Target Identification and Sequencing for Grief
When working with grief and loss, one of the most important clinical tasks is identifying the appropriate targets for reprocessing. For some clients, the most significant target may be a discrete moment related to the death. For others, the loss may consist of a longer series of distressing events. The key is not reprocessing the general loss but understanding how to frame and sequence the experiences surrounding the loss in a way that promotes the most effective reprocessing.
As with any client, history taking will inform case conceptualization and ultimately guide target selection. When working with grief, it is particularly important to gather information about the client's previous experiences with trauma, loss, and attachment. Exploring the client's history with close attachment figures and identifying any psychological difficulties that existed prior to the loss can provide valuable information for target sequencing.
It is important to note that target sequencing should remain flexible and responsive to the client's needs. Some clients benefit from first processing the immediate loss before addressing earlier traumatic experiences. Others may need to reprocess past trauma before they can effectively process grief-related targets. The decision depends on the overall case conceptualization and what is most prominent in the clinical picture.
In some cases, the recent loss is the primary source of distress and is having the greatest impact on day-to-day functioning. In other cases, unresolved traumatic experiences may emerge and interfere with processing of the loss. When this occurs, it is beneficial to address those earlier targets before returning to grief-related material.
The Moment of Realizing the Loss
Once history taking is complete and the client is sufficiently stable, target identification can begin. One way to begin identifying grief-related targets is to focus on the moment the client fully realized the loss.
For some clients, this may be the actual moment of death if they were present. For others, it may be the moment they were informed of the death. In some cases, the realization occurs before the death, such as when the client fully accepts their loved one is going to die. For others, the realization may occur after the death such as during a funeral or memorial service.
The clinician can say:
"I'd like you to think about the moment you first realized the loss. This could be the moment of death, when you were told, when you witnessed it, or another moment when it became real to you. When was that moment?"
To identify past traumatic memories that could be related to the loss, the clinician can complete a Floatback or Affect Scan from the moment of realizing the loss.
Once the moment of realizing the loss is identified, the clinician can then move on to identifying the next set of targets surrounding a death.
Points of Disturbance Surrounding the Death
The clinician can also identify other distressing memories connected to the loss.
One useful method is the Points of Disturbance procedure. The client is asked to mentally review the series of events leading up to and surrounding the death, beginning at the earliest relevant point and going to the end. As they move through the sequence, they are instructed to identify moments that stand out as particularly disturbing or emotionally charged.
The clinician then makes a brief note of each significant moment for future reprocessing.
This process can be thought of as identifying and pulling out the most distressing pieces of the overall experience for individual targeting.
For example, a client whose spouse died from cancer may identify several separate Points of Disturbance, including receiving the diagnosis, witnessing physical decline, a difficult conversation near the end of life, the moment of death, and the funeral service.
The clinician can say:
"I'd like you to think about the events leading up to and surrounding the loss, starting at the earliest point that feels relevant all the way to the end. You don't need to go into detail. Just slowly move through theses experiences in your mind and let me know when you come across a moment that feels especially disturbing. When you notice one of those moments, simply let me know and we'll make a note of it for later."
Nightmares, Flashbacks, and Vicarious Images
Nightmares, flashbacks, and distressing mental images related to the death can also serve as appropriate targets for reprocessing when present. Identifying these types of targets could be done in addition to the Points of Disturbance or in place of it, depending on the client's symptoms and access to this type of material.
These experiences often contain unresolved aspects of the loss and may provide direct access to the most emotionally charged components of the grief.
Unresolved Experiences with the Deceased
Some clients present with unresolved conflict, guilt, regret, or other painful experiences involving the deceased.
These targets are often identified through a Floatback from the moment of realizing the loss, the Affect Scan, or emerge naturally during the course of EMDR therapy. When it becomes clear these unresolved experiences continue to interfere with adaptation to the loss, reprocessing of these targets will be needed.
Secondary Losses
Secondary losses can also be identified and reprocessed. These often involve painful moments when the reality of the loss becomes salient. This often happens around shared activities, traditions, or routines. Examples may include listening to music together, reading together, visiting a favorite place, celebrating holidays, or engaging in an evening ritual. These secondary losses can highlight the absence of the loved one.
Sequencing Grief Targets
When deciding the order in which to reprocess targets, it is important to understand the client's trauma history, attachment history, and relationship with the deceased. In general, reprocessing begins with the moment of realizing the loss. The clinician may then move to other Points of Disturbance surrounding the death, nightmares and flashbacks, or both. From there, treatment may focus on unresolved experiences with the deceased, secondary losses, or both.
Once all grief targets are reprocessed, as well as present triggers and future templates related to grief, the clinician may proceed with other past memories and continue with a more traditional past-to-present treatment sequence. If however, past memories before the loss impede the ability to resolve more recent grief related targets, the clinician will most likely need to reprocess those targets first.
This framework should be viewed as a general guideline rather than a rigid protocol. Target sequencing should remain flexible and be adjusted based on the client's needs and responses to treatment. Assessing blocking beliefs, before and during grief reprocessing, is often one of the most useful considerations when deciding whether past traumatic memories should be addressed before grief-related targets.
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