Unit 12 -- Traumatic Loss and Grief
Grief in a Family Context --HPER F460/F560
Goals for this Unit
In this unit, we will look at the characteristics of the grief of people
who have experienced a traumatic loss, that is, one that overwhelms the
resources of the bereaved, leaving them feeling helpless, with their view
of the world shattered.
Preliminaries
The grief that results from a traumatic loss is particularly difficult
to deal with. The readings and lecture address both the forms of
loss that would generally be seen as traumatic for almost everyone to whom
it occurs. We will also look at the idea of loss as a personal disaster.
For this, I would like you to think of characteristics of losses that you
believe would contribute to their being experienced as traumatic.
I would also like you to think of ways in which families could best cope
with a traumatic loss.
Readings
Anthology
Eisenbruch, M. (1991). From Post-traumatic stress disorder to cultural bereavement: Diagnosis of southeast Asian refugees, Soc. Sci. Med., 33, 673-680.
Gilbert, K. R. (1997). Couple coping with the death of a child, in C. R. Figley, N. Mazza, & B. Bride (Eds.), Death and trauma: The traumatology of surviving. Washington, DC: Taylor & Francis.
Zur, J. (1996), From PTSD to voices in context: From and "experience-far" to an "experience-near" understanding of response to war and atrocity across cultures, The International Journal of Social Psychiatry, 42, 305- .
Read the Eisenbruch and Zur articles together.
Web Resources (the final two are specific to children)
Do not feel that you have to read all of these, I want you to choose
topics that are of particular interest to you. David Baldwin's pages have a
tremendous range of materials. the others are more specific.
"Lecture"
In many ways, regardless of the nature of the loss itself, the loss of someone we love may well be experienced as a traumatic
loss. Even though I want to make a point of acknowledging that, I want
to look, this week, at a more narrowly focused definition of traumatic
loss and look at the grief resulting from this type of loss. These
are losses that are so intense that they profoundly overwhelm the resources
of the bereaved. They are, as one might expect, almost guaranteed to
result in complicated grieving. When seen as stressors, they are those
that most commonly result in post-traumatic stress disorder, a long-term
psychiatric condition, described in the APA's "Warning signs of trauma-related stress." There has been an evolving understanding of PTSD and, in the DSM-IV,
and one that has relevance for this class, is that the event no longer
needed to be markedly disturbing to almost anyone. According to the
DSM-IV, the event must be markedly disturbing to the individual.
This is a significant change in the definition. Particularly relevant to this course are the discussions about the cultural specificity of this diagnosis, as you can see in Eisenbruch and Zur.
Figley and McCubbin (1983) looked at the literature on traumatic
events, defined by them as sudden, unexpected, life-threatening, leaving
the survivors with feelings of helplessness. They found these events
share many of the following characteristics:
- These are sudden-onset events for which there is little or no time
to prepare;
- there is little or no previous experience for those who experience
them;
- there are few sources of guidance on how to respond and what to expect;
- these events are experienced by few (or may be seen that way--with
the resulting sense of isolation);
- those who go through these experiences are unable to determine or predict
the amount of time they will stay in crisis;
- there is an lack of control over the situation and a related sense
of helplessness;
- there is a strong sense of loss (clearly, this is essential when this
is a traumatic loss);
- the lives of the survivors are disrupted and they are (or may feel
they are) surrounded by destruction;
- there is a perception of dangerousness and threat to life (their own
or that of someone about whom they care);
- the emotional impact of the event is intense and, commonly, overwhelming;
and
- often, medical problems result from the trauma (either directly or
indirectly).
When looking at these characteristics, keep in mind that they are a starting
point for thinking of traumatic loss. The simple presence of these
characteristics, even a majority of them, may lead to traumatization, but is not a guarantee.
Bereavement as a "Natural Disaster"
McKissock and McKissock (1991) described bereavement as a "natural
disasters" and identified factors that complicate the grieving process.
As you can see, many of these were echoed in the article by Rando that
you read earlier this semester. These complicating factors are:
- the death of a child -- The death of a child runs contrary to
our belief that children will outlive their parents and that the innocence
of childhood will protect them. Parents grieve for both the loss of the
child and a loss of self. In failing to protect their child, parents may
feel they have failed to carry out the most central role of their lives.
Children also hold the promise of the future and serve as the legacy that
parents hope to leave behind. Children should not predecease their parents
and, regardless of their age, the death of one's child may be one of the
most traumatic losses that can occur in adult life.
- sudden death -- A death for which there is little or no preparation
results in a more abrupt and difficult grieving process. This is because,
in addition to the grief of the loss, there is the sudden shock of loss
and the sense of being overwhelmed. There is no opportunity to anticipate
and/or begin working on any aspect of the loss and grief process.There is also no opportunity for a final (or any) resolution of differences
with the person who has died.
- ambivalence in the relationship -- This may be developmentally
normal conflict or it may be a life-long interpersonal struggle. I would
include the factor, identified by Rando, of conflict in the relationship.
Again, this may be tied to a long-standing conflictual relationship. If
a death occurs after an argument, the survivor may struggle with the fact
that they did not "part on good terms" and can now never resolve
their differences. Although this was mentioned above under sudden death,
a lack of successful resolution of an ambivalent relationship may occur
with any type of loss.
- pre-existing factors -- This can include unresolved grief that
resulted from other or pervious losses. Earlier in the semester, we discussed
the problems of unresolved grief from losses that took place in childhood
and the recurrent nature of the grief from those losses. This recurrence
of grief also takes place for adults with unresolved losses that took place
earlier in their adulthood. Concurrent mental and physical health problems
can add to the impact of the loss and can be exacerbated by the loss.
- perceived preventability of the death -- The more preventable
the loss is perceived as being, the greater the impact. In particular,
if the bereaved person feels as though he or she should have been able
to prevent the death or the deceased should have been able to prevent it,
the likelihood of complications are higher. Interestingly, I found that
people I've interviewed who emphasized personal responsibility for one's
health and safety (and, among parents, for their children) experienced
greater distress at their "failure" to protect their child.
- centrality of the relationship to the bereaved person's life
-- As with preventability, so too, the more central the relationship to
the bereaved, the greater the impact of the loss. This would explain the
impact of a child's death on parents and the impact (particularly on children)
of the death of their parents.
- lack of diversity of social roles -- The more rigid and restricted
the social roles of the bereaved are, the more intense the grief. If options
are available and the bereaved can focus on roles other than the ones they
traditionally held, they then may see themselves as having more options.
The ability for family members to step into (or share) the role previously
played in the family by the deceased is also helpful..
- concurrent crises -- Any additional stressors that run concurrently
with the grief will add to it, simply by reducing the resources available.
As we particularly noted in Unit 4, normal developmental transitions and
behavior normally associated with different developmental stages, could
add to the impact of a loss.
- lack of social support -- Social support, is essential to successful
grief reconciliation. As we discussed in the unit on relationships and
on ambiguous loss and disenfranchised, the support that is needed is not
necessarily available. The intensity of the traumatic loss is so great
that it frightens people away from the bereaved. One suggestion that was
made to me by a grief therapist was that people, in a non-rational, primitive
response, avoid the bereaved because they fear contamination. Perhaps they
feel they are not up to the task of supporting the bereaved, or they are
uncomfortable with the intense emotions and unpredictability of the griever.
Whatever the cause of their avoidance, the result is a perception of the
bereaved that they are unsupported and alone and that they experience their
grief as disenfranchised. This sense of isolation is also reported among
people experiencing traumatic stressors.
Others have looked at traumatic aspects of grief. Attig (1996) includes
violent, mutilating, or random death that shock, horrify and traumatize
those who are left to cope with the loss. Parkes (1997) included
the following factors in traumatic bereavement:
- sudden, unexpected, and untimely bereavements
- witnessing horrific events
- possible personal culpability
- bereavement by murder or manslaughter
- bereavement by suicide
- multiple losses
- personal long-term care of dying person
Especially as it relates to loss that takes place as a result of a disaster,
I would include human-made vs. natural causes -- If the cause of
death is the result of a human-made disaster rather than one that is naturally
occurring, it has a much more negative impact (The bombing in Oklahoma City
would have had a much greater impact than, say, a tornado or earthquake,
because a human being made the choice to inflict harm and death on other humans.
More clearly, we can see this in the immediate and long-term aftermath of the
attacks in the U.S. on 9-11 ).
Why me? -- Making Meaning of the Meaningless
As we've discussed before, what we recognize as grief is a combination
of dramatic psychological, emotional, and somatic changes that result from
a devastating loss of meaning dependent on a significant relationship.
The loss results in intense conflict between the need for an orderly world
in a chaotic reality and an agonizing search for an explanation for the
loss. This explanation is intended to allow the bereaved person to see
the world as predictable and controllable as well as allow them to comprehend
why such a loss should have occurred. Parkes (1997) refers to the process
of revising "basic assumptions, habits of thought and behavior that
have been learned over many years and which we tend to take for granted"
(p. 246) as psychosocial transition (PST). But what does one use
to move through this process?
Throughout the grief process, the bereaved develop a story that helps them
to make sense of their loss. Figley has called this a "healing theory"
and I wrote about this in my chapter I assigned for this unit. This story/theory
can then act as a sort of bridge between what was seen as normal before
the loss and what makes sense afterward. The healing theory must
account, in some way, for thoughts and feelings that are inconsistent with
their world view prior to the loss. It also incorporates elements of their
experience as well as those borrowed from the experiences of others. Information
from cultural and family myths as well as religious or philosophical beliefs
will be tested for inclusion in the modified view. The grieving individual
may find him or herself turning to the person who has died throughout this
process and some of the odd experiences of grief (labeled as hallucinations
or delusions) may be understandable parts of the development of a healing
theory and a new sense of normal that results from the grief process.The underlying goal of this process is to find some sort of understanding
and new sense of stability in life as well as to gain a sense of mastery
and control with regard to the end products of the death.
Traumatic losses confront what appears to be a basic belief of our
Western culture that present the world is fair and just. The loss that
is unfair or unjust can only be described as a loss of balance between
the linked processes of action and result in their lives (" If I am
good, good things must come to me") .
Janoff-Bulman (1992) has proposed that social laws are used to answer the
"why" questions that result form a death. These are laws centered
on justice and control, which allow us to see a pattern of cause and effect
and legitimate ends that results from previous behavior. The initial response
to this imbalance is to look to previously held meaning structures for
guidance and then, if they are lacking, to search elsewhere for answers.
Those grieving may look for a religious or spiritual explanation, a physical
or medical one, a social or psychological one. Ultimately, they may find
that the only answer is that there is no answer, or they may reach a point
where, rather than asking "Why me, why us?" they ask "Why
not me, why not us?"
Anger as a Part of the Grief Process
The process of grief is not an easy one and this is even more so when the
loss is a traumatic one. The intensity of some emotions and thoughts,
which may recur repeatedly, often surprises and frightens the bereaved
and those around them. In particular, an intense anger of a power many
had never experienced before may stay with the bereaved or he/she may experience
episodic bursts of anger and rage. One woman whose daughter had been raped
and murdered said she would experience waves of anger so intense that she
feared they would knock her to the floor. A normally easy going man, months
after he and his wife had experienced their third pregnancy loss (this
time, late in the pregnancy), found himself almost out of control with
rage when a neighbor was making noise early in the morning. It was only
his wife's quick intervention that stopped him from confronting and possibly
killing his neighbor.
In some instances, the anger is unfocused, sometimes so overwhelming as
to be incapable of being focused. In some cases, it may be expressed as
a generalized sense of frustration and unfairness at being "angry
at the whole world." They might target a particular individual or
individuals (e.g., the perpetrator, God, the medical staff) or a particular
institution (e.g., the court system, the medical establishment). It may
also be accompanied by a powerful urge toward revenge. Anger may be directed
toward the individual who has died and this may lead to intense feelings
of guilt at such thoughts.
The Interminability of Traumatic Grief
One issue we have gone back to, over and over, is the idea of grief as
an ongoing, although varying phenomenon. What this means is that
grief does not completely end, as some might expect, but will become a
part of who that person is, sometimes intense and sometimes existing as
a type of "background noise" in their lives. The grief
remains, but the intensity of it is manageable. People who thought
they could never laugh and feel joy do so. They may be surprised,
uncomfortable, and guilty at the thought of feeling joy, but they do. They may even feel the same emotions they felt before. With traumatic
loss, the time until these life affirming emotions are felt will be extended
and they may never feel them to the same intensity or they may forever
after be experienced through the filter of grief.
Given the characteristics of the loss itself and events surrounding it may mean that a traumatic loss is irreconcilable, and is
interminable, that is, never ending (Think of parents whose child has been murdered by a drunk driver and their resulting, ongoing grief). As we have discussed in class, a powerful
belief about grief in our western world is that grief should be resolved
in a reasonable period of time and that the bereaved should be able to
move on to new relationships. This last part has been interpreted to mean
that they should be able to "abandon the deceased" and, after
heaving him or her behind, form new relationships independent of the previous
one. If we think of our experience of grief as a story, the grief of traumatic
loss may seem like some horrible never ending story. In this, the bereaved
are unable to reconcile themselves to their loss and thus are unable to
achieve a sense of closure (Note: remember that it is possible to have
a sense of "closure" on some aspects of one's grief without abandoning the
relationship with the deceased. Also as you know, there is controversy over the
casual use of this term and, if and when it is used, should be at the discretion
of the bereaved.).
I'd like to direct you specifically to the
web readings on children's issues as they are related to children and grief.
Think back to Unit 4 and ways in which children's grief is unique. In
particular, think about issues of their continuing development and how that
might act as a trigger of recurrent or revisited grief.
Families Coping with Traumatic Loss
In a similar process to the one they used to explore the literature on
traumatic loss, Figley and McCubbin (1983) identified 11 functional coping
strategies for coping with trauma. They proposed that, after a trauma,
certain behaviors in families are functional while their opposites are
dysfunctional. They indicate that, in order to successfully cope with loss,
families should take the following approaches:
- adopt a solution-oriented approach to the problem, rather than simply blaming
- showing tolerance for other family members (and acknowledging their
right to grieve differently from each other);
- clearly expressing commitment to and affection for other family members;
- engaging in open and clear communication among members;
- maintaining high family cohesion;
- establishing and maintaining considerable role flexibility within the
family;
- making appropriate use of resources inside and outside the family;
- not using overt or covert physical violence or (coercion); and
- not abusing chemical substances (as well as alcohol and illegal drugs,
this includes over the counter drugs, prescriptions drugs, and tobacco).
Although Figley and McCubbin present this as an opposition dichotomy, you
might find it best to think of each factor as appearing on a continuum
of functionality, particularly if you present these to families. Faced
with a traumatic loss, many (sometimes all) family members will face periods
of time when they will be overwhelmed by the loss and its meaning. There
will be times when individual family members will need to step back from
their participation in family processing of the loss and focus on their
own needs. They may simply be overwhelmed by their own pain, unable to
maintain their role in the family. By viewing the family's response on
a continuum, the tendency to view this "self-focus" as inevitably
dysfunctional for family recovery may be reduced.
In my chapter, I wrote about the ways in which couples dealt with the loss
of their child. The factors I identified as functional for the maintenance
of their relationship were:
- communication,
- a positive view,
- sharing the loss
- flexibility, and
- sensitivity to each other's needs.
One concern expressed to me, and something you may wish to discuss in class,
is that these coping efforts focus more on the maintenance of families
or relationships within families. It may be that these do not facilitate
the grief of individual family members and may be contrary to the needs
of more individual, cognitive, solitary grievers.
General Conclusions
Traumatic losses are overwhelming and are highly likely to complicate the
grief process.
A wide variety of factors contribute to this. These include, but
are not restricted to, the following: the death of a child, sudden death,
ambivalence in the relationship, pre-existing factors, perceived preventability
of the death, centrality of the relationship to the bereaved person's life,
lack of diversity of social roles, concurrent crises, lack of social support,
and human-made vs. natural causes.
The process of making meaning is made more complicated in the case
of traumatic loss by is intense and surprising emotions, especially anger. Of
particular issue, here and elsewhere, is that of human development.
Certain family patterns of behavior and family resources appear to
be effective in helping families and their members to cope with traumatic
loss. Caution should be taken to remember that there is a range of performance
of these patterns, and that families should not be dichotomized into either
functional or dysfunctional.
Questions for Discussion
Post your response to the following questions on the Class Discussion..
- It certainly seems that traumatic loss will overwhelm our ability to make
the loss meaningful. Yet we need to be able to make the meaningless meaningful.
What are your thoughts on this and how would you help someone else make meaning
around a traumatic loss? Any thoughts on what non-Western cultures might teach
us about making meaning? In what ways does the family help to make the meaningless
meaningful following a traumatic loss?
- What are the unique characteristics of children's response to traumatic
loss? What can we do for them?
- What can be done to help families cope with a traumatic loss?
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