The Many Faces Of Bereavement

The Nature And Treatment Of Natural Traumatic And Stigmatized Grief

Ginny Sprang, John McNeil

• Publisher: Routledge
• Year: 2018
• Topic: Psychology
• eBook ISBN:
  9781317772033
• Subtopic: Mental Health in Psychology
• Index: Psychology

First published in 1995. Death and dying have been a concern of mankind as long as humans have existed. This book will explore the development and specifications of traditional models of grief to underline the importance of what is known about the process of grief, considering variables such as relationship, age, and personal characteristics of the mourner, as well as providing a framework of symptomatology specific to non-traumatizing, non-stigmatizing deaths for the purposes of comparative and theoretical specification. It is proposed that what is known about the grief response following the death of a spouse, a child, or an aged parent has valuable implications for grief model development considering other modes of death such as murder, drunk driving, AIDS, critical incidents, and suicide, though these conceptualizations are insufficient in explaining or predicting outcomes with these other types of grief.

II

TRAUMATIC GRIEF

5

A Theoretical Overview of Traumatic Grief^*

The previous section explored the process of bereavement based upon traditional models of grief. This section introduces and expounds upon yet another significant variable, the mode of death. Specifically, we will discuss the nature and course of bereavement in survivors following a traumatic death. Over the past few years, there has been a growing interest in the psychological plight of the trauma victim. Experts are beginning to recognize that a traumatic death produces indirect victims who suffer intense emotional trauma. Even so, there is little information available regarding the impact of a traumatic death on the psychological adjustment of the survivors. As the number of descriptive studies on death and dying increases, a variability is noted in the grief response of those experiencing traumatic object loss. In the following pages, we discuss the death of a family member due to murder, drunk driving, and community disaster.

TRAUMA DEFINED

It is proposed that the nature and course of bereavement are complicated by its traumatic mode. The unexpected and often violent manner of death in a murder, drunk driving collision, or community disaster adds to both the depth and extent of the psychological response to trauma experienced by the surviving family members. A few authors (Ochberg, 1988; Parkes & Weiss, 1983) have noted the differential manner in which the mode of death impacts the way individuals grieve. Just how and why these differences occur is a matter not fully explored in the literature, yet clearly it is an issue relevant to accurate understanding and treatment of traumatic grief.

A review of the DSM-IV’s depiction of bereavement further underscores the necessity for continued exploration of trauma-related bereavement. It is proposed that there is a lack of conceptual clarity regarding the “normal” course of bereavement when the mode of death is considered.

The DSM-IV describes bereavement as a normal reaction to loss that produces symptomatology consistent with a mood disorder. There is a clear distinction, however, between these depressive symptoms (poor appetite, sleep and appetite disturbance) and more marked impairment in social, occupational, and/or familial functioning. Therefore, pathology is assumed if the reactions to loss are intensified and/or extend beyond these established guidelines for bereavement.

As the following chapters in this section point out, the usual course of bereavement after a traumatic death does not fit the diagnostic criteria for uncomplicated bereavement, nor is the clinical presentation of the mourner easily explained by a sole diagnosis of Major Depression. Can it be assumed, therefore, that most trauma-induced grief is complicated or pathological? As with all perceptions, one’s initial reference points are paramount to one’s understanding.

Merriam-Webster (1976) defines a trauma as “a painful emotional experience, or shock, often producing a lasting psychic effect and, sometimes, a neurosis” (p. 1513). A traumatic stressor is understood as a stimulus that provokes an overwhelming affective reaction that can jeopardize existing adaptive capacities and impair psychological and physiological functioning. Typically, descriptions of survivor reactions to trauma have been polarized into a dichotomy of symptomatology depicted in grief models (discussed in Chapter 1) or symptoms associated with Post-traumatic Stress Disorder (PTSD). It is believed that a conceptualization of the psychological response to traumatic death is inadequately depicted in either of these models alone.

These ambiguities and diagnostic problems have clinical implications. The process of grief in surviving family members of traumatic death victims may be misunderstood due to the intensity and duration of their reaction to the death. Uncertainty prevails regarding what responses can be expected and what factors influence the extent of the reaction. To address adequately the impact of trauma on the individual and family system, it is necessary to develop clinical intervention strategies, research programs, and social policy based on the proper theoretical frame work. Toward this goal, the following presentations explore the components of traumatic grief, then explore symptomatology specific to the mode of death. Implications for assessment and treatment follow. Further clarification and exploration of these variables can lead to the formulation of a new paradigm for understanding this type of trauma.

Generally speaking, the trauma victim experiences reactions consistent with the bereavement paradigm described earlier, yet responses take on an added dimension of PTSD symptomatology. Exploration of the nature of traumatic stress reactions are necessary for adequate understanding of traumatic grief.

In 1941, Kardiner first described the syndrome known today as Posttraumatic Stress Disorder. He noted that individuals with PTSD experienced symptoms consistent with five principal features of the disorder. These categories include: (a) persistence of startle response and irritability; (b) proclivity to aggressive outbursts; (c) fixation on the trauma; (d) constriction of personal functioning; and (e) atypical dreams. These symptoms can be classified into positive and negative clusters, the positive cluster including hyperactivity, aggressive outbursts, exaggerated startle response, and intrusive recollections, while the negative cluster contains symptoms of constriction, social isolation, and a sense of estrangement from family and friends. Forty years later, Kardiner’s descriptions were incorporated into the DSM as diagnostic criteria for Posttraumatic Stress Disorder.

A diagnosis of PTSD is indicated if the person has experienced, witnessed, or was confronted with an event that involved actual or threatened death or serious injury, or a threat to the physical integrity of others, and responded with intense fear, helplessness, or horror. In children, it may be expressed instead by disorganized or agitated behavior (DSM-IV, pp. 427-428).

Criteria B states in DSM-IV that the trauma must be persistently reexperienced in at least one of the following ways:

1. Recurrent and intrusive distress at recollections of the event. In young children, distress may manifest during repetitive play in which themes or aspects of the trauma are expressed.
2. Recurrent distressing dreams or nightmares of the event. In young children, there may be frightening dreams without recognizable content.
3. Sudden acting or feeling as if the traumatic event were recurring, including a sense of reliving the experience via illusions, hallucinations, flashbacks, and dissociative episodes (even those that occur upon awakening or when intoxicated). In young children, trauma-specific reenactment may occur.
4. Intense psychological distress at exposure to a stimulus that symbolizes or resembles an aspect of the traumatic event (e.g., a specific sound, landmark, date).
5. Physiologic reactivity upon exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event, (p. 428)

The hallmark of Criteria B of the DSM-IV depiction of PTSD symptomatology is the reliving of some aspect of the trauma in some way. Ruminations on the trauma may center around the violent nature of the death or the extent of physical suffering experienced by the deceased. Denial, shock, and psychic numbing can be considered dissociative mechanisms and should be included as symptoms meeting Criteria B of PTSD. These disturbances may be viewed as symptoms of grief and may not be classified as symptoms of PTSD by practitioners inexperienced in trauma work. Therefore, the diagnosis of PTSD may be overlooked. In addition, the existence of Psychogenic Amnesia (see Criteria C) may occur, so that there is an absence of Criteria B.

Criteria C of the DSM-IV description of PTSD describes an avoidance of the stimuli associated with the trauma or numbing of general responsiveness (not present before the trauma), as indicated by at least three of the following:

1. Effort to avoid thoughts or feelings associated with the trauma.
2. Effort to avoid activities or situations that arouse recollection of the trauma.
3. Inability to recall an important aspect of the trauma (psychogenic amnesia). Psychogenic amnesia is produced by dissociation and repression of the traumatic images brought about by affective flooding. The inability to recall may be linked to a specific aspect of the trauma (e.g., death notification). The development of psychogenic amnesia may be linked to a number of variables such as the type of trauma, the fear of future harm experienced by the survivor, and other endogenous and exogenous variables impacting the individual’s ability to cope.
4. Markedly diminished interest in significant activities. In young children, there may be a loss of recently acquired developmental skills such as toilet training or language skills. In adults, it is not uncommon to see social withdrawal and isolation and a loss of interest in previously pleasurable activities.
5. Feelings of detachment or estrangement from others.
6. Restricted ranges of affect.
7. Sense of foreshortened future (e.g., the individual does not expect to have a career, marriage, children, or long life), (p. 428)

Criteria D of the DSM-IV refers to persistent symptoms of increased arousal (not being present before the trauma) as experienced in at least two of the following:

1. Difficulty falling or staying asleep.
2. Irritability or outburst of anger.
3. Difficulty concentrating.
4. Hypervigilance.
5. Exaggerated startle response, (p. 428)

The startle reaction and the hypervigilance symptoms are most common to PTSD and differentiate it from a Generalized Anxiety Disorder diagnosis. Symptoms of hyperarousal and traumatic reexperiencing have been documented in research addressing combat veterans (Kulka et al., 1990), rape victims (Burgess & Holstrom, 1974), kidnapping victims (Terr, 1983), natural disaster victims (Erikson, 1976), and accident victims (Wilkinson, 1983).

Criteria E (p. 429) refers to the time frame of symptomatology and is perhaps the most controversial aspect of the DSM-IV description of the disorder. The DSM-IV suggests that there should be a duration of the disturbance (symptoms B, C, and D) for at least one month, specifying delayed onset if the occurrence of symptoms lasts at least six months after the trauma. Many practitioners interpret this to mean that the individual must have experienced all symptoms (B, C, and D) together within one month for the diagnosis to be made. Others suggest that the duration of each of the symptoms must be one month, but do not believe the symptoms must occur simultaneously.

Some clinicians seem to look at the syndrome as a frozen moment in time instead of viewing the disorder as a flow of symptoms over time, with certain aspects of the event being predominant at different times. Bard and Sangrey (1986) discuss the concept of “waxing and waning of tension,” which they found is evident in the crisis reaction of victims of crime. During what Bard and Sangrey call the “recoil phase,” the victims they studied experienced intermittent periods of time in which they cognitively, emotionally, behaviorally, and physiologically struggled with the impact of the trauma, and then defended against the feelings by denying them. These two types of activity exemplify the natural process of adaptation to trauma and reintegration of the fragmented sense of self. It is proposed that this unique restorative rhythm is responsible for the variability of symptomatology.

Criteria F of the DSM-IV requires the disturbance to manifest with significant impairment in social, occupational, or other important areas of functioning. While functional impairment is not uncommon after a traumatic event, these symptoms are generally prolonged after a traumatic death. The disorder is said to be acute if the duration of symptoms is less than three months and chronic if greater than three months (p. 429).

There have also been criticisms of the APA criteria for not being comprehensive in their description of PTSD symptomatology. Other manifestations of the disorder that are not included in the DSM-IV’s description of PTSD include:

1. The fear of repetition of the trauma. One indicator of the intensity of the trauma response is the perceived threat of future harm (e.g., a victim who has been threatened with further violence if testifying in court or a survivor-victim who feels unsafe because the perpetrator was not caught).
2. Self-doubt or self-directed anger due to a perceived “failure” to protect loved ones. These reactions may be further influenced by social conditioning, which may dictate certain role performance by specific groups (e.g., males may feel they have failed at their role of protector).
3. Anger and resentment at those exempted from the trauma, at the perpetrator, or at others who were not involved.
4. Survivor guilt about living when those around you have died.
5. A progression of losses after the trauma, such as divorce, loss of a job or home.
6. Morbidity, or an obsession with thoughts of how a loved one felt while dying and concerns about the state and location of the body.
7. Insecurities and self-loathing at one’s vulnerability to harm. Feeling a loss of control over one’s environment.

Other traumatic grief responses specific to the mode of death will be explored in depth throughout the remainder of this section.

DIMENSIONS OF THE TRAUMATIC GRIEF RESPONSE

The above-mentioned symptomatology illustrates the distinctive nature of the traumatic grief response. The addition of PTSD symptomatology to the typical grief models previously used to understand bereavement provides a more accurate description of the traumatic grief response.

Amick-McMullen, Kilpatrick, Veronen, and Smith (1989) proposed a model that addresses the cognitive, affective, physiological, and behavioral dimensions of the traumatic grief response. Further development of this model provides a general framework for understanding the traumatic grief response.

Cognitive Dimension

The cognitive dimensions of this type of response include ruminations, intrusive thoughts, preoccupation with the loss, confusion, memory impairment, denial, and thoughts of revenge.

Although the research examining cognitive functioning in mourners after a traumatic death is scarce at best, there are a few studies documenting cognitive impairment in other PTSD patients that support the inclusion of this type of symptomatology in the model (Cugley & Savage, 1984; Horowitz, Wiloner, & Alvarez, 1979; Wilkinson, 1983). These findings all report symptoms of memory impairment...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Contents
• Introduction
• Section: I Death By Natural Causes
• Section: II Traumatic Grief
• Section: III Stigmatczed Grief
• Name Index
• Subject Index