EMDR as a Healing Tool in Transforming Traumatic Grief

The intense and painful experiences of grief are generally considered “normal.”  However, when those experiences are extremely distressing, unduly interfere with day-to-day functioning or do not subside to a manageable level over time, the bereaved may be experiencing complicated or traumatic grief.  Complicated grief has been proposed as a new diagnostic category in the Diagnostic and Statistical Manual of Mental Disorders (DSM), and suggested components of the diagnosis include (1) that sufferers experience bereavement by death; (2) that their reactions include intrusive and distressing symptoms, including yearning, longing and searching for the deceased; and (3) that the bereaved exhibit at least four marked and persistent trauma reactions, which may include:  “avoidance of reminders of the deceased,  purposelessness, feelings of futility, difficulty imagining a life without the deceased, numbness, detachment, feeling stunned, dazed or shocked, feeling that life is empty or meaningless, feeling a part of oneself has died, disbelief, excessive anger or bitterness related to the death, and identification symptoms or harmful behaviors resembling those suffered by the deceased” (Mitchell et al, 2004, p. 13).

Even in cases that do not fit the criteria for complicated grief as described above, the events surrounding the death may be sufficiently traumatic to interfere with daily functioning or result in unrelenting distress.  As a psychotherapist specializing in grief and loss, I have found EMDR (Eye Movement Desensitization and Reprocessing) to be an effective tool for alleviating trauma in grief.  As in grief, trauma affects the whole person — body, mind and spirit, and on a hierarchy of needs, trauma must be dealt with in order for the healing process of grief to proceed in a healthy, and healing, fashion.

What is EMDR?

In brief, EMDR was developed by psychologist Francine Shapiro after making a chance discovery that the lateral movement of her eyes reduced the intensity of disturbing material she was dealing with in her life (Shapiro, 1995, p. 2).  Dr. Shapiro spent several years scientifically studying this phenomenon, and found that bilateral stimulation, i.e., stimulation on both sides of the body — whether in the form of eye movements, tapping, sound or other forms — released traumatic material from the brain in a way that made the material workable. Trauma that is locked in the brain leads to the “fight, flight or freeze” response, and EMDR helps transform traumatic images into memories that no longer have a deleterious hold on the individual.

In addition to this physiological response to trauma, the traumatized individual often develops negative beliefs about him or herself (such as “I do not deserve love, “I was at fault” etc).  The beauty of EMDR is that it works on a cognitive level as well as the physiological level, not only facilitating the transformation of traumatic images in the brain, but also allowing the individual to replace negative cognitions about him or herself with positive ones (such as “I deserve love”, “I did the best I could”, etc.).  EMDR also works on a somatic level, with the therapist guiding the client to feel the traumatic images and negative beliefs in the body, thus further facilitating the transformation of the images into non-intrusive memories, and also transforming the negative beliefs into positive, useful ones. Therapists need to be trained to practice EMDR, and follow a standardized protocol in EMDR work with clients.

Case Studies

Two cases in my practice are illustrative of the effectiveness of EMDR in resolving traumatic grief.  “Carol”, the mother of two small children, came to see me complaining of ongoing distress after the death of her husband nine months before.  “Bill” was in a motorcycle accident, sustaining a broken leg. After being admitted to the hospital, Bill suffered a stroke and brain swelling, and died after being taken off life support two days later.  Carol was concerned about her irritability, particularly toward her children, and her anger toward Bill for dying and leaving her with two small children to raise alone. She also expressed guilt regarding her anger toward Bill, which I spent time validating and normalizing, since anger is often exhibited as a normal grief response.   Carol spent much time telling her story — a useful healing tool for making meaning of a seemingly senseless situation (White, 1995).  She did not exhibit signs of trauma for the first few months that we worked together.  However, as the anniversary of Bill’s death approached, Carol found it difficult to sleep, being awakened by intrusive images of Bill lying in the hospital bed and her shock when she learned of his condition.  We explored Carol’s negative cognitions around these images and Bill’s sudden death. The negative belief that that most impacted Carol was her belief that Bill’s death was her fault because she had a premonition that he would be in an accident, and she did nothing to prevent it.   In describing the images of Bill lying in the ICU and her belief that it was her fault, Carol felt tightness in her chest and had difficulty breathing. After two 90-minute EMDR sessions, Carol was able to replace her negative belief “I was at fault” with the positive belief “I did the best I could.”  She reported that she still, of course, experienced memories of Bill’s death, and reported she was very pleased that that she could feel sadness without guilt.  Carol was thus finally able to process her grief and loss in a healthy way.

My work with “Mary” was deeply profound and moving.  Mary’s husband “Don” suffered with Lou Gehrig’s disease (ALS) for three years, and Mary witnessed the horrible, inexorable ravaging of Don’s body while his mind stayed strong.  Mary’s expressed purpose for coming to see me was that she was unable to feel Don’s presence in her life.  Mary described Don as her soul mate, and I assured her that because of the strength of their bond, she would find a place for Don in her heart and feel his presence as a support in order to move forward. However, it was clear that she would first have to deal with the traumatic images that prevented her from fulfilling this step in her grief process.  The most disturbing image, and target for our EMDR work, was finding Don lying in a pool of blood on the bathroom floor after falling out of his wheelchair.  I taught Mary the “butterfly” technique, in which the client crosses his or her arms across the chest in a hug and taps alternately below each shoulder, simulating the bilateral stimulation used in formal EMDR sessions. I instructed Mary to use this technique at home as a resource when traumatic images arose.  After two sessions, with Mary working at home with the butterfly hug when disturbing images and emotions arose, Mary reported that those images had receded as mere memories that were no longer unduly disturbing.

Mary came into our next session glowing, and reported that she had felt a tug at the back of her shirt while sitting quietly one day and “knew it was Don, back in my life.”  She reported that she subsequently felt Don’s presence coming to her every night before she fell asleep.  Our trauma work was done, and Mary was well on the way to healing her grief.

Conclusion

My work with both Carol and Mary, as well as many others, has enhanced my confidence in my therapeutic skills in identifying and working with traumatic grief, and has increased my trust and faith in the effectiveness of EMDR as a healing tool in grief.

References

A. Mitchell, Y. Kim, H.G. Prigerson, M.K. Mortimer-Stephens. (2004). Complicated Grief in Survivors of Suicide. Crisis 25(1), 12-18.

F. Shapiro. (1995). Eye Movement Desensitization and Reprocessing:  Basic Principles, Protocols and Procedures. New York:  Guilford Press.

M. White. (1995). Re-authoring lives. Adelaide:  Dulwich Center Publications.

Children and Grief: A Story of Trauma, Abuse and Healing

In my therapy work with grieving children and adolescents, it is important for me to keep in mind that the child’s age and stage of development at the time of the loved one’s death will strongly influence the ways in which the child reacts and adapts to the loss. An understanding of the child’s emotional and cognitive development will enable me to determine how best to communicate about death with the particular child, to understand and empathize with the child’s experience and guide the child through the grieving and healing process with appropriate interventions.

For example, I successfully worked with a grieving twelve-year old girl, who I will call “Abby.” I worked with Abby both individually and in a small group with other grieving pre-teens at a hospice-based children’s grief support group. Abby’s maternal grandfather died suddenly and violently two years ago while cleaning his gun.  There is some uncertainty as to whether the death was accidental or a suicide.    Abby is an only child, who lives with her mother.   Although Abby did not speak with me about it, her mother has reported that Abby’s father physically abused Abby when she was four or five years old and he has been court ordered to not have contact with her. Abby has not seen her father (who is divorced from her mother) since she was six years old.  She had a very close relationship with her grandfather, and spent every Saturday with him, doing special things together.  Abby reports that since her grandfather’s death, she spends her Saturdays alone, mostly sleeping.

The Interdependence of Grief and Development

Childhood grief and development are interdependent:  The early death of a parent or other loved one affects a child’s development, and the child’s development affects how he or she will grieve and reconstruct his or her relationship with the deceased.  Furthermore, children re-experience their grief as they reach each milestone in their development.  .

Capacity to Grieve and Understand Death’s Finality

A child’s ability to understand the meaning and finality of death corresponds to his or her cognitive development.  For example, a three to five year old believes that the deceased person has gone away and will return at some point.  Thus, it is common for a child of this age to constantly ask questions such as “Where’s Daddy?”  and “When is Mommy coming home?” A child of five to approximately nine years of age  believes that death can be avoided.  Furthermore, a child in this egocentric phase also believes that his or her parent died because either the parent was bad or the child was bad, and that if the child is good, the parent can return.  This is thus seen as one of the most vulnerable and difficult developmental stages for adjusting to a parent’s death

In working with Abby’s grief over her grandfather’s death, I always kept in mind that she was dealing with her loss both from her current cognitive developmental stage, and from the earlier stages she was in when her father abused and then left her.  Thus, she was likely relating to her grandfather’s death emotionally from that earlier stage, and may believe that she is somehow be responsible for his death. The child at this stage needs someone who can clarify what the child is thinking and feeling, and can reassure and build self-esteem by praising the child’s accomplishments.   This is something that I tried to do each time I met with Abby.

Although Abby is able to grasp and verbalize abstract concepts about death, her grief process was still informed by early developmental issues of safety and trust, as well as the magical thinking of the child in latency.  Abby’s grandfather’s sudden and violent death, coupled with her father’s abuse and abandonment, seems to have made it unsafe for Abby to trust and truly connect with her peers at a life stage when peers and feeling accepted are so important to social and emotional development.

Developmentally, even in more “normal” circumstances, 12-year olds yearn to belong, but may feel different and isolated, as the brain and body go through a dramatic growth spurt instigated by a surge of hormones. Physically, a 12 year old girl is starting to become a woman, and may experience self-consciousness and awkwardness that may lead to withdrawal.  Emotionally, she may experience a strange and seemingly uncontrollable roller coaster of highs and lows exacerbated by pubertal hormonal changes, as well as grief over the impending loss of her childhood.  Cognitively, in moving from concrete to abstract thought, an introspective and intelligent 12-year old like Abby is increasingly aware that others may not share her feelings, thoughts and values.  A grieving pre-teen, like Abby, may also feel different because so few of her peers have experienced the loss of a loved one.  This recognition can lead to the first taste of existential alienation, causing further withdrawal.  Those who are more firmly in the formal operational stage of abstract reasoning can have a more panoramic view about these differences, and develop true compassion and empathy for others.  The child not quite out of concrete operational thought, especially one dealing with profound grief like Abby, may have a difficult time getting to that stage, and may regress to more egocentric behaviors, like those I have witnessed in Abby’s case.

Tasks of Children’s Mourning

Worden (1996) has identified four tasks of mourning:  (1) accepting the reality of the loss, (2) experiencing the pain and emotional aspects of the loss, (3) adjusting to an environment without the deceased, and (4) relocating the dead person in one’s life.  The satisfactory completion of these tasks depends on both the child’s stage of development at the time of the death and his or her adaptability and ability to attend to any unfinished tasks at later stages of development.

Accepting the Reality of the Loss

A child can accept the reality of losing a loved one when he or she understands, through the achievement of formal operational thinking, “the nature of abstractions such as finality and irreversibility” (Worden, 1996, p 13, citing Piaget, 1954).  Some grasp of such abstractions is possible during the concrete operational stage of cognitive development, and is only fully understood at the formal operational stage.  Thus, if a loved one dies before formal operational cognition has been achieved, the child will experience a deeper level of grief when he or she attains that cognitive stage and fully and deeply comprehends the finality and irreversibility of the loss.

This was clearly the case for Abby.  Abby has an understanding of the abstraction of death’s finality.  She has been grappling in our sessions with giving spiritual meaning to the finality of death.  My job was to empower Abby’s cognitive work by normalizing and validating her process and the private thoughts she has chosen to share with me, while at the same time providing a safe space for her emotional process.  Furthermore, as Abby was then a pre-teen on the cusp of profound developmental challenges, I needed to stay aware that as she comes to terms with the meaning of her grandfather’s death, her new cognitive abilities also opens her to a new level of understanding – and pain – about the loss of her father.

Experiencing the Pain and Emotional Aspects of the Loss

The pain and emotions of grief can be frightening for a child to experience. Awareness of the child’s capacity based on his or her stage of emotional development to cope with strong emotions is important. It is also important to assess the child’s coping and defense mechanisms, and their effect on how the child experiences the pain of the loss.

In Abby’s case, the abuse and abandonment by her father early in her life has left deep developmental holes and she has split off from her emotions, which has complicated her grieving process over the death of her grandfather.  Journaling in a group setting proved to be an effective means for Abby and the other group members to deal with their feelings, as well as allowing them to connect with the others and feel less isolated, empowered by the realization that they have all experienced a loss, and they are not so different, after all.

Adjusting to an Environment without the Deceased

This task is an ongoing process through progressive stages of development as well as important transitions throughout one’s lifetime.  The child– as well as the adult he or she will become –  re-experiences his or her grief at each stage of development as a result of his or her growing cognitive abilities, and also as he or she comprehends the vacuum left by the dead loved one, who is not there to nurture and support the child’s growth and achievements. An intervention I used with Abby was the creation of a memory box for her grandfather, in which she has placed pictorial depictions of their relationship.  We also did an art therapy project together when Abby returned from summer vacation.  This was primarily a non-verbal exercise in which Abby was able to “tell” her grandfather through the medium of collage about her summer activities and experience her emotions of loss and sadness on a somatic level.  My job in this process was to simply sit beside her and be an empathetic witness.  In joining with Abby in this way, we established a good degree of contact and trust.

Relocating the Deceased in One’s Life

As the child grows and changes, his or her relationship with the deceased parent or other loved one also changes (Christ, 2000).  Thus, according to Worden (1996), another ongoing task is to find new ways to memorialize the deceased loved one with the attainment of each developmental milestone:  Children need to “find a new and appropriate place for the dead in their emotional lives – one that enables them to go on living effectively in the world.”  The above-described art therapy projects have been helpful with Abby in this regard.  The narrative therapy intervention of letter writing was also helpful at this stage, having Abby write a letter to her grandfather.  This process helped Abby clarify her feelings and create a safe container for them, allowing her to relocate her grandfather and live an effective life.