exploring the origins of OCD stemming from adverse life experiences, which may include (or induce) Post-Traumatic Stress Disorder [PTSD] (Carpenter & Chung, 2011; Cromer, Schmidt & Murphy, 2007; de Silva & Marks, 1999; Doron et al., 2009; Dyskhoorn, 2014; Fonagy, 1999; Heim & Nemeroff, 2001; Lochhner et al., 2002; Mathews, Kaur & Stein, 2008; Myhr, Sookman & Pinarrd, 2004). According to Bohm & Voderholzer (2010) and Bohm & Luber (2016), this raises an interesting question – if adverse life experiences (traumas) are a potential facet of OCD, then an argument exists for the utilisation of ‘evidence-based’ trauma treatment interventions being integrated with CBT [Exposure and Response/Ritual Prevention]. One such potential trauma treatment suitable for integration is EMDR Therapy – an empirically-supported therapy currently endorsed by the World Health Organisation (2013) as one of only two psychological treatments for Post-Traumatic Stress Disorder (PTSD). EMDR Therapy Eye Movement Desensitization and Reprocessing (EMDR) therapy is an eight-phase, standard protocol, psychological treatment intervention that emphasizes the physiological information processing system in the origin and treatment of mental health issues. Its theoretical basis is the Adaptive Information Processing (AIP) model, which holds that the primary source of psycho-pathology is the presence of memories of adverse life experiences that have been insufficiently processed in the brain (Shapiro, 2014, 2016; Shapiro & Forrest, 2016; Shapiro & Solomon, 2017). The context of AIP, a trans-diagnostic conceptual framework, considers adverse life experiences as ubiquitous and transcend conventional diagnostic frameworks

TREATING OBSESSIVE COMPULSIVE DISORDER (OCD) USING EYE MOVEMENT 77 (Farrell, 2015; Shapiro, 2012, 2016). This in turn raises an intriguing question – what impact would EMDR Therapy have as a ‘sole’ treatment intervention with OCD? Although not all OCD clients have adverse life experiences that generate presently held levels of disturbance, the ‘Intolerance of Uncertainty (IU)’ model can be useful in addressing OCD clients’ experiences of cognitive bias, which then in turn, distort how an individual perceives, interprets and responds to uncertain situations (Wheaton, 2016). This IU model is entirely consistent with the EMDR Therapy Adaptive Information Processing (AIP) paradigm theoretical framework in that OCD is often driven, and potentially maintained by, a future orientated ‘worst fear. EMDR Therapy addresses this future orientated aspect through the use of a ‘Flash-Forward’ technique. EMDR Therapy first purported the idea of the ‘Flash-forward’ as a specific intervention – initially in the treatment of phobias (de Jongh, 2008) however this was originally used with regard to suicide-related images (Holmes et al., 2007). The ‘Flash-forward’ technique (see also Logie & de Jongh, 2014; Romain, 2013) is described as: . . . fear of future danger is common after a threatening event and may take the form of future-oriented mental images. These may appear like “flash-forwards,” echoing “flashbacks” in posttraumatic stress disorder (PTSD) and possess sensory qualities, being vivid, compelling, and detailed (Englhard, 2011, p. 599). The essential elements of the ‘Flash-forward’ technique in EMDR Therapy involves: o A detailed and still picture; o Containing catastrophic elements of what might happen in the future; o A context that is specific and conceptually related to client’s symptoms; o Intrusive and disturbing affect (Logie & de Jongh, 2014) To all extent and purposes, the Flash-forward technique in EMDR Therapy is an adaptation of a CBT intervention that explored suicide-related images and Hofmann’s EMDR Therapy Inverted Protocol (Hofmann, 2009; Holmes et al., 2007). The ever-increasing evidencedbased practice (EBP) and practice-based evidence (PBE) of EMDR Therapy is used in supporting the potential effectiveness of the utilisation of EMDR with other mental health conditions other that Post Traumatic Stress Disorder (Farrell et al., 2010; Maxfield, 2009). There are also case-series designs treating OCD itself (Bohm & Voderholzer, 2010; Carpenter & Chung, 2011; Pozza & Dèttore, 2014). If the condition suggests evidence of a stressful life event that may have precipitated the disorder, then the potential for using EMDR Therapy is pertinent. A detailed case history should confirm this. Evidence suggests a large correlation between adverse life experiences, childhood trauma, and the onset of OCD. This supports a 50% prevalence of childhood trauma in treatment resistant OCD (Cromer, Schmidt & Murphy, 2007a & b; Doron et al., 2009; Dykshoorn, 2014; Fonagy, 1999; Mathews, Kaur & Stein, 2008; Myhr, Sookman, Pinard, 2004; Nazari et al., 2011) Nazari et al. (2011) carried out an intriguing study comparing EMDR Therapy with the SSRI ant-depressant, Citalopram, where ninety subjects with a diagnosis of OCD were randomly assigned into two groups – (a) EMDR Therapy or (b) prescribed Citalopram, with each group being treated over a 12-week period. Using the psychometric Yale-Brown Obsessive-Compulsive Scale (Y-BOC), the results demonstrated significant improvement in both groups, as highlighted by pre-and post-measures. Follow-up results suggested that EMDR Therapy was more efficacious than Citalopram. However, this research is not without critical consideration – the study used sub-doses of Citalopram, as indicated in the pharmacological treatment of OCD, by using doses recommended for depression, rather

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than the higher doses indicated for OCD. In addition, no fidelity checks were made of the EMDR Therapy intervention and follow-up times were extremely short. Nonetheless, the results were promising. A further study highlighted the effectiveness of EMDR Therapy integrated within CBT(ERP), demonstrating the effectiveness of the intervention with a 60% reduction in Y-BOC scores (Bohm & Voderholzer, 2010). Research findings concluded that between 15-40% of OCD patients did not respond to CBT-(ERP), experienced reduced motivation towards treatment, high drop-out rates, persistent difficulties in managing emotions, and a tendency to become overwhelmed by the treatment intervention (Ibid). Nonetheless, the utilisation of EMDR Therapy – as a different treatment intervention for OCD – raises interesting questions worthy of further investigation: and this became the primary motivation for undertaking this particular research study. This research investigation wanted to explore the impact of using EMDR Therapy, as a ‘stand-alone’ treatment intervention for OCD, in order to establish a robust argument for proceeding towards a randomised control study. Materials and Methods The study utilised a Clinical Case Series design integrating an ethno-phenomenological approach. A case series is a sample of individuals, who have experienced a similar adverse health-related issue – namely OCD in this case – to determine if there are any inferences regarding the association between the issue and a psychological treatment intervention (EMDR Therapy). This is considered via psychometric assessment – pre, post, 1-month and 3-month time intervals. This data will form the backdrop of this research paper. A second strand to the methodology is ethno-phenomenology. This research methodology is a fusion between ethnography – the cultural sharing of an experience – and phenomenology, which focuses upon the lived experience (Assay & Lambert, 1999; Baros, 2014). The rationale for ethno-phenomenology is that the research needs to consider the methodological underpinnings of the dual position of the principal investigator, being both clinician and primary researcher, and the different theoretical roles of the research of both observer and participant. A limited focus is given to this aspect in this paper, which is reserved instead for further research publication. In any psychological treatment intervention, not just with clients with OCD, the therapeutic relationship itself is an agent of change (Laska & Wampold, 2014; Marr, 2012; Tschacher, Haken & Kyselo, 2015; Wampold, 1997; Wampold, 2011), so the psychotherapist immersed within the overall psychological treatment experience is thereby an ‘agent of change’, hence – ethnography. At the same time, the client (as both research subject and participant) is utilising their own lived experience as the primary foci of the psychological treatment intervention, hence – phenomenology. To contextualise this further, although each research participant would receive the same psychological treatment intervention (EMDR Therapy) from the same EMDR Therapy clinician (EMDR Europe Consultant), nonetheless the target issues selected for processing are different for each client. Targets for EMDR Therapy Processing (Phases 3-7) for clients with OCD may potentially include: o Traumatic incidents (memories) – onset of OCD or maintenance factors o Imaginary, or real life, triggers of obsessions or compulsion o Automatic and intrusive disturbing imagery

TREATING OBSESSIVE COMPULSIVE DISORDER (OCD) USING EYE MOVEMENT 79 o Underlying dynamics and conflicts o Worst fears / Catastrophic elements The really important phase in EMDR Therapy is that of Phase 8: ‘Re-evaluation’. This phase commences at the start of the next session, after Trauma Processing (Phases 3 – 7) has occurred. Re-evaluation effectively co-ordinates the overall treatment plan, based on the feedback from the client reporting about the previous session. The EMDR Therapy clinician utilises their clinical judgement, in consultation with the client, to determine how the treatment proceeds subsequently. This again highlights the ethno-phenomenological aspect to the EMDR Therapy Treatment Intervention within the context of this research. Although each research participant / client is receiving EMDR Therapy, only the ‘targets’ (traumatic memories) selected for processing are unique to each client’s issues of disturbance. Although this was a predominantly qualitative research study, the reduction of any variable factors was mitigated by robust, external fidelitychecking of the treatment intervention. The rationale for this research study was to consider if EMDR Therapy would be effective in reducing obsessive compulsive symptoms, with clients diagnosed with OCD (APA, 2013), using an evidenced-based (WHO (2013); NICE (2005)) recognised treatment for PostTraumatic Stress Disorder (PTSD). As a result, the research contained six distinct questions: For clients meeting the DSM-5 (APA, 2013) criteria for Obsessive Compulsive Disorder (OCD), what impact does EMDR Therapy have on: 1. Subjective Units of Distress (SUD) and Validity of Cognition (VOC) 2. The overall symptoms of OCD, as measured by the Yale-Brown Obsessive-Compulsive Scale (Y-BOC) 3. Sub-scale Compulsion symptoms, as measured by the Y-BOC 4. Sub-scale Obsession symptoms, as measured by the Y-BOC 5. Levels of Generalised Anxiety, as measured by the GAD-7 6. Levels of Depressive symptoms, as measured by the Patient Health Questionnaire (PHQ-9) Research Participants The primary target group for this research study utilised nine specific inclusion criteria: 1. Fulfilling the DSM-5 diagnostic classification for OCD (APA, 2013) 2. Having previously experienced CBT intervention, specifically for OCD, within the last 5 years 3. Participants needed to have exhibited a minimum symptom duration of at least 1 year 4. Evidence that – despite previous CBT treatment – their OCD symptoms had not abated and that their current OCD symptoms continued to impact on the Social & Occupational Levels of Functioning scale 5. Aged between 16-65 years 6. Willing to commit to the complete psychological treatment intervention and provide informed consent 7. Agreement to complete all psychometric data for the duration of the study (including the ‘post-treatment’ studies 8. All treatment sessions to be DVD recorded for fidelity checking purposes

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PAUL KEENAN, DEREK FARRELL, LYNN KEENAN & CLAIRE INGHAM 9.

Participate in a post-treatment qualitative research interviews – also digitally recorded A critical requirement for recruitment was the intentionally of enlisting those clients with a long-standing history of OCD that, despite being clinically challenging, were motivated to participate in a treatment intervention (EMDR Therapy) which, to date, has only limited empirical support as a primary treatment intervention for OCD. Despite the prevalence of OCD, given the specific inclusion criteria for this study and the time factor, the study was always going to result in small numbers being recruited. However, the specific intention was to recruit at least eight participants meeting the studies specific research inclusion criteria. The exclusion criteria for the study included: – an active thought disorder; other nonrelated mental health conditions; and the commencement or change in psychiatric medication in three months prior to carrying out the agreed research treatment protocol (except for those in relationship therapy and/or supportive intervention / therapy for depression). Ethical approval was successfully acquired through Edge Hill University, UK. An opportunity sample, matching the specific inclusion criteria, was used. Eight research participants were successfully recruited into the study. The research participants had all the following characteristics: o Aged between 20 – 59 (average 40 years) o 50:50 Male/Female o 62.5% currently prescribed and utilising anti-depressant medication o Previously diagnosed by either a Consultant Psychiatrist or Consultant Clinical Psychologist as meeting the DSM-5 criteria for OCD The participants’ specific OCD issues are highlighted in Table 2. As previously stated, all the research participants had on-going OCD symptomatology and had all received a course of OCD-focussed cognitive behavioural psychotherapy (NICE, 2006) within the last five years. For the purpose providing more detail about the results, the eight participants were categorised as: either in a trauma group; or not in a trauma group. With the trauma group, the primary target memory related to a previous traumatic experience; and for the nontrauma group, this utilised the Flash-Forward (Inverted Protocol) approach, in line with the IOU model. Primary OCD Issue for Research Participants Client A: Contamination (Asbestos) Client B: Contamination/Disgust Client C: Checking and Safety Behaviours Client D: Fear of being lesbian or gay

Past Trauma: Standard Protocol No Past Trauma (IOU): Flash-forward Flash-forward Standard Protocol Flash-forward Flash-forward

Client E: Unwanted violent or sexual thoughts

Standard Protocol

Client F: Scrupulosity

Standard Protocol

Client G: Contamination [maggots]

Standard Protocol

Client H: Symmetry and Routine

Flash-forward

Table 2: Research Participants Primary OCD Issue and Targets for EMDR Therapy Processing Phases 3-7

TREATING OBSESSIVE COMPULSIVE DISORDER (OCD) USING EYE MOVEMENT 81 Psychological Treatment Intervention Design and Psychometric Measures Figure 1 (below) outlines the structure of the research design used for the study. The rationale for eight EMDR therapy sessions was to replicate psychological treatment sessions offered within Improving Access to Psychological Therapies (IAPT) in Primary Health Care services within UK. Participants were provided with a research information sheet that outlined: the purpose of the research study; consent, inclusion/ exclusion criteria; the right to withdraw without prejudice; along with details about each member of the research team. Psychometric measures used for the study included: Yale-Brown Obsessive-Compulsive Inventory (Goodman, Price & Rasmussen, 1989); PHQ-9 (Kroenke, Spitzer & Williams, 2001); and the GAD-7 (Spitzer, Kroenke, Williams & Löwe, 2006). A non-treating member of the research team co-ordinated and collected the psychometric data from the research participants. Assessment Interview

Eight Session EMDR Therapy Treatment Intervention

1-month follow-up

3-month follow-up

Figure 1: Outline Structure of the OCD Research As mentioned earlier, all sessions were digitally recorded (DVD), however the clients had the option of appearing either ‘on’ or ‘off ’ screen. A full explanation of the rationale for the DVD was explained to the clients in the participant information sheet, with particular regards to fidelity checking the EMDR Therapy treatment intervention, using the EMDRIA EMDR Therapy Rating Scale. A further consideration of the fidelity checking was to ensure that no CBT interventions were being integrated into the treatment approach. A non-treatment member of the research team (EMDR Europe Accredited Trainer & BABCP Accredited CBT Therapist) carried out the necessary fidelity checks. Results from the fidelity check assured high fidelity to EMDR Therapy in each of its eight phases. All DVD recording were securely stored on a password-protected computer and kept under the conditions incorporated in accordance to the Data Protection Act (1998). Results Throughout the study, each participant experienced eight EMDR Therapy treatment sessions, each lasting between 60-90 minutes. All clients seemed to utilise the clinical time well and appeared motivated towards the treatment intervention and towards instigating change. Furthermore, all the clients demonstrated high levels of motivation in their commitment to the research process. For the purpose of clarity, from the outset, each of the participants knew the Primary Clinician as a clinician of reputation in his specialised area of treating OCD with CBT (ERP), and that this was a factor in participant recruitment. Each client only received EMDR Therapy and subsequent fidelity checks ensured no paradigm drift and high EMDR Therapy treatment fidelity. Figure 2 highlights the overall changes in the Subjective Unit of Disturbance (SUD) and the Validity of Cognitions (VOC) of the eight research participants. When processing occurred, not all the target memories were completely resolved within the same session. However, by the end of the eight sessions, each identified target memory– whether using the Standard Protocol or Flash-forward – had been successful resolved. The results suggest an overall reduction in SUD and increase in VOC.

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PAUL KEENAN, DEREK FARRELL, LYNN KEENAN & CLAIRE INGHAM Impact of Processing EMDR Therapy Phases 3-7: N=8 10 9 8 7 6 5 4 3 2 1 0 Pre Processing

Post Processing SUD010

VOC17

Figure 2: Subjective Unit of Disturbance (SUD) and Validity of Cognitions (VOC) Scores Figure 3 demonstrates the overall treatment effect on each of the three main psychometric measures: Y-BOC, GAD-7 and PHQ-9 for the entire group of eight participants. 25 20 15 10 5 0 Pre

Post YBOC

1month GAD7

3Months

PHQ9

Figure 3: Y-BOC, GAD-7 and PHQ-9 Scores (N=8) As Table 2 highlighted, not all the research participants disclosed evidence of previous trauma experiences (N=4), however, four of them did. Consequently, the EMDR Therapy treatment sessions factored this into the treatment management of the eight sessions. As mentioned previously, those who had disclosed past trauma experiences – connected or related to their OCD – were treated using the EMDR Therapy Standard Protocol; and those who had described no past trauma experiences, but instead, were distressed by a future, ‘worst case’, catastrophic scenario, where treated using the EMDR Therapy Flash-forward Protocol. Figure 4 highlights the differences between the Standard and the Flash-forward Protocol. That said, within the research – no attempt was made to test either the effectiveness

TREATING OBSESSIVE COMPULSIVE DISORDER (OCD) USING EYE MOVEMENT 83 nor efficiency of both these EMDR Therapy protocols, either independently or in comparison to each other. Nonetheless, it does raise interesting questions, and potential direction for future research and development.

YBOC Total Scores N=8 25 20 15 10 5 0 Pre

Post Flash-forward

1-month

3-month

Standard Protocol

Figure 4: Y-BOC Scores comparing the Standard and Flash-forward Protocols The Y-BOC contains two sub-scales – Compulsions and Obsessions (Goodman, Price & Rasmussen, 1989). Figure 5 demonstrates the sub-scale scores for compulsions and Figure 6 the sub-scale scores for obsessions. Both compare differing scores for the Standard Protocol and Flash-forward. As results indicate, there is a continuing reduction at 3-month follow-up, for both interventions; and there is a more marked reduction with the Standard Protocol although both protocols demonstrate symptom reduction.

YBOC Sub-score: Compulsions N=8 14 12 10 8 6 4 2 0 Pre

3-month Flash-forward

Standard Protocol

Figure 5: Y-BOC Subscale – Compulsions, comparing Standard and Flash-forward Protocol

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Y-BOC Sub-score: Obsessions N=8 12 10 8 6 4 2 0 Pre

3-month Flash-forward

Standard Protocol

Figure 6: Y-BOC Subscale – Obsessions, comparing Standard and Flash-forward Protocol

GAD-7 Scores N=8 12 10 8 6 4 2 0 Pre

Post Flash-forward

1-month

3-month

Standard Protocol

Figure 7: GAD-7 Scores comparing the Standard and Flash-forward Protocol

PHQ-9 Scores N=8 12 10 8 6 4 2 0 Pre

Post Flash-forward

1-month Standard Protocol

3-month

Figure 8: PHQ-9 Scores comparing Flash-forward with the Standard Protocol

TREATING OBSESSIVE COMPULSIVE DISORDER (OCD) USING EYE MOVEMENT 85 Figures 7 and 8 also demonstrate symptom reduction in the research population with regards to GAD-7 and PHQ-9. A similar trend in each figure highlights that the Standard Protocol witnessed a greater reduction in symptoms. Overall, the results indicate a positive impact of the EMDR Therapy Intervention with all eight research participants. Discussion Results seem to indicate that the EMDR Therapy treatment was effective as a ‘stand-alone’ treatment for OCD as measured by SUD, VOC, Y-BOC, GAD-7 and PHQ-9 – as demonstrated by figures 2 and 3. Although the study never set out to compare the EMDR Therapy Standard Protocol with the Flash-forward it was purely coincidental that the research participant group was equally split between the two versions of the protocol. However, preliminary results seem to suggest that those research participants with past traumas (Standard Protocol) had more improved psychometric scores than those using the Flash-forward. Further research is needed to explore this difference more thoroughly. A review of research participant’s progress between treatment sessions, was carried out in Phase 8: Re-evaluation, which is a practice that is highly consistent with EMDR Therapy Intervention. Feedback was then utilised, in negotiation with the research participants, to form the direction of ‘target memories’ selected next for processing – i.e. from EMDR Therapy Phases 4, 5 & 6. This highlights the ethno-phenomenological aspect of the research – although the primary focus was EMDR Therapy – the treatment programme itself was highly collaborative and thus tailored to the specific needs of the client / research participant. The eight session EMDR Therapy treatment sessions were adapted to the needs of the client’s OCD symptoms, rather than making the clients fit the EMDR Therapy model. However, these ethno-phenomenological aspects will be explored in more detail in subsequent publications about this study. The results from Figure 5 are consistent with existing data in support of EMDR Therapy, and – in fact – the reduction in SUD and the increase in VOC with all eight research participants is almost identical to Shapiro’s original Ph.D. study and seminal work (Shapiro, 2001). Figure 6, as mentioned earlier, shows some evidence of symptom reduction, although it was interesting that – for the PHQ-9 – there was a slight increase at post-treatment point. In discussing this with the research participants, their consistent feedback focussed on a desire for more ‘treatment sessions’ and some anxiety that the ‘treatment was coming to an end’. However, at the 1-month and the 3-month check, a reduction in their PHQ-9 scores was in evidence. Although the rationale for eight treatment sessions was to replicate current UK Health Care practice with this OCD client group, every research participant expressed a desire for more therapy time than the number of sessions allocated. Mindful of this, it is worth bearing in mind that the overall symptom reduction (brought about by just eight treatment sessions) was still significant with, what was after all, a difficult and challenging clinical population. Results from Y-BOC, total and sub-scale scores, yield interesting data consistent with CBT[ERP] (Rector et al., 2009). No attempt was made in this study to directly compare the Standard Protocol with Flash-Forward. Nonetheless, an interesting research question emerges for future consideration – for example, is one protocol more effective, more efficient, and better tolerated, than the other? Figures 8 and 9 yield intriguing results with symptom reduction showing for both of the sub-scale scores for compulsions and obsessions. The data set suggests a more marked

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reduction for obsessions, in relation to compulsions, and rationale for this could be that obsessions tended to be more ‘future orientated’, if the obsessional ‘future anxiety’ is processed (EMDR Therapy: Phase 4, 5 & 6) then potentially, is it easier to see reductions in obsessions, that is in thoughts, as opposed to reductions in actual compulsive behaviours. This sort of dynamic obviously needs further exploration and consideration. As the Y-BOC is an established psychometric for OCD, the important message is that EMDR Therapy revealed symptom reduction – which is certainly intriguing – and is, again, worthy of further investigation and future research. The rationale for using GAD-7 and PHQ-9 (Figures 7 & 8) is that these are established psychometrics with UK National Health Service’s IAPT (Improving Access to Psychological Therapies) services. The explicit intention of the research was to collect data that makes it important, and able, to compare it with the existing CBT data. Symptom reduction on all of these psychometrics – post, 1-month and 3-month – suggest potential promise in using EMDR Therapy as a treatment intervention for OCD. Although both psychometrics yield results highlighting symptom reduction, again the ‘Standard Protocol’ results are more marked in comparison to the ‘Flash-forward’ results – but again, more research is needed to explore this potential distinction further. Although this was predominantly a qualitative study, albeit a very labour intensive one, the research participant group was both highly specific and relatively small. Consequently, no statistical analysis of the data was carried out, nor deemed appropriate to this study. The results acquired through undertaking this study suggest the potential for ‘scalability’ – moving towards the construction of a larger Randomised Control Study (RCT) which specifically compares different treatment interventions (CBT/ERP, EMDR Therapy, Integrative intervention, TAU, Waiting List, etc.,) and also the potential component parts, for example: ‘Standard Protocol’ versus ‘Flash-forward’. The intention of this paper was to present psychometric data from the study – later publications will explore, in more detail, some of the qualitative data. However, the rationale for using ethno-phenomenology was to account for the EMDR Therapist being an ‘agent of change’ as part of the treatment intervention. As mentioned previously, this was to explicate the twin roles of treating clinician and principal research investigator. To emphasize this point further, feedback received from the research participants described their EMDR Therapist as: o Being very experienced as a mental health clinician; o Being proficient and highly experienced as an EMDR Therapist; o Having a natural ability to establish an effective, robust therapeutic relationship; o Being confident in their therapeutic interventions and treatment planning; o Having a detailed knowledge and understanding of OCD; o Being accommodating, empathic, but at the same time challenging and robust; o Being safe, effective and efficient; o Having an enhanced commitment – a real sense of being ‘in it together’ and being ‘truly collaborative’. Despite the clinicians only using EMDR Therapy, these integral therapeutic factors were also part of the psychotherapeutic process and thus potential ‘agents of change, either individually, collectively, or in constellation. The feedback from the research participants, of the treating clinician, was overwhelmingly positive. A consideration – if these interviews had been carried out by another person, might different feedback have been received? There is some merit in this argument. Although the feedback received was very welcome, it was, nonetheless, only positive. In mind of this, might the research participants’ have demonstrated

TREATING OBSESSIVE COMPULSIVE DISORDER (OCD) USING EYE MOVEMENT 87 ‘demand characteristics’ to potentially extol the positive, rather than the negative regarding their experiences? This phenomenon may also be true regarding the psychometric data, as no attempt (within the study) was made to triangulate the research participants’ data and experiences. That said, for the treating clinician, adhering solely to the utilisation of using EMDR Therapy, rather than CBT(ERP + EMDR for this OCD client group, was clinically challenging, as there were many times when the urge to reinforce ERP and changes in behaviour was very strong. As the EMDR Therapy treatment sessions were relatively few, research participants may have presented as ‘better’ than they may have been. There could be other factors worthy of consideration: including various client factors (motivation, resilience, perseverance, etc.) and / or hope and expectation characteristics (rather than a specific psychotherapeutic approach or method) used to explain the treatment effect. Although a degree of caution needs to be exercised, the research, despite being very labour intensive, suggests that EMDR Therapy was well-tolerated by all eight participants and was successful in bringing about some symptom reductions in their OCD presentation. Conclusion This research study demonstrates three considerations: Firstly, that the theoretical framework of EMDR Therapy (Adaptive Information Processing) has some potential, even if only partially, in explaining various symptomatology within OCD by exploring adverse life experiences (past, present or imagined future), that generate presently held levels of disturbance; Secondly, results appear to indicate that the use of EMDR Therapy, for those clients with OCD, can bring about some symptom reduction, (however, caution needs to be expressed that this is only within the context of the psychometrics measures utilised within the study and some of the feedback received from the qualitative interviews); Thirdly, that further research is needed to explore the potential of using EMDR Therapy as – either a ‘stand-alone’ treatment intervention – or in conjunction with other empirically validated interventions, such as CBT (ERP) and / or pharmacology, to determine greater effectiveness and to maximise efficiency. That said, the results from this small, yet intensive study, shows some promise that EMDR Therapy may be considered as a useful psychological treatment intervention for those clients with Obsessive Compulsive Disorder. Authors Derek Farrell (Corresponding & Submitting Author) is a Principal Lecturer in Psychology at the Institute of Health & Society, Worcester University, UK. E-mail: [email protected] Paul Keenan is a Senior Lecturer in Mental Health, at Edge Hill University, Faculty of Health and Social Care, Lancashire, UK. E-mail: [email protected] Lynn Keenan is an EMDR Europe Accredited Consultant/ Facilitator & Accredited CBT Practitioner at Mersey Psychotherapies in Birkenhead, Merseyside, UK. E-mail: [email protected] Claire Ingham is an EMDR Accredited Europe Practitioner & Accredited CBT Practitioner at Mersey Psychotherapies in Birkenhead, Merseyside, UK. E-mail: [email protected]

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Declarations Ethics approval and consent to participate: We, the authors, declare that Ethical Approval for the study as granted by Edge Hill University, Ormskirk, Lancashire, United Kingdom. Furthermore, consent to participate was obtained from each research participant. Consent to publish: We, the authors, provide our consent to publish Availability of data and materials: We, the authors, declare that all data underlying the findings described in this manuscript is fully available without restriction Competing interests: We, the authors, declare no competing interests in the undertaking, carrying out or subsequent publication and dissemination of the research findings. Authors’ Contributions: The primary writers for the publication were Derek Farrell and Paul Keenan Acknowledgements: Lynn Keenan and Claire Ingham for their contribution to the study Data availability: We the authors declare that all data underlying the findings described in this manuscript is fully available without restriction Funding: None Declaration of Conflict of Interest: None References ACT, D.P. (1998). c. 29. UK Parliament. APA DSM-V. (2013). Diagnostic and statistical manual of mental disorders (DSM-5). Washington, DC: American Psychiatric Association. ASAY, T.P. & LAMBERT, M.J. (1999). The Empirical Case for the Common Factors in Therapy: Quantitative findings. In: M.A. Hubble, B.L. Duncan & S.D. Miller (Eds.), The Heart and Soul of Change: What works in therapy, (pp. ٢٣-٥٥). Washington, DC, US: American Psychological Association. BARROS, R. (2014). The Portuguese Recognition of Prior Learning (RPL) policy agenda: Examining a volatile panacea by means of ethno-phenomenological interpretations. Encyclopaideia, 18(40), pp. 53-68. BARTON, R. & HEYMAN, I. (2009). Obsessive–Compulsive Disorder in children and adolescents. Paediatrics and Child Health, 19(2), pp. 67-72. BELLECCI-ST ROMAIN, L. (2013). EMDR With Recurrent “Flash-Forwards”: Reflections on Engelhard et al.’s 2011 Study. Journal of EMDR Practice and Research, 7(2), pp. 106-111. BÖHM, K. & VODERHOLZER, U. (2010). Einsatz von EMDR in der behandlung von zwangsstörungen: Eine fallserie. [Use of EMDR in the treatment of obsessive-compulsive disorders: A case series]. Verhaltenstherapie, 20(3), pp. 175-181. BRIGGS, E.S. & PRICE, I.R. (2009). The relationship between adverse childhood experience and obsessive-compulsive symptoms and beliefs: The role of anxiety, depression, and experiential avoidance. Journal of Anxiety Disorders, 23(8), pp. 1037-1046. BUHR, K. & DUGAS, M.J. (2002). The Intolerance of Uncertainty Scale: Psychometric properties of the English version. Behaviour Research and Therapy, 40(8), pp. 931-945. CARPENTER, L. & CHUNG, M.C. (2011). Childhood trauma in Obsessive-Compulsive Disorder: The roles of alexithymia and attachment. Psychology and Psychotherapy: Theory, Research and Practice, 84(4), pp. 367-388. CLARK, D.A., PURDON, C. & BYERS, E.S. (2000). Appraisal and control of sexual and non-sexual intrusive thoughts in university students. Behaviour Research and Therapy, 38(5), pp. 439-455. CLARK, D.A. & RADOMSKY, A.S. (2014). Introduction: A global perspective on unwanted intrusive thoughts. Journal of Obsessive-Compulsive and Related Disorders, 3(3), pp. 265-268. CLARK, D.M. (2011). Implementing NICE guidelines for the psychological treatment of depression

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