SHARING SPACE I: Reduction of Anxiety and Pain in Labor and Delivery Using an EMDR Model: A Single Case Study*
ABSTRACT: A single case study in the treatment of anxiety and pain associated with labor and childbirth using an Eye Movement Desensitization model in 5 sessions. The client ultimately delivered a baby via Cesarean Section with a spinal block, but reported that the therapeutic procedure aided in reduction of medication and anxiety during the experience. In the debriefing session, she reported that the process allowed her to maintain a sense of calm and control.
Several psychological modalities for pain, anxiety and relief, such as hypnosis, have been used in pregnancy and childbirth over the past 45 years. Eye Movement Desensitization and Reprocessing (EMDR) is another such modality. However, its use in the management of peripartum pain and anxiety has not been described in the literature. EMDR was first discussed by Shapiro (1989) as a procedure that enables rapid and effective treatment of traumatic and anxiety complaints. EMDR is based on desensitization of negative cognitions and installation of positive processes or thoughts by use of planned, rapid, rhythmic eye movements and internal body scanning of the results. The client rates the level of anxiety using a 10-point Subjective Units of Disturbance Scale (SUDS) where 0 represents neutral intensity and 10 equals the highest possible anxiety (Wolpe 1991). The client follows the therapist's finger as it moves rapidly from side to side 20-25 times. This activity is conducted while the client is instructed to focus on an image of an anxiety-provoking situation or thoughts and (internally experiences the associated irrational cognition or negative self-statement). The psychotherapist monitors the decrease in SUDS level of anxiety during the process. Upon desensitization of the negative cognitions, an installation of identified (desired) positive cognitions is performed using the same eye movements. The patient rates the success of this process through a 7 point semantic differential scale-designated the Validity of Cognition (VOC) scale where 1 represents \"completely false\" and 7 means \"completely true\" (Shapiro 1995). The client then internally scans his or her body for unexplained sensations indicating incomplete work or thoughts.
Studies have shown this technique to be highly effective in treating the stress-related symptoms of Post-traumatic stress disorder (PTSD) and other anxiety states (Marquis, 1991; Puk, 1991; Shapiro, 1989; Wolpe & Abrams, 1991). EMDR has been found to be increasingly efficient in the treatment of PTSD and anxiety compared with hypnosis, biofeedback and exposure treatments (Azar 1995). Since childbirth pain is enhanced in anxiety states, measures for reducing anxiety are thought to reduce the pain experienced in childbirth. The purpose of this paper is to report on the use and findings of prenatal childbirth preparation using EMDR. This report is based on the single-case study method. The application of EMDR, modified for childbirth preparation, is described.
A 34-year-old primipara at seven months gestation, sought psychological services to help her experience labor and childbirth with minimal or no use of sedation. The client was effectively treated approximately 2 years prior to pregnancy for smoking cessation using EMDR. Although she had a history of athletic training, and accepted pain associated with the burn of physical training, she had reported an extreme fear of unexplained pain, for example a headache or body ache would first be thought of as a tumor. The identified negative cognitions (measured by SUDS) to be desensitized were unexplained pain. The self-identified positive installations measured by VOC were the image of the baby and the positive and athletic energy to move the baby (the positive end result).
The application of the technique was modified from the original form described by Shapiro (1989), and resembled the EMDR model for smoking cessation introduced by Popky (1992). The model incorporates EMDR, Ericksonian hypnosis and anchoring devices of NeuroLinguistic Programming (NLP). The personal background information and introduction of the procedure were abbreviated for this client since she had previous use of this modality.
A total of five prenatal sessions were performed. Preparation for the therapeutic procedure was divided into four steps: (1) additional background information, (2) identification and reinforcement of the therapeutic processes to be used, (3) client identified the positive and negative cognitions (perception) associated with labor and birth, and (4) labor rehearsal using \"moving picture\" imagery of the pain and anxiety associated with the childbirth process. This client identified her SUDS as 10 for the pain to be experienced and 8 for the anxiety associated with the pain.
The procedure was conducted in four stages within the five sessions. First, EMDR of the pain and anxiety was practiced. This was followed by a labor rehearsal where the labor/childbirth process was divided into seven patient-identified segments and EMDR was performed for each segment in the \"moving picture\" imagery. The third stage included the guided imagery of the seven-segment labor process which was then done in reverse-order from birth to the beginning of labor. This was continued on the fourth session.
The fifth psychotherapy session utilized hypnotherapy. While the client was in a hypnotic trance, the following procedure in four stages was used:
1. The client was asked to go through her \"moving picture\" image. She was instructed that, if at any time she could not resolve the pain or anxiety, she should open her eyes and follow the therapist's fingers to do EMDR until the negative thoughts were resolved. At that time she should close her eyes and continue with the \"moving picture\" process in the hypnotic state.
2. Upon completion of the forward order labor rehearsal, the EMDR intervention with hypnosis was then repeated with reverse-order labor (birth to labor phases).
3. The client was then asked to split her \"moving picture\" image of labor into three sections in a \"panoramic mind's picture\": a) on the right the process moving forward from labor to birth, b) on the left the process in reverse; and c) center was a still picture of the baby and mother after birth. The hypnotic and EMDR procedure was repeated. At the end of the process, using EMDR, the three images were integrated and merged.
4. The client was then asked to hold the one image (a positive cognition) and double it, then EMDR was performed (while under hypnotic trance). This segment was repeated two additional times. At the end of this segment, (while under hypnosis) the client was given a NLP anchoring/trigger device on her wrist. Both husband and wife were trained as to its application.
Upon completion of this procedure, the client reported the following SUDS, pain: 10 and anxiety: O, VOC = 7. She reported that although the pain remained at the same level, she now could make more sense of it and that it was necessary in order to move the baby. A body scan performed by the client identified that no further work was necessary.
The client failed to dilate significantly. On Day 3 after her expected due date, she was admitted to the hospital to induce labor, which was described as painful and unsuccessful. After 30 hours, a Cesarean section with a spinal block resulted with a successful delivery. During the debriefing session, the client indicated that the EMDR procedure allowed her to maintain a sense of calm and control. She also stated that self-triggering of the EMDR-induced NLP anchor allowed her a feeling of more control during the surgical procedure. She reflected that self-triggering gave more of a sense of control to her than her husband or support coach doing it for her. She reported reflecting back on the procedure that normally the attempts to induce labor and the Cesarean section would have made her feel \"out of control\" without the use of EMDR. At 6 months post delivery, the client believes that the EMDR procedure was successful and will use it again in approximately one year for her second pregnancy.
In this one case study, the EMDR model of reduction of anxiety associated with labor and delivery was shown to be an effective technique during the induction of labor and Cesarean section childbirth. Future studies should focus on the effectiveness of non-complicated pregnancies ending in vaginal deliveries. Future studies optimally would include a good clinical history for obtaining the necessary negative and positive cognitions and moving picture images necessary during the EMDR procedure.
* Use of Eye Movement Desensitization & Reprocessing (EMDR) in labor and delivery clients.
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Raymond J. Taylor, Ph.D.
Raymond J. Taylor, Ph.D. is in private practice, as a Licensed Clinical Social Worker and Certified Trauma Specialist. He received his Ph.D. in Psychology and Social Psychology from the Union Institute Graduate School, Cincinnati, Ohio and a MSW in Clinical Social Work from San Diego State University. He may be reached at: P.O. Box 3805, Grand Junction, Colorado 81501, (970) 242-6061 (0) (970) 245-8825 fax e-mail address: firstname.lastname@example.org
The single client in this case study signed an informed consent for participation in this study.