Larissa Meysner Webinar for the EMDRAA March 2016
Grief Theoretical considerations Evidence-base Key tasks in grief Practical implications Phases of EMDR Questions
Grief Responses, both internal and external, to the loss Bereavement The state in which a grieving individual is in Mourning Adaptation to the loss A set of practices and acts influenced by sociocultural factors (Malkinson, 2007)
DSM IV Bereavement exclusion Major depression could not be diagnosed within first two months after loss DSM - 5 Exclusion removed Controversial decision outside scope of today s presentation
Risk Factors Attachment and relationship to deceased 1. Loss of a child 2. Loss of a spouse Dependency on deceased History of separation anxiety Traumatic death Suicide Death that was perceived as preventable Lack of social support Protective Factors Anticipation of the loss Belief systems that support the idea of a just world Combined, these are some of the strongest protections against complicated grief (often seen in those over 85 years of age, a group with some of the lowest levels of complicated grief)
Study of recently bereaved widows More respondents who were stuck in grief were receptive to psychotherapy over medication (93.8% vs 81.3%) 96.3% were open to receiving a diagnosis for their grief, with most citing relief to known I am not going crazy as a primary reason Johnson et al (2009)
Interventions are most effective when the client is significantly distressed and functioning impaired No evidence for treating grief that is healthy and normal Functioning not impacted, symptoms within expected limits CBT effective for grief Behavioural activation, challenging avoidance Unhelpful thoughts about deceased, their death, or themselves.
Symptom similarities include: Intrusion Intrusive images and thoughts of deceased Avoidance Avoidance of places, people, things associated with deceased Hyperarousal Somatic expression of grief symptoms (often less relevant but varies with culture, ability to verbally express feelings)
Participants asked to recall a negative memory of a deceased loved one Three conditions Recall plus eye movements Recall plus relaxing music Recall only (control) Significantly greater reduction in emotionality after EMs compared with other conditions Hornsveld et al. (2010)
Compared EMDR with Guided Mourning (grief counselling based on behavioural principles) EMDR patients performed better on questionnaires for anxiety, grief, and posttraumatic stress EMDR increased positive recall of loved one EMDR took approx. 8 sessions to reduce symptoms whereas GM took 13 sessions on average Limitation: study not randomized Sprang (2005)
RCT comparing EMDR for CBT, 7 week waitlist control N=19 Findings: Both effective Those who are more distressed benefit most from an intervention i.e. no need to always intervene in natural grief Meysner, Cotter & Lee (2016)
Therese Rando (1993)
Don t use too early Warning signs Denial, numbness, dissociation Respect these defences Once emotional impact of loss is felt, then consider EMDR Dissociative Experiences Scale Inventory of Complicated Grief
Nature of complicated grief Absent or denied Delayed Chronic, prolonged Distorted ie. Extremely angry, guilty Traumatised Key task Start grief Once time is right, start grief End grief Access full spectrum of emotions Resolve trauma, proceed to grief
Does the client have adequate coping skills and support systems in place? Resource Development Safe place Grounding Container exercise
Past Memories Actual events Loved one s suffering Being notified of the death Funeral Negative memories of loved one (i.e. fighting with partner just before car accident) Intrusive images Nightmare images
Present triggers It can be helpful to discuss any avoidance behaviours to identify these Issues of personal responsibility, mortality, or previous unresolved losses Key emotions of guilt, regret
Practical considerations: "What is it about what happened that you need to hold on to, and what do you want to let go of?" Steve Lazrove Difficulty in eliciting a self-referencing belief when it comes to the death of another
Don t try to take their pain or grief away Identify and target what is blocking healthy or adaptive grieving Acknowledge your own stuff Countertransference Patience!
Opportunities for painful memories (ie. Death, suffering) to be reprocessed and give rise to positive memories about the loved one For key sticking points like responsibility, guilt Affect bridge may be useful here and give rise to other memories/issues Cognitive interweaves
Gestalt empty chair (especially useful for unfinished business, forgiveness, saying goodbye ) Have you ever heard of someone who could not stop crying? 'What do you need to forgive yourself? what is stopping you from living again? The scales, restoring balance Dr Joany Spierings
Remembering loved one in a balanced way (positive images and positive affect) Adaptive sense of self we to I Changing to past tense Positive belief may emerge that wasn t identified at start E.g. strength, ability to cope, I m not a bad person (for smiling, being happy again)
Be mindful that client may not have anyone to go home to Container imagery task Homework may involve: Looking at photos of loved one from a happy timerecollecting Engaging with social supports Behavioural activation tasks - reinvesting Letter writing relinquishing old attachments
Future Template Create a future template Birthdays, anniversaries, Christmas, weddings etc. Strengthen using EMs Depending on how long it has been since the death Future template for dating or new partners? Having more children? May need to process guilt around this in further session Establish rituals, traditions
Case studies Two cases of grief, illustrated by some of the world s best illustrators (ie. Disney) Discussion on how we might use EMDR in these cases
How would you characterise Simba s grief? Risk factors? Would you treat his grief, and if so, how? Targets /techniques for EMDR?
How would you characterise Carl s grief? Risk factors? Would you treat his grief, and if so, how? Targets /techniques for EMDR?
Books Therese Rando Treatment of Complicated Mourning Papers Roger Solomon and Therese Rando (2012) Treatment of grief and mourning through EMDR: Conceptual considerations and clinical guidelines Marilyn Luber (2012) Protocol for Excessive Grief