EMDR Therapy and OCD
Guest Blog Post by C. Paula Krentzel and Jennifer Tattersall
Tell us a little about you, your experience becoming an EMDR therapist, and your experience working with people struggling with obsessions and compulsions.
In 2017, Paula Krentzel, Ph.D., created The Distancing Technique while working with a client who displayed OCD symptoms. She and Jennifer Tattersall, LCSW, collaborated and further developed the technique. They began teaching The Distancing Technique at regional EMDR groups in 2018. In 2021 Dr. Krentzel and Ms. Tattersall presented at the EMDRIA National Conference and the EMDR Conference in Canada. At that time, Dr. Krentzel and Ms. Tattersall began using distancing with clients diagnosed concurrently with dissociative identity disorders and OCD. In 2023, they understood they had a comprehensive EMDR treatment approach to working with obsessive-compulsive disorder. The technique was updated and became the Distancing Approach.
Can you briefly help us understand a little more about OCD, its prevalence, and how it might show up for a client?
Across the globe, there is about a 1.6% prevalence of OCD in the general population (Nicolini, 2017). This suggests that biology may be a determining factor in OCD. Those who suffer from OCD may have a genetic component to their disorder and/or have a trauma-based component. Cromer, Schmidt, and Murphy (2007) reported that patients with exposure to traumatic events in childhood were five to nine times more likely to meet the criteria for OCD, while those who experienced sexual abuse were up to seven times more likely to meet the criteria for OCD. Patients with OCD report more physical abuse and neglect in childhood than anxious and nonclinical samples. Trauma in childhood also increases the risk of developing post-partum OCD. According to the World Health Organization, OCD is ranked seventh in terms of debilitating illnesses, including medical illnesses.
Popular culture identifies a limited number of behaviors as OCD. OCD is more than the known contamination/cleaning, sexual/religious, or aggressive type. Other less well-known forms of OCD are relational and Meta-OCD. Relational OCD is checking on the status or having continuous doubts about the attachment relationship. Meta-OCD is having obsessive symptoms over whether they are experiencing OCD. It is not unusual for a client with OCD to have multiple obsessions and/or compulsions. Once an obsession and/or a compulsion is worked on in treatment, another may arise or become noticeable.
The same OCD behavior can have distinct functions depending on the individual. For example, one client with contamination OCD may fear wearing a sports mouthguard due to social anxiety of being part of a team, whereas a different client’s underlying fear is thinking that they are not good enough to be on a team. In both cases, contamination OCD is the symptom. In the first case, the client avoids the fear of being part of a team, whereas in the second case, the client avoids confronting their fear of thinking they are not good enough or imperfect.
Can you share about working clinically with OCD? How can EMDR therapy help people struggling with obsessions and compulsions?
Clients may experience OCD-type behaviors years before experiencing those behaviors as distressing. When OCD interferes with social, occupational, or school functioning, the person requires professional assistance. The interference in daily life is determined by the amount of time and avoidance of engaging in activities that the client deems distressing. Guillén-Font et al. (2021) reported that poor insight is related to poorer treatment outcomes, greater symptom severity, younger age of onset, and worse prognosis. Insight is understanding that the obsessions and compulsions are OCD and not rational.
Dr. Krentzel and Ms. Tattersall have worked with clients with moderate to severe OCD and have been able to reach subclinical or mild OCD.
OCD symptoms may increase when the client has a catastrophic interpretation of a thought, image, urge, or sensation or when the client observes an event in their environment, such as someone talking about, reading, or watching a scene on the television, and has a catastrophic interpretation of what they are observing. This catastrophic interpretation of internal and external events may trigger an increase in obsessive or compulsive behavior. A comprehensive history, including the history of obsessive thoughts, compulsions, and any past trauma, is essential. It is also important for the clinician to understand that OCD is often considered a traumatic experience in and of itself for the client.
For EMDR-trained clinicians, it is essential when working with a client with OCD that the first, worst, and most recent activating OCD experiences be reprocessed using EMDR therapy. In addition, it is essential to identify events that trigger an increase in OCD behavior.
The therapeutic work will have to be as relentless as the OCD and will have to address OCD symptoms anytime they arise, even between sessions or within the session itself. The labeling of behavior or thoughts as OCD is one of the kindest forms of attunement therapists can offer.
Clinicians are to familiarize themselves with standardized diagnostic tools such as the Yale-Brown Obsession Compulsion Scale-Second edition, the BECK depression inventory, and the GAD 7 to address any comorbidities. OCD is often hidden from the therapist, and often the client experiences distress but does not know that it is OCD. Due to the plethora of research on the relationship between trauma and OCD, the clinician must take a thorough trauma and attachment history as part of treatment planning.
What else can you tell us about EMDR therapy with folks dealing with OCD?
EMDR is an alternative treatment to cognitive behavioral therapy and Exposure and Response Prevention therapy. Krentzel and Tattersall’s experience in treating this population suggests that the presentation of aggressive or sexual OCD is particularly traumatizing for many clients. In addition, EMDR also addresses the traumatizing aspects of the OCD presentation and can address the client’s worst fear. Finally, the work of Krentzel and Tattersall on developing The Distancing Approach appears to enhance EMDR’s efficacy in working with this population.
Shapiro’s (2001) adaptive information processing model (AIP) hypothesizes that during EMDR reprocessing, dysfunctional memory networks are linked with more adaptive information, resulting in the development of insight and a broader understanding of the past event. In applying the AIP model to working with OCD, the clinician assists the client in reprocessing dysfunctional memory networks, such as the first time the OCD interfered with daily living, past traumas that are associated with the OCD, and current situations that trigger OCD. New adaptive information is developed to assist the client in gaining insight into what contributes to the increase and/or decrease of OCD symptomatology.
Are there any myths you would like to bust about using EMDR therapy with these clients?
There are several myths regarding OCD. First, the general population has been taught that compulsions are “habits” such as hand washing, repeated checking, or organizing. However, clients’ compulsions can also be repeated internal thoughts or images.
Second, people confuse rumination with OCD. Rumination is a form of problem-solving. The person ruminating can stop and start thinking. With OCD, the client cannot control the intrusive thoughts, images, sensations, or urges. Obsessive thoughts are intrusive and time-consuming and cannot be stopped; however, with treatment, obsessions can be decreased or eliminated. People talk about OCD behaviors offhandedly, such as, “Oh, that’s my OCD.” However, people who have OCD experience a great amount of suffering and shame.
Another myth is that when a person with aggressive or sexual OCD indicates they have intrusive thoughts about hurting another person, they will act on these thoughts. These clients often experience distress and shame over having OCD thoughts, images, or sensations. These thoughts cause a great deal of distress. For clinicians, a thorough clinical history is imperative. If clients have hurt others in the past and are having aggressive thoughts, that is a different diagnostic category.
Are there any specific complexities or difficulties that people coping with obsessions and compulsions deal with that other populations may not? How does this affect therapy?
One of the major differences between treating OCD using EMDR therapy is that clients will have homework to learn to manage their OCD symptoms. Guillén-Font et al. (2021) reported that poor insight is related to poorer treatment outcomes, greater symptom severity, younger age of onset, and worse prognosis. Spouses, parents, and families need to be involved in the treatment process so that they do not reinforce OCD behaviors.
There are usually other comorbidities, such as depression, ADD/ADHD, anxiety, and eating disorders with all types of OCD. People with OCD often do not feel understood, do not belong, or are disgusting or vile. With aggressive OCD, it is common for clients to express the negative cognition, “I’m a bad person.”
OCD is a psychological disorder that needs to be managed throughout the lifespan, when a client with OCD that is subclinical experiences a new life stressor symptom, the OCD may arise again.
With treatment, the client can recognize the emergence of a new OCD behavior or thought and respond with the tools learned in treatment. The client can have a neutral rather than a catastrophic interpretation of the behavior and thus, dismiss this new behavior without increasing symptomology. In summary, with treatment, clients with OCD have the potential to live a full life that is not shameful or intensely distressing. These clients manage their OCD such that they can find joy and all the human emotions that are part of daily life.
What multicultural considerations might EMDR therapists need to consider regarding EMDR therapy and OCD?
Few studies have examined how OCD is influenced by culture. It is important to understand the person’s cultural identity, including ethnicity, race, gender, sexual orientation, religion or spiritual beliefs, socioeconomic class, education, and history of migration. The client’s cultural explanation of OCD is also to be evaluated.
Nicolini and colleagues (2017) reviewed studies on the impact of culture on the presentation of OCD. Although not much research has been reported on the impact of culture, several studies have shown differences among cultures on the type of obsessions and the severity of the symptomatology. More research is needed to understand the complex nature of the impact of culture on the presentation of OCD.
What is your favorite free resource to suggest to other EMDR therapists on this topic?
- The podcast “OCD Stories” https://theocdstories.com/
- The video explaining OCD to children (www.youtube.com/watch?v=J1kjw0kmMds) is clear, concise, and informative
- The International OCD Foundation had informative and helpful information
- And EMDRIA members: Stay Tuned! “The Distancing Approach: A comprehensive EMDR Psychotherapy for Obsessive Compulsive Disorder” (Krentzel and Tattersall) is to be published January 2024 in The Journal of EMDR Practice and Research.
Dr. Krentzel has been a practicing psychologist for three decades, is a certified EMDR clinician and an Approved EMDR Consultant and Facilitator. She was trained at Massachusetts General Hospital and Children’s Hospital, Boston, MA. She is trained in AEDP, Sensorimotor Psychotherapy, Structural Dissociation and completed the 200-hour requirements for Yoga teacher training. Dr. Krentzel has developed The Distancing Approach – A comprehensive EMDR psychotherapy for OCD. She presented at EMDR Canada and EMDR International Association in 2021.
Ms. Tattersall has worked in a variety of settings and has worked with adults for over 20 years and has been EMDR trained for 9 years. She is currently pursuing AEDP certification. She is trained in Sensorimotor Psychotherapy, Hypnotherapy, Structural Dissociation, and completed the 200-hour requirements for Yoga teacher training. Tattersall has co-presented The Distancing Approach- A comprehensive EMDR psychotherapy for OCD. She presented at the EMDR International Association Annual Conference in 2021. Dr. Krentzel and Ms. Tattersall have collaborated on several training courses; namely, “Ego State and Distancing, Ego State and EMDR – How to Work with Complex PTSD and Dissociative Disorders” and “Distancing with Children and Teens.”
Cromer, K., Schmidt, N., & Murphy, D. (2007.) An investigation of traumatic life events and obsessive-compulsive disorder. Behavior Research and Therapy, 45(7), 1683-1691. https://doi.org/10.1016/j.brat.2006.08.018
Daniels, N. (2017). What is OCD? Explaining Child OCD to Kids. YouTube. https://www.youtube.com/watch?v=J1kjw0kmMds
Guillén-Font, M. A., Cervera M, Puigoriol Emily, Foguet-Boreu Q, Arrufat FX, Serra-Millàs M. (2021). Insight in obsessive-compulsive disorder: Relationship with sociodemographic and clinical characteristics. Journal of Psychiatric Practice, 27(6):427-438. https://doi.org/10.1097/pra.0000000000000580
Krentzel, CP., & Tattersall, J. (In press, 2024). The distancing approach – a comprehensive EMDR psychotherapy for obsessive-compulsive disorder. To be published January 2024, EMDR Journal of Theory and Practice.
Krentzel, C. P., & Tattersall, J. (2021.) The distancing technique: OCD and anxiety disorders, how to treat with EMDR. Presented at the EMDRIA Annual Conference. EMDRIA OnDemand: https://www.emdria.org/course/the-distancing-technique-ocd-and-anxiety-disorders-how-to-treat-with-emdr/
Krentzel, C. P., & Tattersall, J. (2021.) Distancing technique for treating OCD, panic, and phobias – how to treat with EMDR therapy. Webinar, presented at EMDR Canada.
Nicolini, H., Salin-Pascual, R., Cabrera, B., & Lanzagorta, N. (2017.) Influence of culture in obsessive-compulsive disorder and its treatment. Current Psychiatry Review, 13(4), 285 – 292. https://doi.org/10.2174%2F2211556007666180115105935
Shapiro, F. (2001.) Eye movement desensitization and reprocessing: Basic principles, protocols, and procedures (2nd ed.). New York, NY: The Guilford Press.
Resources on EMDR and OCD
Beniwal, A., Jamwal, A. S., Biswas, D., Brar, T., & Saran, B. (2022). A case report on the effectiveness of virtual eye movement desensitization and reprocessing therapy in childhood OCD. International Journal of Food and Nutritional Sciences, 11(10), 908-910. Open access: www.ijfans.org/issue-content/a-case-report-on-the-effectiveness-of-virtual-eye-movement-desensitization-and-reprocessing-therapy-in-childhood-ocd-3164
Bohm, K. R. (2019). EMDR’s efficacy for obsessive-compulsive disorder. Journal of EMDR Practice and Research, 13(4), 333-336. Open access: https://dx.doi.org/10.1891/1933-3126.96.36.1993
Bohm, K., & Voderholzer, U. (2010). Use of EMDR in the treatment of obsessive-compulsive disorders: A case series. Verhaltenstherapie, 20(3), 175-181. https://doi.org/10.1159/000319439
Castle, D., Feusner, J., Laposa, J. M., Richter, P. M. A., Hossain, R., Lusicic, A., & Drummond, L. M. (2023). Psychotherapies and digital interventions for OCD in adults: What do we know, what do we need still to explore? Comprehensive Psychiatry, 120, 152357. Open access: https://doi.org/10.1016/j.comppsych.2022.152357
Cusimano, A., (2018). EMDR in the treatment of adolescent obsessive-compulsive disorder: A case study. Journal of EMDR Practice and Research, 12(4), 242-254. Open access: https://dx.doi.org/10.1891/1933-3188.8.131.52
de Jongh, A., & ten Broeke, E. (2009). EMDR and the anxiety disorders: Exploring the current status. Journal of EMDR Practice and Research, 3(3), 133-140. Open access: https://dx.doi.org/10.1891/1933-3184.108.40.206
de Veer, M. R., Waalboer-Spuij, R., Jan Hijnen, D., Doeksen, D., Busschbach, J. J., & Kranenburg, L. W. (2023). Reducing scratching behavior in atopic dermatitis patients using the EMDR treatment protocol for urge: A pilot study. Frontiers in Medicine, 10. Open access: https://doi.org/10.3389/fmed.2023.1101935
Gorgulu, S. A. (2020). Trichotillomania treatment based on trauma: Case report. Archives of Clinical and Medical Case Reports, 4(1), 158-163. Open access: http://dx.doi.org/10.26502/acmcr.96550181
Keenan, P., Farrell, D., Keenan, L., & Ingham, C. (2018). Treating obsessive-compulsive disorder (OCD) using eye movement desensitization and reprocessing (EMDR) therapy: An ethno-phenomenological case series. International Journal of Psychotherapy, 22(3), 74-91. www.ijp.org.uk/shop/product.php?product=495
Marr, J. (2012). EMDR treatment of obsessive-compulsive disorder: Preliminary research. Journal of EMDR Practice and Research, 6(1), 2-15. Open access: https://doi.org/10.1891/1933-3220.127.116.11
Marsden, Z. (2016). EMDR treatment of obsessive-compulsive disorder: Three cases. Journal of EMDR Practice and Research, 10(2), 91-103. Open access: https://doi.org/10.1891/1933-318.104.22.168
Marsden, Z., Lovell, K., Blore, D., Ali, S., & Delgadillo, J. (2017). A randomized controlled trial comparing EMDR and CBT for obsessive-compulsive disorder. Clinical Psychology & Psychotherapy, 25(1), e10-e18. https://doi.org/10.1002/cpp.2120
Mazzoni, G. P., Pozza, A., La Mela, C., & Fernandez, I. (2017). CBT combined with EMDR for resistant refractory obsessive-compulsive disorder: Report of three cases. Clinical Neuropsychiatry, 14(5), 345-356. Open access: www.clinicalneuropsychiatry.org/clinical-neuropsychiatry-volume-14-issue-5-october-2017/
Nazari, H., Momeni, N., Jariani, M., & Tarrahi, M. J. (2011). Comparison of eye movement desensitization and reprocessing with citalopram in treatment of obsessive-compulsive disorder. International Journal of Psychiatry in Clinical Practice, 15(4), 270-274. https://doi.org/10.3109/13651501.2011.590210
Nijdam, M. J., van der Pol, M. M., Dekens, R. E., Olff, M., & Denys, D. (2013). Treatment of sexual trauma dissolves contamination fear: Case report. European Journal of Psychotraumatology, 4, 19157. Open Access: https://doi.org/10.3402/ejpt.v4i0.19157
Potick, D. (2017). “Winter is Coming!” – treatment of obsessive-compulsive disorder imagery after viewing the television series Game of Thrones. Journal of EMDR Practice and Research, 11(3), 147-161. Open access: https://doi.org/10.1891/1933-322.214.171.124
Potick, D., Moghrabi, F., & Schreiber, S. (2020). Case report: Pharmacotherapy and EMDR psychotherapy as an effective treatment for OCD imagery in a patient with a psychotic disorder. The Israel Journal of Psychiatry and Related Sciences, 57(1), 47-54. Retrieved from: https://ijp.doctorsonly.co.il/2020/07/201628/
Pozza, A., Mazzoni, G. P., Neri, M. T., Bisciglia, R., La Mela, C., Fernandez, I., & Dettore, D. (2014). “Tackling trauma to overcome OCD resistance” (The TTOOR Florence trial): Efficacy of EMDR plus CBT versus CBT alone for inpatients with resistant obsessive-compulsive disorder. Protocol for a randomized comparative outcome trial. American Journal of Applied Psychology, 2(5), 114-122. Open access: http://pubs.sciepub.com/ajap/2/5/3
Sarichloo, M. E., Taremian, F., Dolatshahee, B., & Haji Seyed Javadi, S. A. (2020). Effectiveness of exposure/response prevention plus eye movement desensitization and reprocessing in reducing anxiety and obsessive-compulsive symptoms associated with stressful life experiences: A randomized controlled trial. Iranian Journal of Psychiatry and Behavioral Sciences, 14(3), e101535. Open access: https://dx.doi.org/10.5812/ijpbs.101535
Talbot, D. (2021). Examination of initial evidence for EMDR as a treatment for obsessive-compulsive disorder. Journal of EMDR Practice and Research, 15(3), 167-173. Open access: http://dx.doi.org/10.1891/EMDR-D-21-00004
EMDRIA. (2022). EMDR therapy and OCD with Dr. Kendhal Hart. Let’s Talk EMDR Podcast. https://www.emdria.org/letstalkemdrpodcast/
Bohm, K. (2016). Obsessive-compulsive disorder and EMDR therapy. In M. Luber (Ed.), Eye movement desensitization and reprocessing (EMDR) therapy scripted protocols and summary sheets: Treating anxiety, obsessive-compulsive, and mood-related conditions (pp. 102-136). New York, NY: Springer Publishing Co.
Marsden, Z., & Bohm, K. (2023). EMDR therapy and OCD. In D. Farrell, S. J., Schubert, & M. D. Kiernan (Ed.), The Oxford handbook of EMDR. https://doi.org/10.1093/oxfordhb/9780192898357.013.8
Popky, A. J. (2005). DeTUR, an urge reduction protocol for addictions and dysfunctional behaviors. In R. Shapiro (Ed.), EMDR solutions, pathways to healing (pp. 167-188). New York, NY: W. W. Norton and Co.
Shapiro, R. (2009). Attachment, affect tolerance, and avoidance targets in obsessive-compulsive personality disorder. In (Author), EMDR solution II, for depression, eating disorder, performance, and more. New York, NY: W. W. Norton and Co.
Zampieri, M. A. J. (2023). EMDR safety platform for early and transgenerational trauma: Description and an OCD application. In J. Y. Elshimali (Ed.), Research developments in medicine and medical science Vol. 8 (pp. 84-98).
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