The use of compassion-focused techniques to support memory reconsolidation in EMDR therapy for complicated grief

This case study presents use of EMDR to treat Complicated Grief. The client is a young woman in her twenties with a diagnosis of Bipolar Affective Disorder and history of mental health inpatient admissions who, for fifteen years, has struggled to come to terms with the loss of her cousin. The process of therapy is described, highlighting not only the work on the target memory, but also on the barriers that prevented the client from moving forward with her life including her dysfunctional belief that she was defective and the internal conflicts this produced. The client’s outcome measures indicate that symptoms of PTSD were alleviated post-therapy. Techniques such as compassionate imagery, use of symbolic objects and letter-writing were found to provide experiential learning supporting memory reconsolidation. This paper concludes with a discussion and comments on key aspects of the therapeutic process and the implications these have for EMDR therapy in the treatment of Complicated Grief and with individuals who struggle with beliefs of self-defectiveness.


This case study presents the use of Eye Movement Desensitization Reprocessing (EMDR; Shapiro, 2001) therapy to treat Complicated Grief (CG).  CG has been described as “a persistent form of intense grief in which maladaptive thoughts and dysfunctional behaviours are present along with continued yearning, longing, and sadness and/or preoccupation with thoughts and memories of the person who died.  Grief continues to dominate life and the future seems bleak and empty.  Irrational thoughts that the deceased person might reappear are common and the bereaved person feels lost and alone” (The Center for Complicated Grief).  An individual experiencing such difficulties may experience catastrophising thoughts about what life may be like ‘moving on’ without their loved one, or ruminate on whether they could have done something to save their loved one.  In an attempt to cope with overwhelming emotions in response to loss, they may avoid reminders relating to the loss or use avoidance as a way of trying to escape a painful reality.  They may ruminate and overly-focus on maladaptive thoughts which in turn increase overwhelming feelings, yet struggle to give themselves permission to acknowledge their grief and sense of loss. Their routines, including diet, sleep and personal care, can become disrupted, and contribute further to their difficulties in adjusting to loss.

The way in which an individual experiences complicated grief can be likened to symptoms of post-traumatic stress disorder (PTSD).  In particular, the experience of feeling intense emotions in response to reminders of the loss or traumatic event, nightmares relating to the loss or trauma, intrusive thoughts, and anxiety.  O’Connor et al. (2010) found considerable overlap between the dimensions of CG and PTSD, with a particular shared experience for intrusive components of PTSD.  For this reason, trauma-focused therapies used to address PTSD can be considered in the treatment of CG.

EMDR has been applied to address CG with clinically significant improvements in symptomatology (Meysner, Cotter, & Lee, 2016; Sprang, 2001).  Meysner, et al. (2016) compared EMDR and Integrated-Cognitive Behavioural Therapy (CBT) for grief and found both treatments were as effective as each other (72 per cent clinically significant improvements on a measure of grief, and 82 per cent on a measure of trauma).  These effects were observed in a wide range of presentations from low to high distress.  Francine Shapiro, founder of EMDR (2001) developed the Excessive Grief Protocol (Shapiro, 2006) which guides therapists using EMDR with bereaved individuals to process the actual events of the loss, intrusive images, associated nightmares, triggers, and dysfunctional cognitions and beliefs.  It is therefore evident that EMDR can be applied to this client group and this case study presents an example of this.

Client Background

Zoe [1] is a 29-year old young woman with a diagnosis of Bipolar Affective Disorder.  Zoe came into contact with mental health services five years before the present case study started.  Zoe had presented to the service in crisis, exhibiting symptoms of heightened anxiety, panic attacks, and what was described as “erratic behaviour”.  Zoe reported a significant life event whereby her cousin Becky [2], was suddenly killed in an accident some years before and Zoe was assessed as having some symptoms of trauma in relation to this loss. There was high-profile media attention on this death due to the young age of Becky and the nature of her death.  Zoe was prescribed medication and discharged but presented in crisis one month later. This time Zoe exhibited symptoms of mania, irrational thought process and racing thoughts, and was transferred to an inpatient ward. Zoe had in the past attempted to take an overdose and had self-harmed as a way of relieving emotional distress.  She reported shifting between periods of high energy, setting herself high standards of productivity, and then “crashing” and experiencing increased suicidal ideation. At this point Zoe was diagnosed with Bipolar Affective Disorder. There followed a repeating pattern over the next three years whereby Zoe would have a period of stability and be discharged but then return to the service in crisis in response to painful and overwhelming feelings. Zoe was eventually seen under a specialist team where longer-term intervention was agreed in order to build stability and offer psychological input and medication.

Zoe completed five sessions of here-and-now focused cognitive analytic-informed therapy with the author one year prior to the present case study. During this work, Zoe identified that since the death of Becky, she had battled with a desire to move forward with her life, and also an urge to stay-put, feeling guilty for living when Becky’s life had ended so suddenly. She reported a prolonged and marked difficulty in regulating her emotions in response to her bereavement. It became clear that Zoe’s way of trying to cope was to spend much of her time focusing on Becky’s death in an attempt to understand it, and also striving to meet others’ and her own expectations to ‘move on’ by taking employment in various jobs. Zoe learnt to notice, however, that the more she strived to move on, the more exhausted she felt, and she would eventually ‘crash’. During this work Zoe was able to build understanding of her coping patterns and ways of relating to herself and others which kept her feeling ‘stuck’. After a period of consolidation and practising revision of these patterns, Zoe was referred for EMDR to focus specifically on processing the loss of Becky.

Presenting problem

Zoe identified intrusion symptoms such as images of the moment she saw the news of Becky’s death break on television, the newspaper front pages that same week, and the crowds of people and press at Becky’s funeral. Zoe also said that she would have nightmares more than three times per week where she would dream that she could not save Becky from death. Zoe reported trying to avoid reminders of anything relating to Becky’s death such as similar stories in the news, avoiding going shopping or out in public places in case she heard a particular song on the radio which had been played at the funeral. Zoe identified in previous therapy that she often tried to function within her ‘drive system’; keeping busy and trying to meet high expectations of productivity in an attempt to distract herself emotionally. Zoe explained that due to the public experience of Becky’s death, the funeral never felt personal or real to her. She recalled her family trying their best to make their grief as private as possible in an attempt to retreat from the public spotlight. Zoe understood that this created an atmosphere where she did not feel she could share her feelings openly.  

Zoe also recognised symptoms of hyperarousal: she would experience tension, agitation and restlessness. She reported struggling to regulate her emotions and would feel “jumpy” or “sensitive” emotionally. Zoe also reported symptoms of hypoarousal whereby she could feel emotionally disconnected at times, for example feeling “numb” and “blank”. Zoe experienced dissociation, identifying that occasionally she could feel as though her body did not belong to her, that sometimes other people, objects, and the world around her did not feel real, and that sometimes she felt as if she were in a video game, or watching herself on television as if she were in a movie. She recognised that although these occasions were rare they had been a significant feature during psychotic episodes.  

We identified that Zoe’s key triggers were hearing a particular song which was played at Becky’s funeral, seeing certain newsreaders on the television, and hearing about similar incidents in the news. 

We agreed to build stabilisation initially and Zoe completed four sessions building a sense of safety, practising grounding techniques, emotional regulation skills and safe place imagery, whilst developing an understanding of the EMDR process. Zoe was able to recognise what constituted her ‘window of tolerance’ and how we might recognise her ‘tipping’ out of this in our sessions. Zoe was able to practise and use stabilisation techniques such as ‘The Container’ and ‘Safe Place’ to good effect when noticing distress to help herself feel more grounded and physically calmer.

Course of therapy


Impact of Events Scale-Revised (IES-R)

The IES-R is a 22-item scale which measure hyper-arousal, avoidance, and intrusion symptoms (Horowitz, Wilner & Alvarez, 1979; Weiss & Marmar, 1996).  A score above 33 is considered to be indicative of significant difficulty in daily functioning and is high enough to cause clinical concern and would indicate post-traumatic stress disorder is present (Creamer, Bell, & Falilla, 2002).

Dissociative Experiences Scale- Taxon (DES-T)

The DES-T is an 8-item self-report scale measuring daily dissociative experiences (Waller & Ross, 1997).  It is a shortened version of the DES-II which is a 28-item scale where a score of 20 and above can indicate PTSD (Carlson & Putman, 1993). 

Subjective Units of Disturbance Scale (SUDs)

A 1-item scale to measure the level of distress one experiences in relation to a target incident (0 = no disturbance at all, 10 = most disturbance). 

Validity of Cognition Scale (VOC)

A 1-item scale to measure how truthfully one believes in a positive cognition (1 = completely false, 7 = completely true).


Zoe scored 34 on the IES-R reflecting a significant level of distress and impact on daily functioning in relation to the trauma.  Zoe scored 27.5 on the DES-T suggestive of PTSD.

Zoe’s target memory was the moment she learned the news of Becky’s death.  She recalled the worst part of this memory as seeing the headlines in the news on television.  She described feeling “sick” and “empty”, and we identified that she held a feeling of responsibility or blame, with her negative cognition (NC) being “I should have done something to stop this”.  Zoe’s desired positive cognition (PC) was “I am human and can only do my best”, where the VOC was rated as a 1.  Zoe reported a SUD of 8 in relation to her target image and NC.


Sessions 1-3: reducing the initial emotional distress and noticing barriers to moving forward

We spent eight sessions processing difficult memories. Zoe was visibly emotional and tearful throughout Session 1, and fed back during processing that she felt conflicted about moving forward as this felt like letting go of the memory of Becky. Zoe described feeling a raw sadness and pain in connecting with the memory. After processing these emotions using bilateral eye movements Zoe reported feeling a sense of “peace” and “relief”, commenting on the strangeness and unfamiliarity of this after so many years of feeling distressed and being eager to avoid connecting with this memory. She repeatedly reported positive affect and as the SUD reading was 3, we agreed to explore what was residual in the next session. Zoe reported a shift in how she felt about the memory of this loss, reporting less fear in relation to the loss and a more peaceful state. We reflected that the “shock-impact” of returning to the memory for the first time had significantly lessened for Zoe. We returned to the target memory and Zoe reflected that her SUD was now 1, but that she would never reach zero as there would always be some sadness in relation to the loss of Becky.  It was not clear at this stage whether Zoe was unwittingly putting up barriers to connecting to the memory -this may have explained the lack of affect she experienced – or if she had indeed processed the memory. On further exploration, Zoe identified that she felt concerned about forgetting Becky and that this prevented her from fully allowing herself to move forward.

We explored potential feeder memories, and the fear of what it would mean to move forward. We identified that underneath the feeling of being somehow responsible for Becky’s death, Zoe believed that moving forward would mean she had forgotten about Becky, she would then feel like a “bad/horrible” person, and that self-defectiveness could have been an underlying dysfunctional belief for Zoe. We hypothesised that this potentially fuelled the conflict she experienced around allowing herself to move forward in life, as she feared this would leave Becky behind, exposing Zoe as selfish and bad. Zoe identified her earliest memory of feeling defective. She was five years old and she had hurt her sibling in retaliation during an argument and was chastised for doing so. As we used eye movements to process this feeder memory, Zoe reflected that she struggled to connect with this emotionally as she tried to rationalise that she was a young child and reacting to her sibling and this did not mean that she was a bad person. Zoe said she cognitively felt that she was not a bad person, but emotionally and within her body, she continued to avoid accepting this. We identified that some compassion-focused resource building might help Zoe and explored this in her next session. 

Zoe was able to bring compassionate others to mind as a way of connecting to self-compassion in relation to her memory but continued to feel distracted. At this point in the therapy, we acknowledged that Zoe may have been striving to perform during the therapy and “get it right” which made it harder for her to connect emotionally to the work. I utilised clinical EMDR supervision to explore how we might further explore this, or return to Zoe’s original memory (which was her goal) but bring some compassionate resources along too as a way of helping to encourage Zoe to build her self-worth, as she would need this in order to allow herself to move forward.

Sessions 4-5: using compassion to stay connected and processing triggers

After a break in the therapy (over the Christmas period), we returned to Zoe’s original memory of losing Becky. It became clear that Zoe continued to maintain to her negative cognition that she was somehow to blame or responsible for Becky’s death. She rated her SUD at a 1. On further exploration, we identified that this sense of responsibility was closely connected to Zoe’s fear of moving forward. Zoe said that she felt responsible for protecting Becky’s memory and the thought of moving forward without her was what kept her ‘stuck’. During this session, I encouraged Zoe to share her thoughts and feelings, creating open discussion around what it means to be “connected” to Becky. Zoe talked through her fears of leaving Becky behind, but then a clear shift in her thinking was evident as she started to voice how she felt as if Becky was “everywhere” in a positive sense; Becky was present in the stories, the ‘in-jokes’, the objects, the places they had travelled together. We acknowledged that prior to this work starting, the fear of connecting to Becky in any way felt overwhelming.  Since this initial distress was processed, Zoe had felt more confident in connecting with Becky’s memory and was able to recall the positive experiences, rather than memories of Becky’s death consuming her. As Zoe connected to the ‘happy-go-lucky’ nature in which Becky lived her life, the way in which she would seek out new and exciting experiences, Zoe stated that she now believed that she could not have done anything to stop Becky from going on the holiday which led to her death. Nothing Zoe could have said would have changed that. We thought about ways in which Zoe could stay connected to Becky as she moves forward with her life, using compassionate imagery and symbolic objects. Zoe was able to imagine what Becky would be saying to her, her words of encouragement, the sisterly jokes she might make to Zoe now. Zoe described feeling as though she could imagine Becky just sitting next door- nearby but no longer at the centre of her focus such that it consumed her.  Zoe identified symbolic objects such as bracelets from shared past holidays, photographs, hair clips, and animal toys which she could add to a memory box. Zoe also thought about a book which Becky had given to her which she had hidden in her attic, and she stated that now felt like the right time to bring it out of hiding again. At this stage in the therapy it became clear that Zoe was starting to move forward but there were some residual concerns we agreed to explore in her next session.

We spent Session 5 exploring a key trigger. Zoe identified this to be a song which was played at Becky’s funeral. Zoe rated her SUD as 8/10 in relation to this trigger. She stated her negative cognition to be “I cannot cope” on hearing this, with the desired positive cognition being “I can cope” which she rated as completely false (1/7). We processed this trigger by playing the song and working through the distress using sets of bilateral stimulation, allowing Zoe to connect with the music and feed back any shifts in her experience. We found that Zoe responded better to BLS via tapping whilst listening to the song through headphones. This was the first time Zoe has listened to this song in full for 14 years. Zoe reflected on the lyrics, how fitting they were for Becky, and she said that she was starting to feel more relaxed. Zoe was realistic; she still connected to the sadness of the song, however, she was able to shift to a position whereby she would not feel utterly overwhelmed when she heard it. We explored how Zoe could plan for times where she may hear this music in shops or on the radio; rather than it being a sign that she would be overwhelmed, perhaps this could be a sign that Becky was nearer to her, something to be noticed rather than avoided. Zoe aligned with her positive cognition, “I can cope” as we processed this trigger.

Zoe responded better to BLS via tapping whilst listening to the song through headphones.
Sessions 6-7: Future Template

The final step in Zoe’s treatment was thinking ahead to the future. Zoe identified that she continued to notice distress when planning ahead for an event which would ask her to travel to the place where Becky was killed for a (positive) family occasion. Zoe reported some nightmares in relation to the fears this elicited. We identified that, again, Zoe’s fear was that she would be overcome emotionally and struggle to cope. We worked through the Future Template over two sessions. Zoe was able to run through in her mind the various steps of this journey she would take.  Zoe incorporated the compassionate imagery that we had previously used during processing; imagining compassionate others around her, the words they would say and the words she could say to herself. Zoe was creative in thinking about what she would take with her on this trip to feel connected to Becky in a safe way that was on her own terms. She decided that she would pack particular objects or jewellery which hold significance. Zoe thought about the points in her journey where she would need such resources the most, and wrote a diary-like plan of what she would do in these situations. We identified that some grounding techniques might be useful to help her focus on some practical steps in her journey, but at other times Zoe was able to make clear plans to seek out opportunities to connect with Becky’s memory whilst on her trip. We looked at pictures and maps of where this trip would take Zoe, so that she could re-famliarise herself with these places which, as a child, had held so much happiness for her but which she later avoided because they were connected with Becky’s death. As we installed this future template along with Zoe’s positive cognition “I can cope”, including all her compassionate resources along the way, Zoe was able to say to me that she was genuinely excited to take this trip. 

Final session

In Zoe’s final session (number 8), she reflected on the process of therapy and how a recent difficulty in her life had encouraged her to access her own “inner therapist”, noticing an urge to blame herself for something, and instead give herself compassion and kindness. Zoe presented a letter at the session, which we had not planned.  She explained that, for many years, she had wished to write a letter to Becky but had never felt ready to do so until now.

Zoe read her letter out loud and it was clear to see the profound connection she had to Becky. She said she was continuing to write her own story, but that this did not mean she was leaving Becky behind. Zoe reflected that the places, memories and objects that were previously embroiled in the darkness and pain of Becky’s death had now become spiritual ‘aids’ that would help her to connect positively to Becky. She articulately explored how she had worried that connecting with Becky’s memory would somehow destabilise her, had sometimes led to hospital admissions, yet now she was building on this new confidence in acknowledging the pain of the loss. She said this allowed her to move forward in positive ways, embracing the complexities that this could bring rather than trying to avoid them. Zoe had also applied for a job the same week as her final session. This was an emotional end to her therapy and I reflected with her how hard she had worked to engage and commit to this challenging process. 

Throughout the treatment I received clinical EMDR supervision which provided an extremely helpful space to explore the practicalities of following the EMDR protocol, but also in adapting this to respond to the barriers we noted during processing, and employing creative and compassion-focused approaches to support Zoe’s learning. It also provided containment in terms of reflecting on therapeutic processes and using self-awareness such as recognising parallels between Zoe’s experience of loss and some of my personal experiences of loss.


Post-therapy, Zoe scored 6 on the IES-R reflecting some infrequent occasions where she might be reminded of what happened suddenly and experience some emotion, but not to a level which caused clinical concern. This score is significantly lower than prior to therapy, reflecting Zoe’s increased confidence in her own coping and ability to safely notice and acknowledge her feelings in relation to her loss, whilst moving forward with her life.

Zoe’s post-therapy DES-T score was 6.25 which is not suggestive of PTSD.


This case study supports existing research (Meysner, Cotter, & Lee, 2016; Sprang, 2001) which posits that EMDR can effectively treat Complicated Grief. Zoe’s outcome measures indicate a marked difference in functioning post-therapy, where she no longer scores at a level which would cause clinical concern, or reflect PTSD.  

Although Shapiro’s Excessive Grief Protocol (2006) was not explicitly used in this case, it is interesting to note on reflection that the work naturally followed the protocol, starting with the initial loss event and then addressing how to move forward, noticing barriers, triggers, and future concerns along the way. Beginning with the processing of actual events of the loss (the first moments in which Zoe learned of Becky’s death and the details around these first experiences) was logical for Zoe because these moments were so overwhelming that they acted as barriers to any future exploration of what it would mean to connect to Becky, to move forward, and to unpick the dysfunctional beliefs she had developed. It was imperative to address this emotional distress from the start for those reasons. Once this initial distress had reduced, Zoe was more able to access and notice the internal barriers which were blocking her potential of moving forward beyond this loss. At this stage in the therapy, it became clear that a self-defective dysfunctional belief was at the root of Zoe’s difficulty in moving forward; what it meant to ‘move on’ for her triggered feelings of low self-worth and self-blame as Zoe believed this only served to leave Becky behind, lost and forgotten. As we explored this briefly, Zoe was able to reconsolidate her memories of Becky; moving from an intertwined sense of loss, responsibility and blame to what it meant to connect with Becky she had shared her life with.

This reconsolidation for Zoe occurred in varying ways, and it seems could occur only once that initial emotional distress had been processed.  First, it entailed her holding and truly believing two juxtaposing ideas: Zoe truly believed that if she connected to the memory of Becky she would be emotionally overwhelmed and become very unwell; Zoe also truly believed that during therapy when she did connect with Becky’s memory, this actually felt safe and eventually positive for her. This ‘mismatch’ of competing beliefs was enough to challenge Zoe’s negative assumption that she would become destabilised if she allowed herself to think about Becky. Following this, it was clear to see that Zoe in fact welcomed the connection with Becky, as a way of strengthening positive memories of Becky and actually feeling even closer to her. 

Another way in which this reconsolidation occurred is suggested by a further two conflicting ideas that Zoe appeared to hold: first, she believed that moving forward meant that she was leaving Becky behind; second, via the therapy Zoe noticed that she could move forward with Becky’s memory alongside her. Again, Zoe was able to embrace the idea of moving forward because her thinking had significantly shifted, allowing her to creatively and compassionately explore how she could stay connected to Becky even though she chose to progress with her own life.

These examples reflect the process of Memory Reconsolidation, as described by Ecker and Bridges (2020) as “…the brain’s innate mechanism by which new learning experiences directly revise existing contents of memory acquired in prior learning”.  They go on to state that this occurs not only on an emotional level for individuals, but also at the level of neural encoding. For Zoe, her negative assumptions were necessary for her, reflecting “symptom coherence” (Ecker & Bridges, 2020); she needed to avoid the memory of Becky as she believed this protected her own functioning. She also needed to avoid moving on as she believed this prevented exposure as being selfish. The therapy acted as a platform for which she could engage in experience-driven neurological change. The new learning she acquired was a direct result of her using her therapy sessions to challenge her negative assumptions – connect with Becky (learning that this felt safe) and, later, using her therapy sessions to explore how she could move forward whilst still connecting to Becky. The creative way in which Zoe used compassionate imagery (imaging Becky present with her, the words she might say, the jokes she might make) and resources (symbolic objects) to do this may have strengthened this ‘new learning’, ultimately leading to what can be termed ‘transformational change’. For this reason, the current case study suggests that the use of such creative exploration and compassion-focused exercises within EMDR when addressing CG, can aid the process of Memory Reconsolidation, thereby encouraging better outcomes post-therapy.

A similar process occurred when Zoe was processing her main trigger – the song.  By experientially connecting to the music in-session, Zoe was surprised to notice the actual lyrics of the song, and how they spoke deeply to Becky’s character and nature. Where previously Zoe had avoided hearing this through fear of unravelling herself, she in fact had an experience where she felt closer and more meaningfully and positively connected to Becky. After practising this in-session Zoe was able to listen to the song in the car at home and although she stated she would not frequently seek the song out, she knew that if she did hear it, she would not feel a need to turn down the volume.

The creative approach which we adopted in this therapy may not suit all individuals; but Zoe’s interest in books, travel and music were key elements of the therapy, as she was supported to identify how she could use, as tools, things in her life with which she already felt a connection in order to strengthen her connection with Becky.  Zoe had always had an interest in writing, having studied English at university. Her letter which she presented in the final session appeared to be a useful tool for her to consolidate and summarise her learning in her own voice. The letter served a therapeutic function in that she was able to reflect compassionately on her own hard work, and she also spoke sincerely and compassionately to Becky’s memory. This was an extremely powerful moment in the therapy, and one which we both found emotionally and therapeutically significant. Research shows the use of compassionate letter-writing has been used as part of EMDR with good effect (Beaumont & Hollins-Martin, 2013) and compassion-focused techniques incorporated in therapy have been recommended as useful ways to address self-criticism (Gilbert, Baldwin, Irons, Baccus & Palmer, 2006). In the current case study it could be argued that Zoe’s beliefs of self-defectiveness were serving to maintain some of the barriers to her moving forward; the compassion-focused interweaves and compassionate letter were particularly valuable tools in helping her consolidate the therapy as a whole. For these reasons, I suggest these techniques are worth considering when working with individuals who identify with cognitions of defectiveness in relation to the trauma they have experienced. 

This piece of work invited me to think about a loss within my own life, how bereaved family and friends might experience their grief and the inner conflict that can hinder moving forward, particularly when the life lost is young. The progress that Zoe made through committing to this work to develop a fresh outlook on her life has not only enabled me to build experience employing the EMDR protocol with good therapeutic effect, but reinforces my hope and confidence that people can recover from traumatic loss. My work with Zoe will, I am sure, stay with me throughout my career as an EMDR Therapist.


  1. Pseudonym to protect the client’s identity

2. Pseudonym

Dr Jenny Ward is an EMDR Therapist and Clinical Psychologist working within Rotherham Adult Mental Health Services


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