Thursday, January 28, 2010

Thursday's Therapy - Ways We Grieve, Part Four: Violent Death Bereavement

Thursday's Therapy

Ways We Grieve

Part Four:

Violent Death Bereavement

Natural or violent dying may be followed by an intensely traumatic and confusing emotional aftermath for family members. Following a natural death, a minority of family members may present with Complicated Grief (Prigerson and Jacobs, 1999).

Complicated Grief refers to a dysfunctional (at least, according to these experts) response of traumatic distress subsequent to interrupted attachment in vulnerable individuals, i.e., complicated grief occurs in someone whose psychological integrity was dependent upon the relationship with the deceased. When that relationship is no longer available, the survivor experiences a persistent state of self-devastation.

11 Factors of Complicated Grief:

  • Numbness,
  • Avoidance,
  • Purposelessness,
  • Disbelief,
  • Emptiness,
  • Hopelessness without the deceased,
  • Partial self death,
  • Shattered world view,
  • Facsimile symptoms,
  • Protestation of death which they view as primarily related to
  • Traumatized self-integrity.

Separation Distress (or Bereavement) is defined by mourning, pining and searching - thoughts, feelings and behaviors to reestablish the presence of the deceased.

Complicated Grief is defined by thoughts, feelings and behaviors of self-disintegration.

Their data is largely drawn from community and clinical populations of adults following the death of a spouse, particularly widows.

In this model, it is the event of terminal separation that is primarily traumatic. The model suggests a vulnerability to separation (irreversible separation triggers personal disintegration) as a necessary precondition for the occurrence of Complicated Grief.

Prigerson and Jacobs acknowledge the independent, "traumatic" effects of violent dying on bereavement, but ascribe it to a separate disorder, PTSD. However, the traumatic effects of violent, unnatural or unexpected dying are not completely described by the criteria for PTSD. After violent dying, the

PTSD Phenomena:

  • Intrusive reenactment imagery of the dying,
  • Avoidance of reminders of the dying,
  • Physiologic hyper-arousal and
  • Persistent dysfunction

may describe some of the reactive signs and symptoms, but there are specific effects of violent dying not included in the list of criteria for Traumatic Grief or PTSD.

Violent Dying:


Violent dying is a human act, associated with human intention or negligence. Suicidal, homicidal, accidental, or terrorist "killing" is followed by a socially proscribed inquiry to investigate and determine who is "responsible" because this is a dying that should not have happened. This intense inquest by the medical examiner, the police, and sometimes by the courts socially reinforces the personal demand for investigation, and retribution if investigation determines that the deceased was the "victim" of a crime. Natural dying is rarely followed by such an inquiry, and it is not normative for grief following natural dying to include persistent thoughts, feelings, or behaviors of retaliation or retribution or dread of its recurrence.


Since violent dying is the most common cause of death before age 40, a disproportionate number of younger parents and siblings are forced to accommodate to the violent dying of a primary family member. Parents, particularly mothers, are over-represented in every study (usually representing over half of the sample) who present for treatment.


Mothers seeking treatment after the violent death of their child may meet criteria for both complicated grief and PTSD, but they are also intensely remorseful because of their perceived failure in protecting their child from violent death. Mothers serve as the primary attachment provider to their child (different than the attachment dynamic within a spousal relationship) and because of their parental obligation of protection, mothers feel inordinate remorse for the dying.

Violent Death Bereavement Clinical Differentiation:

There is not enough evidence to designate Violent Death Bereavement as categorically distinct from Complicated Bereavement or PTSD. However, there are clinical phenomena and dynamics specifically associated with Violent Dying that need to be included in supportive guidelines and interventions:

Violent Dying:


The immediate aftermath of violent death demands an intense engagement of the family with community agencies of the media, police, and eventually the courts and prisons if someone is apprehended and tried.

- Guidelines for this public aftermath include active advocacy and education.


Mothers and young children are particularly vulnerable to a prolonged bereavement after the violent death of a loved one.

- Guidelines for their delayed adjustment include proactive outreach and follow-up of family members (particularly mothers and children) for 18-24 months.


Vulnerability to prolonged bereavement is associated with a syndrome of obsessive thoughts and flashbacks of the dying reenactment and secondary thoughts of remorse, retaliation, and recurrence.

-Guidelines for this traumatic aftermath include interventions that moderate distress, restore resilience, and modify the obsessive narratives of dying, remorse, retaliation, and recurrence.


Resiliency After Violent Death: Lessons for Caregivers

Dr. Ted Rynearson, M.D. and Daniel W. Clark, Ph.D.

Dr. Ted Rynearson, a prominent psychiatrist recommends

clinicians, clergy, and caregivers shift their focus from the

death itself to the longer term needs of loved ones dealing

with the tragedy of losing a loved one to violent death.

Three Common Psychological Responses to Violent Death

and Treatment Implications:

Phase 1. Intense Separation & Trauma Distress:

The immediate challenge following a violent death is over-

whelming distress related to both the reality of death

(separation distress), as well as the reality of violent

dying (trauma distress).

Intense Separation & Trauma Distress is the immediate

challenge for families. The experts recommend that

families be given the facts of their loved one's death,

when they feel ready for that information. Lacking such

factual information, many family members, including

children, create vivid fantasies about the death, which

can be more harmful than the facts themselves.

Phase 2. Reframing Dying & Nurturing Imagery:

the next challenge involves revising and synthesizing

the traumatic memories of the killing with the nurturing

memories of the deceased.

Dr. Rynearson recommends asking patients about their

concept of death - what do you think occurs? Spiritual

beliefs may play an important role, both explanatory and

comforting. Also important is listening to survivors tell

their story. The experts remind the helpers they should

listen to the family members without imposing their own


Phase 3. Meaningful Reengagement:

A later challenge is in establishing a meaningful reconnec-

tion with the flow of life - beyond the tragedy of violent

death - by a hopeful recommitment with valued activities

and relationships.

The experts highlight the importance of supportive family

and friends, the importance of "just being there," and the

importance of letting the process develop over time without

trying to rush it. Surviving parents (point out) the importance

and meaningfulness of reaching out to others, after time.

The information on this Website is presented for educational

purposes only. It is not a substitute for informed medical

advice or training. Do not use this information to diagnose

or treat a mental health problem without consulting a

qualified health or mental health care provider.

 (excerpts from)

Feb 27, 2003 ... Rynearson, E.K. (1984). Bereavement after Homicide: A Descriptive Study. .... ... Copyright 2003-2009, Violent Death Bereavement Society Email contact: ...

Review by Daniel W. Clark, Ph.D., WA State Patrol Psychologist


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