Trauma, Loss and Traumatic Grief
Few things in life are as painful as the death of a loved one. Grief is simultaneously a universal and very personal response to loss that, even in the best of circumstances, can dominate one’s emotional life for many months and, frequently, many years. Ideally, the anguish of acute grief is gradually transformed over time into a way of remembering and honoring the loved one that is less emotionally painful and disruptive. Over time, the loved one can be remembered without being flooded with the pervasive heartache of acute grief.
But sometimes grief becomes complicated, and bereaved survivors remain shaken and acutely distressed for months or years after the loss. They may find it difficult to get through the day, to connect with others, to have hopes for the future; in short, grief-stricken people may find it exceptionally hard to move on with their lives. In many instances, these complications and additional problems indicate or impede adjustment to the death. Professional help may remedy this so that grief no longer presents an insurmountable obstacle to adaptation to life in the aftermath of the loss.
Sudden shocking losses can be particularly difficult. These include: (1) deaths that occur without warning, providing no opportunity to anticipate, prepare or say goodbye; (2) the death of one’s child (some evidence it’s worse with young children than adult children); (3) deaths that occur as the result of violence or of violent harm to the body; (4) a death in which the body is never recovered; (5) multiple losses deaths of more than one person; and (6) deaths that occur as a result of the willful misconduct of others, carelessness or negligence. Causes of such losses include disease, accidents, suicide, homicide, war and terrorism.
What is the difference between normal grief and complications of grief?
Grieving reactions can vary a great deal from person to person and from culture to culture. Grief is not a single emotion, but usually involves a wide range of intense emotions. There is an overwhelming sense of loss with strong feelings of yearning or longing for the loved one. Survivors may feel a profound sense of emptiness and a sense that a part of them has died. Some may feel confused or unsure of who they are without the deceased and wonder what exactly they should be doing. They often speak of generalized pain or heaviness in their chest. They may feel depressed and hopeless about the future. Things that were once important may not seem to matter so much any more. In addition, they may cry easily, lose interest in eating, or experience stomach upset, headaches and feelings of restlessness.
It can take a significant amount of time to accept the reality of a death. Survivors may know intellectually that their loved one is dead, but find themselves expecting the loved one to walk through the door or call on the telephone. It can be particularly hard to part with the loved one’s possessions. The death of a loved one may provoke existential, spiritual or identity crises that challenge one’s faith or one’s assumptions about life’s meaning. Current research on grief and loss teaches us to respect an individual’s way of coping with a loss, while at the same time looking for signs and symptoms of potentially serious complications that could be alleviated. For example, plans to commit suicide, a persistent inability to function for weeks to months after the death, abuse of alcohol and drugs, or symptoms of severe major depression or posttraumatic stress disorder should all be addressed professionally and immediately, even if the person is grief-stricken.
Although grief resembles major depression in many ways, a skilled clinician can determine whether a bereaved person is suffering with depression. It is a mistake to assume that a bereaved person with major depressive symptoms is just having a “normal” reaction, since depression is a serious but treatable disorder. When the death is particularly shocking in some way, there also can be symptoms of posttraumatic stress disorder (PTSD). There are four groups of symptoms that indicate PTSD: (1) re-experiencing of the traumatic event as indicated by painful, intrusive thoughts or nightmares about the death; (2) avoidance or emotional numbing, as indicated by marked efforts to stay away from activities, places or things related to the loved one’s death; (3) feeling detached from others and an inability to feel positive emotions; and (4) increased persistent anxiety and physiologic arousal, as indicated by difficulty sleeping, irritability, difficulty concentrating and a tendency to become startled easily. Although many of these symptoms also are common in normal grief, if all four clusters are present it is likely that the person is also experiencing PTSD.
Survivor guilt is common among bereaved persons, but may be excessive and unreasonable in those with major depression or traumatic grief. Survivors may blame themselves for the death or for not protecting their loved one somehow.
After loss, how long will the feelings last?
Because survivors of the death of a loved one must often come to terms with not only the death itself, but the manner of the death (e.g., if it were violent or painful) as well as all the day-to-day consequences of being without the person (e.g., financial, social), it can take many months for the most painful feelings and thoughts to diminish. It is common for survivors to agonize about what their loved ones experienced during their final moments of life. If other persons were directly or indirectly responsible for the death, the survivor must grapple with the realization that others can and will commit malevolent acts. This awareness can provoke intense reactions including powerful rage toward those perceived to be responsible. If the loved one’s actions led to the death (for example by suicide or drug overdose), anger at him or her is a common feeling as is feeling abandoned by the deceased.
It also may take longer to deal with the loss if the survivor (1) has previously experienced psychological problems, such as major depression or separation anxiety; (2) was very dependent (e.g., practically, financially as well as emotionally) on the person who died; (3) has experienced previous trauma or traumatic loss, especially if it is similar in some way to this loss ; (4) has few friends or relatives who are supportive; or (5) is simultaneously coping with other serious concerns, such as dislocation, major health problems, psychosocial stresses or other losses. Other factors which contribute to greater difficulty in recovery include loss of parent before age 16, physical/sexual abuse or serious neglect as a child.
As the initial shock of the death diminishes, there may be intervals when the survivor is able to focus on other issues and not feel the pain of the loss so intensely. Gradually, these intervals will become longer, and there will be good days and bad days. However, people can experience setbacks during the process. On a relatively good day, the bereaved person may encounter a reminder of the loved one, and this may cause the reemergence of painful feelings of loss. People often have difficulty dealing with occasions such as holidays, birthdays, the anniversary date of the death, or other times that have meaning.
Recent research suggests that if after about six months the acute grief reaction has not shifted into a set of feelings that is easier to bear, the bereaved person should consider taking extra steps to facilitate this process.
What can survivors do to help themselves?
Because physical health may be affected by grief, it is important for survivors to try to maintain adequate nutrition, sleep and exercise. It’s especially important for individuals with any chronic health problems, such as heart disease, to stay in contact with a physician, if at all possible, to ensure proper monitoring of their condition. Survivors often are preoccupied by their grief and may be prone to other sorts of mishaps, such as accidents, so extra caution is important. Similarly, it may be more difficult if survivors must make major decisions during the first several months after a loss, since life changes may bring on additional stress.
Most experts recommend that survivors confide in someone about the loss and find a support system. This can be a friend, a member of the clergy or another person who has experienced similar loss. It may take some time to identify friends who can be good listeners. Not everyone knows what to say or do to be helpful. Some survivors withdraw from social contact to avoid hearing hurtful comments. This is unfortunate, because the bereaved person loses the opportunity to heal with the help of others.
Through the grieving process, the many memories that come to mind of the loved one may at times seem like more than the survivor can bear. It can be helpful for survivors to learn ways to calm themselves. These might include such things as taking a walk, being with people or participating in a distracting activity. Some survivors find it useful to write or to read.
When is it a good idea to seek professional help?
If the intensity of grief is unremitting after about six months or more, or if there are also symptoms of posttraumatic stress disorder or major depression, or if these reactions interfere with other parts of normal life such as being able to care for one’s children or hold a job, asking for support from a professional can be helpful. In addition, any of the following experiences suggest that professional help may be needed:
Continuing to experience intense yearning for the deceased that does not diminish over time
Struggling with substantial feelings of guilt or uncontrolled rage
Becoming severely depressed and feeling hopeless about the future
Harboring persistent suicidal thoughts
Abusing alcohol or other drugs or increasing tobacco use
Treatment can help
No matter how long someone has been suffering from the impact of a sudden traumatic loss, comforting and effective treatments are available. It is important for survivors of sudden traumatic loss to select a therapist who is experienced in treating both trauma and bereavement. A variety of individual psychotherapies and support groups are available. Medication and psychotherapy may be effective with symptoms of both depression and PTSD. In addition, temporary medication may be useful for those who initially experience intense anxiety or the inability to sleep at all. A family doctor, clergy person, local mental health association, state psychiatric, psychological or social work association, or health insurer may be helpful in providing a referral to a counselor or therapist with experience in treating sudden traumatic loss.
For more information about psychological trauma or the International Society for Traumatic Stress Studies, call 847-480-9028.
© 2005 International Society for Traumatic Stress Studies. Traumatic Loss Revised.
All rights reserved.