درمان سوگ و سوگواری از طریق EMDR: ملاحظات مفهومی و دستورالعمل های بالینی

Abstract Introduction Eye Movement Desensitization and Reprocessing (EMDR) is an empirically-supported psychotherapeutic approach for treating trauma, which is also applicable to a wide range of other experientially-based clinical complaints. It is particularly useful in treating grief and mourning. Literature findings EMDR is guided by the Adaptive Information Processing Model (AIP), which conceptualizes the effects of traumatic experiences in terms of dysfunctional memory networks in a physiologically-based information processing system. Numerous empirical studies have demonstrated EMDR's efficacy. Discussion The death of a loved one can be very distressing, with memories and experiences associated with the loss becoming dysfunctionally stored and preventing access to adaptive information, including positive memories of the deceased. EMDR can be utilized to integrate these distressing experiences and facilitate the assimilation and accommodation of the loss and movement through the mourning processes. Conclusion Applying the eight phases of EMDR to grief and mourning can yield potent clinical results in the aftermath of loss.

1. Introduction The death of a loved one typically confronts human beings with particularly difficult challenges at a time of often unparalleled distress. It has long been known that even when uncomplicated, bereavement can precipitate significant psychological, behavioral, social, physical, and economic sequelae (Osterweis, Solomon, & Green, 1984). Consequently, there are few, if any, situations that warrant greater consideration for the application of therapeutic methodologies to alleviate pain, reduce dysfunction, work through conflicts, and promote adaptation. This article describes the rationale and clinical considerations for utilizing Eye Movement Desensitization and Reprocessing (EMDR) within an overall treatment framework for grief and mourning. EMDR is an integrative psychotherapeutic approach comprised of eight phases and a three-prong methodology to identify and process past memories that underlie current problems, present triggers that elicit disturbance, and positive templates to be incorporated into the client's repertoire for adaptive future behaviors. Currently, EMDR is recognized and recommended as a first-line treatment for trauma in numerous international guidelines (American Psychiatric Association, 2004, Bisson and Andrew, 2007, Department of Veterans Affairs and Department of Defense, 2004 and National Institute for Clinical Excellence, 2005). Over the past two decades, more than 20 randomized studies have established its efficacy with a wide range of trauma populations (Bisson & Andrew, 2007). Each phase of EMDR therapy includes a variety of standardized procedures. However, one component of EMDR therapy that has garnered considerable attention is the use of eye movements. A meta-analysis (Davidson & Parker, 2001) found little support for this component. However, a later review of the research included in the analysis conducted by a committee of the International Society for Traumatic Stress Studies (Chemtob, Tolin, van der Kolk, Pitman, 2000) found the studies flawed because of a variety of factors. Since that time, more than 20 randomized controlled trials have demonstrated positive effects for the eye movement component (Bisson & Andrew, 2007), including decreases in emotionality and imagery vividness. These two factors alone would be expected to make treatment more tolerable for any trauma victim, including those suffering from the loss of loved one. One of these studies (Hornsvelt, Landwehr, Stein, Stomp, Smeets, & van den Hout, 2010) specifically evaluated participants recalling an aversive experience of loss. They were asked to hold in mind the image of the most distressing scene while either performing eye movements, listening to relaxing music, or not performing any dual attention task (recall only). The eye movement condition was found to be more effective than recall only, or recall with relaxation in decreasing emotionality of the most distressing scene related to loss. In a nonrandomized study, Sprang (2001) demonstrated the effectiveness of EMDR therapy in the treatment of those suffering from the loss of a loved one. EMDR therapy was compared to exposure based Guided Mourning (GM) for treatment of complicated mourning. Of the five psychosocial measures of distress, four (State Anxiety, Impact of Event Scale, Index of Self-Esteem, and PTSD) were found to be significantly altered by the type of treatment provided, with EMDR clients reporting the greatest reduction of PTSD symptoms. Positive treatment effects were attained more rapidly with EMDR which necessitated fewer sessions. Data from the behavioral measures showed similar findings. Both groups had significant decreases in grief intensity with no significant difference. The author concluded that the benefit of EMDR treatment lies in the expeditious reduction of trauma symptoms, which can have an availing, though indirect effect on grief. Conversely, and as would be predicted by the Adaptive Information Processing (AIP) model which guides EMDR therapy, subsequent to treatment the rate of positive memories improved at a significantly greater rate for those treated with EMDR therapy than with GM. As predicted by the AIP model, several studies and clinical reports have shown the beneficial effects result from processing the experiences that underlie current problems, which can include the deep distress, sense of powerlessness, vulnerability, or guilt that accompany a significant loss (Gattinara, 2009, Lazrove et al., 1998, Puk, 1991, Solomon and Shapiro, 1997, Solomon, 1995, Solomon, 1998, Solomon and Kaufman, 2002, Solomon and Rando, 2007 and Solomon and Shapiro, 1997). The application of EMDR therapy with grief and mourning will be explored through a case example below.

17. Conclusion The death of a loved one can be very painful, generating a level of distress that interferes with the healthy assimilation and accommodation of the loss and appropriate reintegration into the new world without the deceased. EMDR therapy is an eight-phase treatment approach that views symptoms arising from experiences that are dysfunctionally stored, unable to process and be integrated into the wider memory networks. The constant triggering of the memory is manifested as the painful images, emotions, thoughts, sensations, and beliefs associated with the loss. This easily triggered, dysfunctional, unprocessed memory also blocks access to other parts of the memory network. Therefore, the mourner experiences the pain of the loss and is prevented from experiencing the positive memories (and other adaptive information) associated with the loved one. EMDR treatment protocols target the painful experiences enabling the integration of the dysfunctionally-stored experiences, along with current situations and future templates. Upon successful completion of treatment, the mourner can then think of their loved one beyond the painful memories and continue to move unimpeded through the mourning processes.