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.

Specific Phenomena of Violent Dying:

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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.

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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.

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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:

Specific Phenomena of Violent Dying:

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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.

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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:

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

beliefs.

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.

http://www.vdbs.org/html/study.html (excerpts from)

Feb 27, 2003 ... Rynearson, E.K. (1984). Bereavement after Homicide: A Descriptive Study. .... www.ncptsd.org/facts/disasters/fs_grief_disaster.html ... Copyright 2003-2009, Violent Death Bereavement Society Email contact: laura@vdbs.org ...

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

Produced by Gift From Within- A Non-profit Organization Serving PTSD Clients and Counselors

Thursday's Therapy - Ways We Grieve - Part One

Thursday's Therapy

Ways We Grieve

Part One

The following article is provided on the internet via the Health Library. It provides a summary of some of the many factors with which we are faced when we find ourselves dealing with sudden loss. Mr. Fridman presents Therese Rando's theory of how we grieve called "The Six R's." Rando's theory is just one view of the Ways We Grieve.

Unique Concerns When Grieving for a Sudden Loss

by Sherman M. Fridman, JD

The sudden loss of a loved one can be one of the most painful and difficult things to go through. But, the experts say, there is no one correct way to grieve.

Famed British historian Arnold Toynbee said,

"There are always two parties to a death, the person who dies and the survivors who are bereaved...and in the apportionment of suffering, the survivor takes the brunt."

Any loss of a loved one is tragic and painful, but when death occurs from a sudden, unexpected cause such as an accident, natural disaster, suicide or murder, the reactions of the survivors in coping with their grief are more intense and varied than they may be following a death that occurs after a prolonged illness.

An unexpected loss brings with it factors that do not normally exist when death is anticipated. Not only must the survivors cope with feelings of grief, but they often have to cope with intrusion into their mourning by the media or with the vagaries and slowness of the criminal justice system. Other factors adding to the burden of an unexpected death are the lack of an opportunity to say goodbye or to plan for the financial future of the family left behind.

No Time to Prepare

Donald Mossman, PhD, director of graduate studies at Concordia College in Michigan and teacher of a college course on death and dying, identifies another factor, which is often overlooked by sudden loss survivors and their caregivers.

Regardless of the cause, a sudden death deprives the survivors of what Mossman calls anticipatory grief. This is the grief that begins when a loved one is diagnosed with a terminal illness. It helps prepare the survivor for the coming loss and reduces the intensity of the psychological reaction to the eventual death.

Violent Death

The mind has trouble comprehending sudden, violent death. Deaths involving violence or mutilation engender frightening feelings in the survivors, ranging from terror to anxiety to powerlessness, making them particularly traumatic.

Often the violence of the act resulting in death, arouses strong feelings of hostility in the mourner, causing severe internal conflict leading to guilt, shame, or depression.

Suicide

Family members of someone who has committed suicide also face special burdens. According to Judith M. Stillion, PhD, a professor of psychology at Western Carolina University, many family survivors of suicide have higher levels of guilt, shame, and anger than do survivors of sudden loss from other causes. Persons grieving a loss through suicide are often left with questions, such as why their loved ones killed themselves, and what, if anything, they might have done to prevent the suicide. These questions are often unanswerable and can prolong the process of grieving and coming to grips with the loss.

"Natural" Causes

Heart attacks and strokes are major causes of death in this country, and these deaths are often sudden and unexpected. The sudden loss of a loved one, even from these "natural" causes, can be as unexpected and devastating to the survivors as the death of a loved one from a murder or an accident.

Emotional Challenges

What most, if not all, survivors of sudden loss have in common are a series of emotional challenges, including:

Disruption of family functioning

Redefining of responsibilities and roles within the family

Challenges to the survivors' belief systems

Financial change

Public intrusion into private anguish

Lack of opportunity to say goodbye and resolve other unfinished business with the deceased

Hurt, often inadvertent, caused by the well-intentioned words and actions of other family members and friends

Therese Rando's "The Six Rs"

Therese A. Rando, PhD, is a Rhode Island psychologist specializing in loss and grief counseling. She has identified six mourning processes that survivors of any loss must go through in order to achieve a healthy accommodation of the loss.

However, Rando acknowledges that survivors of sudden loss often have a more difficult time with one or more of the processes, which she identifies as "the six Rs."

These (grief) processes are:

Recognize the loss—Acknowledge that the loss has occurred and understand it.

React to the separation—Survivors should allow themselves to experience the pain and give expression to their feelings of loss.

Recollect and re-experience the deceased and the relationship—However, the recollections should be realistic, both good and not so good.

Relinquish the old attachments of the deceased—This involves the attachments of the deceased, not the survivors' attachment to or feelings for the deceased. For example, just because the deceased's clothes have been donated to charity doesn't mean that all memories have been disposed of as well.

Readjust to move adaptively into the new world—Rando suggests that this be done through survivors adopting new ways of continuing on with their lives while not forgetting their old ones. The Hospice Foundation of America (HFA), says that survivors never fully detach their feelings for the deceased and that grieving should not be looked upon as a means of letting go of the person who has died.

Reinvest—Survivors need to reestablish close personal feelings with the living.

There Is No "Right" Way to Grieve

Survivors need to be patient with themselves. Mourning is an individual process that should be done at the survivor's pace, and not be dictated by friends or family.

Elizabeth K. Carll, PhD, a psychologist specializing in trauma, violence, and family relationships, believes that there is no "cookie cutter" approach to the grieving process.

The Hospice Foundation of America, as well as Dr. Carll, debunk the theory that we slowly and predictably recover from grief.

The HFA calls grief "an uneven process" with no time line.

Dr. Carll emphasizes that the circumstances of the loss as well as anniversary dates of the loss are significant for the survivors and should be acknowledged.

The HFA also says that grievers need opportunities to share their memories and grief. They are not best left alone and they do need support.

Don't tell survivors to take their mind off the loss or to keep busy.

Becoming Active Again

Dr. Carll recommends that survivors of sudden loss not dwell on the negativity of the event, but rather turn their response to the loss into a positive, active experience. She suggests that a survivor grieving over the loss of a loved one from an accident campaign for tougher safety regulations. The family of a murder victim could campaign for victim's rights. And a survivor could positively respond to a sudden loss caused by illness by becoming active in the fight against the disease.

No one experiences or copes with a loss in the same way, but when the loss is sudden and violent, the emotional and behavioral characteristics are intensified.

It is this intensity that must be focused upon so that normal reactions to the psychological trauma of sudden loss do not become the foundation of a dysfunctional lifestyle for the survivors.

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(Thank you to http://bit.ly/6GzUIk for access to this article from Health Library.)

Picture: http://www.instantshift.com/2009/12/19/100-beautiful-examples-of-black-and-white-photography/

Article: http://bit.ly/6GzUIk