The death of a loved one confronts us with particularly complicated challenges. Grief is a natural response, yet a highly individual experience. Learning to cope with a loss can take many different forms, and I have found Eye Movement Desensitisation and Reprocessing (EMDR) to be particularly effective in alleviating the trauma associated with events surrounding a death. The use of EMDR to unlock grief that has become complicated and stuck leads to a healthy healing process and response, which in turn allows the person to move on and find some resolution to their anguish.
My EMDR training took place in 2008 and was some of the most inspiring I have been involved in. At the time, the enthusiasm around it was immense. For the first time in ages I felt empowered and confident to offer something that worked. The very nature of it seemed almost magical to me when I first discovered it, and I continue to be fascinated and inspired by its results and potential.
Integrating EMDR with children’s work
The challenge for me was trying to integrate the protocol into my work with children and adolescents. It is not unachievable, and others have done it in their own way1-4, but it did present me with some problems. So I quickly had to adapt the techniques of the standard eight-stage protocol and develop a more flexible and creative approach. Despite EMDR’s structured process, I have found it helpful to be able to use discrete parts of the protocol as a stand-alone intervention. I have, on many occasions, just used the ‘safe place’ part to create feelings of comfort and security, or installed positive resources for those with low self-esteem and confidence issues. Obviously, I have had to think outside the box and adapt EMDR to the needs and level of understanding of the child or young person I am working with. But remaining as close to the protocol as possible is important, and the philosophy I have come to follow is about being as flexible as is necessary for each client.
Regardless of the challenges, I have now been able to use EMDR to successfully treat a range of difficulties in children and young people – from using art work and pictorial representations with a seven-year-old girl with a choking trauma, to working with older teenagers who have body-image issues or who have witnessed domestic violence. Adapting the protocol is an ongoing theme for me and brings regular new dimensions to my work.
And now grief…
Working with grief and EMDR, however, was an issue I had not yet tackled. Meeting Emma (not her real name) changed this dramatically. Her story was particularly moving, and I felt my skills in EMDR and as a nurse were about to be tested to the full.
Emma was 11 when she was referred to our CAMHS counselling service following the death of her maternal grandfather. She had been involved in discovering him and had observed the resultant paramedic attempts to resuscitate him.
Over the months since the death, Emma had become increasingly clingy and anxious, had great difficulty sleeping at night, would experience regular flashbacks, had lost confidence and had developed low self-esteem. She reported having regular feelings of great sorrow and nausea whenever her flashbacks occurred or when she thought about the incident. She appeared to be totally consumed by her grief. She would not talk about what she had seen or what her flashbacks contained, because she found the content too distressing.
Emma was seen for a counselling appointment with my colleague, who quickly recognised that she had become stuck in the grieving process. She was unable to move on due to the constant reminders from the involuntary memories she experienced. I was therefore approached because it was felt that EMDR could help Emma tackle the distress linked to her memories. We hoped that EMDR could help release the trapped traumatic material and allow Emma to process her grief in a natural way.
Introducing EMDR to the family
Initially, I met with both Emma and her mum to explore the possibility of using EMDR and to get a sense of their views about it. I always try to give as much information as possible, whilst also considering the age of the child and the level of understanding within the family. I have found it helpful in the past to include some of the science around trauma and brain function in explaining how EMDR can be useful. My explanations often involve cartoon or simplified pictures to highlight how trauma material can become blocked and prevented from being stored correctly in the brain. For this, I use simple drawings of the brain, filing cabinets, brick walls and arrows. I usually spend at least an hour with families going through the therapy, answering any questions they have about how it works and what will be done, before engaging in any therapeutic role. In all cases, especially this one, it was imperative that I could be as open and honest as possible. It was important to gain Emma’s trust, so that she felt comfortable enough with me to be able to share some of her most painful thoughts and memories.
Emma and her mum had some previous knowledge of EMDR from a family friend, and together with the information given in our session, they were keen to give it a go.
Developing the safe place – and using the Stop! sign
I spent quite some time getting to know Emma and developing her safe place. It was important to promote her feelings of safety within EMDR in order to reduce her anxieties and give her the sense of control. To help with this, we talked about Emma having the choice to stop the intervention at any given time. I have found it helpful with younger ones to give them a physical way of saying stop, such as having a red ‘stop!’ sign. This can increase their sense of control by having something they can hold onto or something they can see.
Which kind of bilateral stimulation?
Emma and I discussed and practised using the different options for bilateral stimulation, which include stereo audio sounds5, a handheld device that buzzes, physical taps or eye movements. Emma opted for the handheld device which delivers a buzz or pulse of vibration to each hand alternately. We then used the handheld buzzers to install and strengthen her safe place, which worked successfully. At the time, Emma reported very positive and strong feelings of being calm and relaxed when visualising her safe place, during both practitioner-guided distress and self-cued distress.
On with the work
The next session proved to be practically life-changing for Emma. Previous to this session, Emma had not uttered a word about the bereavement or what she had witnessed, the only signs of her distress being physical and emotional changes. Emma’s initial SUD rating (Subjective Units of Distress) was 7/10. She felt her negative cognition was ‘I feel stupid’, which was based on feeling powerless to help in the situation. With me then using a very gentle and non-threatening approach, Emma was able to tell me that she had been very close to her grandfather. She was able to share with me the most prominent image that stuck in her mind – that of her grandfather being in his chair and her father trying to rouse him. With the desensitisation phase of the EMDR protocol, it took less than an hour for Emma to change from being extremely tearful, hunched over, head down and physically shaking, to sitting up, giving good eye contact, and talking about what she had witnessed with no tears or sense of extreme sadness. Of course, Emma still had memories of the event, but she was able to access these when she chose, rather than when they chose her. And the major difference was that she no longer felt nauseous or intensely sorrowful when she did access them. Emma rated her end SUD as 0.5/10, which she was happy with. She didn’t feel the need to continue with processing.
I had two follow-up appointments with her, always prepared each time to re-evaluate her SUD and act if necessary. Each time we met, however, she continued to report a SUD of 0.5 – the feelings of nausea and sorrow remained at bay. Emma was no longer overwhelmed by flashbacks, her sleep had returned to a regular pattern and she had regained some of her confidence.
Following the EMDR intervention, Emma felt ready to re-engage with counselling, and was much more able to vocally articulate her thoughts and feelings about her grandfather’s death. EMDR appeared to have been instrumental in unlocking her grief. For Emma, EMDR did not change the reality but released her from her torment and allowed her to begin to proceed naturally through her unique grieving process.
My experience with Emma has highlighted yet one more arena in which to use EMDR. Each time I have the privilege to use it, my confidence in – and admiration of – this effective technique grows, and I will continue to learn and to respect its potential.
Lisa Mundell is a Registered Mental Health Nurse working as a Primary Mental Health Specialist in a Tier 2 Community CAMHS in Sunderland.
References
1 McGuinness V. Integrating play therapy and EMDR with children. 1st Book Publishing; 1997.
2 Greenwald R. Eye movement desensitization and reprocessing (EMDR) in child and adolescent psychotherapy. New York: Aronson; 1999.
3 Tinker RH, Wilson SA. Through the eyes of a child. London: Norton; 1999.
4 Adler-Tapia R, Settle C. EMDR and the art of psychotherapy with children. New York: Springer Publishing; 2008. Samples from the accompanying training manual are at www.springerpub.com/samples/ 9780826111197_chapter.pdf (and see the index in CCYP Dec 2010 for a list of other articles on EMDR for young people).
5 For a sample audio and/or tactile device, see Tac/AudioScan at www.neurotekcorp.com/taudscan.htm – or for sample software (for Windows or a Mac running Windows emulation), see www.neuroinnovations.com/bilat_bilateral_audio.html