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Treating Traumatic Bereavement

A Practitioner’s Guide



In writing this book, we came together with one goal: to improve the treatment available to people who have experienced the sudden, traumatic death of a loved one. Such deaths take many forms. In some cases, the death may have come about through the deliberate actions of another, as when a young woman is murdered by her ex-boyfriend. In other cases, the mourner may have contributed to the loved one’s death, as when a father purchases a handgun that he neglects to lock up, which his teenage son then uses to commit suicide. In still other cases, the survivor experiences many profound losses in addition to the loved one’s death, as when a tornado touches down in the neighborhood. To some degree, these survivors will face different issues: Some will live in fear that another loved one may be killed, some will struggle with guilt, and some will be exposed to bureaucracy at every turn as they try to rebuild what was lost. Despite these differences in how people experience the death, these losses share two common elements: Survivors of such losses can expect to experience painful feelings of grief as well as symptoms of trauma such as flashbacks, sleep disturbances, and problems with concentration. Treatment that focuses on only one of these elements is unlikely to be effective.

In this book we present a multifaceted therapy for these survivors. Our comprehensive treatment approach supports mourners in addressing both the trauma and grief associated with their losses. The treatment approach has three core components: building resources, processing trauma, and facilitating mourning. Briefly stated, the treatment will help traumatic bereavement clients develop the internal and external resources they need to process the traumatic dimensions of the death. The trauma processing, using cognitive-behavioral and exposure techniques, allows clients to address the trauma complicating their grief. Facilitating the processes of mourning enables clients to accommodate their loss. Through resource building, trauma processing, and the work of mourning in the context of a supportive relationship with their therapist, mourners are gradually able to adopt healthy new ways of moving forward in the world without the deceased.

Who We Are And how This Book Came About

This book is the result of a long-term, stimulating collaboration among five psychologists who share a common aim: to help people with traumatic bereavement come to terms with what has happened and, ultimately, to lead more fulfilling lives. Some of us have sudden, traumatic losses in our personal backgrounds; all of us have encountered these survivors in our professional and personal lives. Their anguish and lack of treatment options motivated us to develop this approach.

On many occasions, we have had the opportunity to speak with survivors of traumatic loss who were disappointed in the treatment they received. Here are four examples:

  1. About a year after losing her son in an accident, a woman began seeing a therapist. After 9 months of weekly treatment, the therapist told her, “You have a lot of trauma symptoms and I don’t know how to treat those. We can either take a break, and I will attend some trauma workshops, or I can refer you to someone else.”
  2. A man whose son, a pedestrian, was killed by a drunk driver, struggled with flashbacks about what had happened that night. “My therapist advised me to stop dwelling on these thoughts, and to just put them out of my mind and try to think about something more pleasant. He implied that the problems that I had with these thoughts reflected a lack of willpower on my part.”
  3. A young man lost his brother, whom he had not seen in a year, in an airplane crash that he had witnessed while awaiting his arrival at a small airport. Two years later, still plagued by images of the crash, he entered therapy. After he told the therapist that he wanted to preserve some sense of connection to his older brother, the therapist told him that he had attachment problems and required intensive psychotherapy for what obviously were long-standing issues.
  4. About 6 months after losing her husband in an industrial explosion, a woman made an appointment with the employee assistance person at her husband’s workplace. She showed up at the appointment with her two daughters, ages 10 and 12. As she expressed it, “I told him a little bit about what happened to Robert and he literally went running out of the room. He said that he didn’t have the training to help us. I thought he would send in someone else, but that didn’t happen.”

In addition to hearing from survivors, we have had countless conversations with therapists who had a strong desire to help traumatically bereaved clients, but who were uncertain or misguided about how to do so. In some cases, it appeared that therapists were unaware of the prevalence or the intensity of trauma symptoms. Similarly, many therapists seemed to be uninformed about the duration of these symptoms, not recognizing that following a traumatic death, debilitating symptoms of grief and trauma can last for several years.

As they learned more about traumatic bereavement, some therapists conveyed concerns that in the past, they may have responded inappropriately to bereaved clients’ disclosures of traumatic experiences. Some expressed regret that they pathologized clients who displayed intense and prolonged trauma symptoms. For example, one therapist stated, “If I knew then what I know now, I would have been able to legitimize my client’s responses to his loss. This would have made a big difference.” Another therapist treated a woman whose daughter had been shot, told us that one of the most difficult aspects of the loss was what the client witnessed when she discovered her daughter’s body. “I have to admit that I had great difficulty initiating discussion around this issue. When it did come up, I told myself that we should not focus on it too long or it might destabilize my client. I can now see that my client was avoiding this topic, and I was aiding and abetting her effort to do so.” We have also reflected on our own difficulties in doing this work. Our personal reflections, heartbreaking stories from survivors about inadequate and incompetent treatment, and the suffering of our colleagues caused by regret or a sense of helplessness are what led to our collaboration and determination to create a treatment approach that would be accessible to therapists who wished to help the traumatically bereaved.

This treatment approach has truly been a co-creation, blending our different perspectives and backgrounds. Camille Wortman gathered and convened our group based on her vision of bringing together the accumulated wisdom in the fields of trauma and grief. We have spent hundreds of hours together sitting around a big worktable, participating in conference calls, writing and then editing each other’s work, as well as sharing meals, laughter, and our own losses. After developing the approach, we pilot-tested it with clients at the Traumatic Stress Institute/Center for Adult and Adolescent Psychotherapy, formerly located in South Windsor, Connecticut (and now closed). Following the terrorist attacks of September 11, 2001, we were invited to teach our approach to psychotherapists from three universities in New York: Pace, Stony Brook, and Columbia. With each step, we have reshaped and refined the treatment approach. At many points along the way, individuals and groups who were interested in implementing our treatment program contacted us. Consequently, we decided to publish it as this book, which provides the background for this treatment approach, as well as the details of its implementation.

These chapters bring together cutting-edge work in the fields of trauma and loss. We draw from a wealth of clinical experience concerning ways to help clients build their resource base, process the traumatic elements of the death, and accommodate the loss and move forward with their lives. We address many specific issues that confront therapists who choose to work in the field of traumatic bereavement. Some of these problems concern the challenging matters and questions our clients bring to us. For example, a mourning parent may ask us why God allowed her child to die. Others stem from the nature of the work itself. For example, we offer support and guidance regarding how to help a reluctant client understand the value of recounting the murder of her child. We believe our approach represents the best integration and elaboration of the theory, research, and clinical wisdom that the fields of trauma and bereavement have to offer.

In collaborating on this book, we have made every effort to be mindful of the tension that often characterizes the relation between clinical research and practice (see, e.g., Bridging Work Group, 2005; Jordan, 2000; Neimeyer & Harris, 2011). Authors associated with the Bridging Work Group have emphasized that there is a gap between the interests, values, rewards, and work settings of bereavement researchers and those of practitioners. As the Bridging Work Group (2005) expressed it, “Many practitioners regard research as holding little relevance for their work, and many researchers believe that clinical practice has little to contribute to the scientific study of bereavement” (p. 93). The divergence in points of view was highlighted by the title of an early conference on improving communication between the two groups: “Therapists Are from Venus. Researchers Are from Mars” (Jordan, 2000).

The very composition of our team guards against the emphasis on theory or research over practice. Four of us are clinical psychologists who have had active psychotherapy and consultation practices focused on trauma (L. A. P., C. H. F., and C. A. F.) or bereavement and trauma (T. A. R.). The fifth (C. B. W.) is an academic psychologist who specializes in grief, and who serves as a legal consultant for survivors of sudden, traumatic death. As a group, we represent a variety of theoretical approaches, including cognitive- behavioral theory, psychodynamic theories, trauma theory, and humanistic psychology. Our broad experience base includes a wide range of clients and issues, which have informed and enriched the development of this approach. We considered each component of our treatment approach from multiple perspectives. Although all of us collaborated fully in developing the treatment approach, and each has contributed varying amounts of content to it in earlier iterations, Laurie Pearlman and Camille Wortman have played the primary role in writing the final version of the book. They contributed equally to this endeavor.


Authors must choose terms that convey their meanings as specifically as possible and terms that include all who might be part of the work. We have alternated use of the masculine and feminine pronouns. At times, we have addressed therapists as “you” and other times used “we” to acknowledge our own participation in this community. In describing those we are treating, we have alternated the term “survivor” with “mourner,” “client,” and “the bereaved.”

We sometimes refer to the deceased as the “significant other.” We chose this term in an effort to be as inclusive as possible when referring to the person who died. While many survivors will have had a positive attachment with their deceased family member or friend, others will have had highly ambivalent relationships or largely negative attachments for which terms such as “loved one” may seem inappropriate. Yet, in any of these cases, the connection will have been significant. In the text, we alternate among “loved one,” “significant other,” and “the deceased.”

Who May Benefit from this Book?

We wrote this book for psychotherapists and counselors who want to work more effectively with people who have experienced a sudden, traumatic death. In the past decade, there has been increasing interest in treating this population. There is growing awareness that traumatic bereavement may require treatment approaches that are unique to the specific challenges these survivors face. Many clinicians with a sincere interest in treating them have received little formal training in how to help. We have addressed this book to psychotherapists, with the implicit understanding that therapists also have had losses and may themselves be consumers of this type of treatment at some time.

For the most part, our target audience is psychotherapists who treat people with a variety of typical life problems such as divorce, job loss, and chronic stress. In all likelihood, these therapists have treated some clients with a “normal” or “typical” loss, such as the death of an elderly parent, but may not have treated many clients who experienced a traumatic loss. Our approach will show clinicians how to augment their skills to treat individuals experiencing traumatic bereavement.

Some therapists may have had the opportunity to treat a number of clients who have experienced a traumatic death. These therapists may feel that they would benefit from a treatment approach developed especially for this population, as well as treatment tools and resources that will help them to implement the approach.

We designed the treatment for clinicians representing a wide variety of experience levels and theoretical frameworks. We offer those with a particular orientation to therapy (e.g., cognitive- behavioral therapy) the opportunity to recognize the importance of including additional treatment components (e.g., building self-capacities), and provide resources for doing so. We also describe ways to apply their particular orientation to this unique population – for example, how to change maladaptive thinking patterns in people who have experienced a loss of this kind.

Regardless of their level of experience or their theoretical orientation, many therapists rely on a grief or bereavement approach in treating the loss of a loved one. The basic idea is that clients must work through their grief by accomplishing certain tasks, such as accepting the loss. We demonstrate why such an approach, by itself, is insufficient to treat traumatic bereavement. The treatment approach described in this book assists clients in coping with trauma as well as grief.

We believe practicing psychotherapists working from a trauma, bereavement, or general background will find this book a useful overview of the problem and a source of ideas about treating clients. We hope it serves as a key reference for clinicians interested in traumatic bereavement. Scholars who may be looking for a clinical base for their study of sudden, traumatic death may also find the book informative. In addition, the book is useful as a teaching tool in graduate programs designed to train clinical practitioners. It is ideal for use in graduate courses in clinical psychology, social work, pastoral care, nursing, and related fields dealing with the treatment of traumatic bereavement. We also hope to inspire research on this approach to allow for its further development. Above all, we hope this book assists therapists in bringing relief to the thousands of survivors who are struggling with the ramifications of traumatic loss.




Part i. fundamentals of Traumatic Bereavement

  1. Sudden, Traumatic Death and Traumatic Bereavement 3

Traumatic Death Prevalence 4

Psychological Consequences of Sudden, Traumatic Death 4

Persistent and Pervasive Effects of Traumatic Death 7

The Need for Integrated Treatment of Traumatic Bereavement 9

An Overview of Our Treatment Approach for Traumatic Bereavement 9

Clinical Integration 16

Concluding Remarks 17

  1. Theoretical Foundations 18

Loss 18

Grief and Mourning 20

Psychological Trauma 25

A Relational Treatment Approach 33

Integration in the Traumatic Bereavement Treatment Approach 33

Clinical Integration 35

Concluding Remarks 36

Part ii. Living with Traumatic Bereavement

  1. Psychological Dimensions 39

Symptoms and Adaptations 39

Shattering of the Assumptive World 40

Clinical Integration 48

Concluding Remarks 49

  1. Domains of Life affected 50

Interpersonal Relationships 51

Structures of Daily Life 56

The Legal System 60



Social Support 62

Clinical Integration 64

Concluding Remarks 66

Part iii. risk factors and related evidence

  1. event-related Factors 69

Characteristics of the Death 70 Mode of Death 77

Clinical Integration 89

Concluding Remarks 90

  1. Person-related Factors 91

Gender 92

Religion and Spiritual Beliefs 94

Personality and Coping Strategies 98

Kinship Relationship to the Deceased 99

Nature of the Relationship with the Deceased 100

Attachment Style 101

Additional Person-Related Variables 103 Clinical Integration 104

Concluding Remarks 106

  1. Treatment research 107

Treatment for Grief and Mourning 108

Treatment for PTSD 121

Integrating Grief and Trauma Treatment Research 126 Clinical Integration 129

Concluding Remarks 130

Part iv. guidelines for implementing The Treatment Approach

  1. client assessment 133

Appropriateness of This Treatment Approach for a Particular Client 134

Progression through the Six “R” Processes 137

Resources 138

Trauma and Loss History and Processing 139 Clinical Integration 142

Concluding Remarks 143

  1. implementation issues 145

General Psychotherapy Issues 145

Designing the Treatment Plan 152

Integrating This Approach into an Ongoing Treatment 162

Clinical Integration 162

Concluding Remarks 164

  1. Building Resources Self-capacities 165

Coping Skills 170

Social Support 172

Bereavement-Specific Issues 177

Meaning and Spirituality 182

Values and Personal Goal Setting 185

Clinical Integration 188

Concluding Remarks 189

  1. Processing Trauma 191

Cognitive Processing Interventions 193

Emotional Processing Interventions 198

Behavioral Interventions 205

Clinical Integration 206

Concluding Remarks 207

  1. Facilitating Mourning 208

First “R” Process: Recognize the Loss 209

Second “R” Process: React to the Separation 211

Third “R” Process: Recollect and Re-experience the Deceased and the Relationship 215

Fourth “R” Process: Relinquish the Old Attachments to the Deceased and the Old Assumptive World 217

Fifth “R” Process: Readjust to Move Adaptively into the New World without Forgetting the Old 218

Sixth “R” Process: Reinvest 225

Clinical Integration 226

Concluding Remarks 227


Part V. Challenges in imPlementing the treatment aPProaCh

  1. Treatment Challenges 231

Potentially Challenging Aspects of the Treatment 231

Guidelines for Identifying Treatment Challenges 236

Responding to Clinical Hurdles 236

Challenges Arising from Working in a Different Paradigm: Stronger and Weaker Suits 243

Clinical Integration 245

Concluding Remarks 247

  1. Effects of the Treatment on Therapists 248

Countertransference 249

Vicarious Traumatization 254

Training and Consultation: Supporting Yourself in the Work 260

Rewards of the Work 264 Clinical Integration 264

Concluding Remarks 266


Appendix. Handouts 267

  1. Sudden, Traumatic Death and Traumatic Bereavement 269
  2. Orientation to the Treatment 273
  3. Treatment Goals and Tools 275
  4. Self-Care 277
  5. Exploring the Impact of the Death 278
  6. The Six “R” Processes of Mourning 279
  7. Breathing Retraining 280
  8. Feelings Skills 281
  9. A Model for Change 288
  10. What Are Automatic Thoughts? 289
  11. Identifying Automatic Thoughts Worksheet 291
  12. Sample Automatic Thought Record 292
  13. Automatic Thought Record 293
  14. Challenging Questions Worksheet 294
  15. Processing the Loss 296
  16. First Account of the Death 298
  17. Secondary Losses 299
  18. The Importance of Enhancing Social Support 303
  19. Building Social Support 304
  20. Second Account of the Death 306
  21. Values 307
  22. Third Account of the Death 312
  23. Psychological Needs 313
  24. Positive and Negative Aspects of Your Relationship with Your Significant Other 318
  25. Fear and Avoidance Hierarchy Form 320
  26. Account of Your Relationship with Your Significant Other 321
  27. Guilt, Regret, and Sudden, Traumatic Death 322
  28. Anger and Sudden, Traumatic Death 325
  29. Letter to Your Significant Other 329
  30. Exploring the Meaning of the Loss 330
  31. Spirituality 331
  32. Final Impact Statement 332

References 333

Index 352



Part I. fundamentals of Traumatic Bereavement






chapter 1. Sudden, Traumatic Death and Traumatic Bereavement

One hot summer day when she was 6 years old, Emily discovered her father’s lifeless body hanging in their garage. It was a grisly scene, replete with horrific sights and smells. Thereafter, Emily saw a succession of therapists. Each one addressed with her the psychological impact of dealing with her father’s decision to take his own life, the resulting sense of abandonment that she experienced while growing up fatherless, and her grieving for all she had lost. Although she improved somewhat over the years, Emily continued to experience frequent nightmares, some emotional numbness, fear of intimacy, an exaggerated startle response, and increased agitation in hot, humid weather. Somehow, she felt unable to move on with her life.

It was fully 25 years before one therapist finally asked Emily, “Exactly what did you see when you found your father?” Finally someone had begun to tap into Emily’s experience of the grotesque circumstances associated with her father’s death, not solely the deprivations it had caused.

For many of us, the description above is disturbing to read. Like other survivors for whom this treatment is designed, Emily experienced the sudden, traumatic death of a significant other. In the instant she found her father dead, her life was fundamentally changed. She struggled on her own with trauma symptoms for 25 years, despite seeking help. As bereaved survivors attempt to pick up the shards of their lives and move forward, what lies ahead for them? If survivors want or need professional help, what sort of treatment would be most useful? This book addresses these questions.

Our goal is to provide a comprehensive treatment approach for therapists working with individuals who have experienced the sudden, traumatic death of a loved one. These mourners face the twin tasks of mourning the loss of their loved one and coping with the trauma that accompanied the death. Some therapists may not bring such a dual focus to their work with survivors of sudden, traumatic loss. Historically, the fields of traumatology (focusing on the study of traumatic events and their aftereffects) and thanatology (focusing on the study of dying, death, and bereavement) have existed relatively independently of one another, despite their conceptual, clinical, and often empirical relationship (Rando, 1997). This curious phenomenon has persisted despite the reality that most traumatic experiences include loss, and that most major losses have traumatic elements (see Rando, 2000).

This book presents a treatment approach designed to address both trauma and grief. In this chapter, we provide an overview of the psychological consequences of sudden, traumatic death, and broadly describe our integrated treatment approach for traumatic bereavement. Traumatic bereavement arises from an interaction between the circumstances of the death and other situational variables on the one hand, and aspects of the survivor (e.g., gender, attachment style, religious beliefs, personality) on the other, all within a particular social and cultural context.

Sudden, traumatic death is abrupt and occurs without warning. Although lack of anticipation alone can render a death traumatizing to a survivor, a death is more likely to be traumatic if it is untimely; if it involves violence or mutilation; if the survivor regards it as preventable; if the survivor believes that the loved one suffered; or if the survivor regards the death, or manner of death, as unfair and unjust. Other kinds of deaths likely to be regarded as traumatic include a death perceived as random (i.e., the loved one was in the wrong place at the wrong time); a death caused by a perpetrator with intent to harm; a situation where the survivor witnessed the death; a situation where the survivor is confronted with many deaths; and situations where the survivor’s own life is threatened. Following a sudden, traumatic death, a survivor may experience traumatic bereavement, which is associated with enduring problematic reactions, including symptoms of trauma and grief. Causes of deaths most likely to precipitate traumatic bereavement include accidents, homicide, suicide, natural disasters, and war. In addition, acute natural events (e.g., a brain aneurysm) can have violent or traumatic elements.

Traumatic death Prevalence

According to the National Vital Statistics Report (Heron, 2012), the largest group of people who die between the ages of 1 and 44 do so as a result of a sudden, traumatic event. In most cases, a single traumatic death triggers a cascade of suffering and heartache, affecting the spouse or partner, parents, siblings, and children of the person who died. The tragedy may also affect extended family members, close friends, and co workers.

Causes of traumatic deaths change over the lifespan. Accidents are by far the most common cause of death in all age groups younger than 44. For example, those in the 15 – 19 age group are approximately eight times more likely to die in an accident than to die from cancer, which is the leading cause of natural death in this group. Beginning at age 15, homicide and suicide emerge as prevalent causes of death. Among the 15 – 19, the 20 – 24, and the 25 – 34 age groups, suicide and homicide are among the top three causes of death, along with accidents. Those in the 15 – 19 age group are approximately six times more likely to die as a result of homicide or suicide than of cancer. Moreover, while deaths from accidents, homicide, and suicide become less prevalent after age 44, deaths resulting from sudden cardiovascular events become more prevalent.

These figures provide a conservative estimate of the prevalence of sudden, traumatic deaths. They do not include deaths from natural disasters, war, or terrorist attacks. They also do not include sudden deaths that result from heart attacks, strokes, or aneurysms.

Psychological Consequences of sudden, Traumatic death

Following the sudden, traumatic loss of loved ones, survivors typically experience painful trauma symptoms (such as disturbing, intrusive thoughts), as well as grief symptoms (such as yearning for their loved ones). Because of the way the death occurred, the survivor is typically

Sudden, Traumatic Death and Traumatic Bereavement

flooded with intense and painful affect. The deaths often completely overwhelm their defenses, leaving them unable to cope. As one survivor expressed it, “It was as though someone cut my insides out.” In most cases, their symptoms are more intense and prolonged than those experienced by survivors of natural deaths.

If a death was sudden, was perceived as random, and occurred without warning, feelings of shock may be profound. A survivor may feel helpless, confused, and unable to grasp the implications of what has happened. Such deaths are also likely to evoke intense death anxiety, leading these bereaved person to fear her own death as well as that of surviving loved ones. As one father indicated following his wife’s murder, “I was terrified that I would also be killed and that my children would be left with no parents.”

Untimely deaths often cause distress because survivors feel their loved ones were cheated. If the loss was untimely or viewed as preventable, feelings of anger may be predominant. Most mourners in this situation find it difficult to live with the fact that their loved ones’ deaths were unnecessary. Anger is also a common reaction to deaths that are regarded as unjust. Most survivors believe that perpetrators should be held accountable for what has happened. Particularly if a perpetrator intended harm or was cruel or callous, a survivor must confront the human capacity for malevolence. Deaths resulting from intentional acts of violence often trigger powerful feelings of generalized rage, as well as rage specifically directed toward the perpetrator.

A violent death typically results in mutilation of the loved one’s body, such as when the deceased died in a fiery car crash or was shot at close range. In such cases, vivid images of the loved one’s body are often seared into the survivor’s mind. Such images typically emerge even in cases where the survivor did not witness the fatal incident. These disturbing images often return as intrusive thoughts or as parts of dreams or nightmares. In addition, the violence associated with the death and the mutilation of the body are likely to heighten the survivor’s concern with what the loved one experienced during the final moments of her life.[1]

As we detail in later chapters, research has identified a set of core issues that survivors of sudden, traumatic death typically experience (Wortman, Pearlman, Feuer, Farber, & Rando, 2012). First, it is common for survivors to question their religious beliefs, or even to feel betrayed and turn against God. In such cases, religious faith can become a casualty of the death. Second, survivors are often preoccupied with whether their loved ones suffered at the time of their death. Third, most mourners are troubled by their inability to make sense of what has happened. Finally, survivors often struggle with feelings of guilt. This was the case for the parents of a young man named Greg, who was an honor student and a varsity athlete. When he turned 17, Greg began working evenings and weekends at a convenience store to save money for college. One evening at about 11:00 P.M., Greg and the manager were murdered during a botched holdup attempt. Greg’s parents experienced intense guilt following his death. About 8 months before the tragedy, he had asked his parents whether he could take karate lessons. They said no, reasoning that his schedule was already overloaded. After the tragedy, they berated themselves for this decision, thinking that if he had taken the classes, he might have survived the assault.

In Chapter 3, we discuss each of these core issues in more detail.

In attempting to understand why a traumatic death can evoke so many debilitating reactions, we must recognize that such a death typically provokes an existential crisis. The nature of the loss forces most mourners to question assumptions that they previously took for granted (see

Bowlby, 1969; Marris, 1975; Parkes, 1971). These include beliefs that the world is meaningful and operates according to principles of fairness and justice, that one is safe and secure, that the world is benevolent, and that other people can generally be trusted (Janoff- Bulman, 1992).

The traumatic death of a loved one challenges these fundamental assumptions. Often the bereaved simply cannot absorb what has happened; the loss seems incomprehensible. It demonstrates that life is capricious and unpredictable. The dismantling of basic assumptions about the world may also invalidate much of the bereaved’s past behavior. For example, two young parents did everything possible to protect their 3-year-old son, such as putting locks on their kitchen cabinets and buying the most highly rated car seat. Despite their precautions, the child was killed in a motor vehicle crash caused by an under-age driver who had been drinking. In addition to the loss itself, it was painful for his parents to recognize that they were unable to protect their child. Should the couple have other children, they are likely to experience intense and prolonged anxiety about the safety of those children.

It is generally well established that the presence of trauma symptoms interferes with the process of accommodating the loss (Rando, 1993, 2013). An important part of successful mourning involves recollecting the loved one and reviewing the relationship that was lost. Gradually, the mourner is able to put her life with the deceased into perspective, and to begin moving forward. When a person has suffered a traumatic loss, attempts to recollect the loved one are often associated with distressing memories or images, such as what happened during the loved one’s death. These thoughts and images are so disturbing that in many cases, individuals try to avoid thinking about their loved one, making it far more difficult to process their loss. An additional burden is that survivors often become alarmed at the intensity of their trauma symptoms. As one man explained following the murder of his daughter, “I’m the kind of guy who would never even hurt a fly. But after her death, all I thought about was killing the man who did this to her. I kept thinking about all the ways I could kill him. I really thought I was going crazy.”

Trauma symptoms are likely to undermine the resources survivors have available to deal with day-to-day living. Physiological hyper arousal and the resulting sleep and concentration difficulties, for example, can sap a mourner’s energy and make it difficult to function well at work and at home. While coping resources are impaired as a result of the tragedy, the demands placed on the mourner often increase dramatically following the loss. For example, one woman whose husband died in an occupational accident experienced major difficulties with her surviving sons. Her 15-year-old quit the soccer team his deceased father had coached; the boy also became sullen and argumentative. Her 6-year-old started having nightmares on a frequent basis and began wetting the bed – something he had not done since he was toilet- trained.

Traumatic deaths are more likely than natural deaths to bring mourners into contact with situations that can be profoundly disturbing. For example, one couple rushed to the hospital to see their teenage daughter, who had been shot by her ex- boyfriend. Upon arriving, they were told that their daughter did not survive. The young woman’s mother cried out, “I want to hold my baby.” The nurse in charge informed her that her daughter’s body was “evidence” for the case against the perpetrator, and that no contact or touch was permitted. Other issues that often emerge in regard to a traumatic death and exacerbate a survivor’s distress include removal of the loved one from life support, insensitive death notification, identifying the body, a request for an autopsy (and the autopsy itself), lack of an intact body to bury, media attention, and criminal or civil trials. Most of these situations occur around the time of death. Consequently, survivors are forced to contend with them while in the throes of acute grief.

Many of the factors that can characterize traumatic deaths tend to occur together. A single mother lost her only child, a 10-year-old boy, when he was shot and killed in the home of a classmate. The gun, without adequate safety devices, was loaded at the time of the shooting. It

Sudden, Traumatic Death and Traumatic Bereavement

was stored in a completely accessible, unlocked bedroom closet. The child’s death was sudden and, at age 10, was untimely. It was regarded as preventable because if the gun had been stored properly, the accident would not have happened. A subsequent investigation revealed that her son did not touch the gun, but was accidentally killed while his classmate was playing with it. This led the mother to believe that her son’s death was unfair. In most cases, the impact of these factors is cumulative: The more of them that are present, the more intense and prolonged the survivor’s distress is likely to be.

Persistent and Pervasive effects of Traumatic death

Back in the 1980s, one of us (Camille B. Wortman) was contacted by the Insurance Institute for Highway Safety, a private foundation. The foundation was interested in the long-term psychological effects of losing a spouse or child in a motor vehicle crash. A study was designed to investigate this issue. Interviews were conducted with people 4 – 7 years following the death of their spouse or child in a car accident. The researchers also interviewed control respondents who had not lost loved ones. The purpose of the study was to determine whether people continued to be affected by such losses years after they occurred. Would most respondents be functioning well, or would they still be struggling with the ramifications of the death?

The results provided compelling evidence that the traumatic death of a spouse or child poses long-term difficulties (Lehman, Wortman, & Williams, 1987). Comparisons between bereaved persons and controls revealed significant differences on several psychological symptoms, including depression as assessed on the SCL-90 scale (Derogatis, 1977). Following the loss, bereaved respondents also became anxious that something bad would happen to another family member; this anxiety did not arise among controls.

Bereaved individuals also reported a significantly lower quality of life than did control respondents, as assessed by the Bradburn Affect Balance Scale (Bradburn, 1969). This scale measures the extent to which respondents find their activities interesting and meaningful, experience feelings of pleasure and enjoyment, and feel proud about things they have done.

Whereas some bereaved couples reported that the death of a child had a pronounced negative impact on their marriage, others said that the death brought them closer together. As a group, however, the bereaved parents in this study tended to report more stress in their marriages and were significantly more likely to seek and obtain a divorce than controls. Bereaved parents were also significantly less likely than controls to be working for pay, and to be working at the same job that they held before the loss. When they did remain at the same job, they tended to have difficulty sustaining interest in and motivation for their work. Following the death, bereaved spouses and parents reported earning significantly less family income than controls. Bereaved parents were also significantly more likely to move. Many commented that their prior homes were an endless source of painful memories.

Bereaved spouses reported more difficulty in getting involved in leisure activities and in carrying out their housework. They also scored significantly higher on loneliness than did controls. Both groups also reported more conflict with relatives and friends than controls. For example, they were more likely than controls to indicate that these relationships made them feel hurt and disappointed. As we describe in more detail below, those who lost a spouse or child were more likely than controls to experience problems in their relationships with surviving children – for example, agreeing that they felt more “emotionally worn out.” Moreover, in response to an open-ended question about the impact of their spouse’s death on their surviving children, an overwhelming majority of respondents (73%) reported that their children had suffered negative effects. Forty-seven percent of responses were coded as “extremely negative effects,” including depression, drug abuse, and suicide.

Negative effects were common even in cases where surviving children or siblings were quite young. Reports of withdrawal, obsessive behavior, and anger were typical. For instance, one mother spoke of her 5-year-old daughter’s reaction to the loss of her father: “She stopped playing. She hasn’t been the same since then. She doesn’t show interest like she used to.” Another mother described how her daughter was affected by the traumatic death of her older brother: “[My daughter] was very withdrawn for 1½ years. When her emotions finally came out, it was almost a disaster. She said she didn’t love any of us any more because it would only hurt her.”

The results revealed significant differences in mortality between bereaved and control respondents. By the time we started the study, more than 6% of those individuals who lost a spouse or child had died; none of the respondents in the control group had died. This is a very high mortality rate for such a young population (most of the respondents were in their early 40s).

The interview also included a number of questions to determine whether the bereaved were still dealing actively with their loss. Over 90% of those who had lost a spouse or child had experienced thoughts or memories of their loved one during the past month. Of those who had such thoughts, 56% of the bereaved spouses and 68% of the bereaved parents reported that these memories made them feel “hurt and pained,” and none of the respondents were able to block unpleasant thoughts when they wanted to. Sixty percent of the bereaved spouses and 67% of the bereaved parents reported that during the past month they had had at least one conversation with a friend or family member about their loved one.

Despite the time that had elapsed since their loved ones’ deaths, the data indicated that most respondents had not achieved a state of resolution regarding their loss. Nearly 50% of those who lost a spouse or a child stated that they had relived the accident or the events surrounding their loved one’s death during the past month. Approximately 60% of the bereaved respondents reported having had thoughts during the past month that the accident was “unfair” or that they and their loved one had been cheated.

If a person is having difficulty coming to terms with the death of a spouse, child, or parent 4 – 7 years after it occurred, others might conclude that the person is coping poorly with the loss. What these data suggest is that lasting distress following the traumatic death of a family member is not a sign of individual coping failure. Rather, such distress is typical in response to this type of loss.

Since the motor vehicle study was conducted, a number of additional studies have corroborated these findings. For example, in an important study on the impact of losing a child through accident, suicide, or homicide, Murphy, Chung, and Johnson (2002) found that 5 years after the loss, a majority of mothers and fathers were experiencing significant mental distress. The percentage of mothers and fathers meeting formal criteria for posttraumatic stress disorder (PTSD) was still considerably higher than for women and men in the general population. Moreover, a majority of mothers (61%) and fathers (55%) continued to re-experience visual or mental imagery of their loved one’s death (Murphy, Johnson, Chung, & Beaton, 2003). These and other studies have shown that following a traumatic death, it is common for a survivor to experience painful symptoms of trauma and grief for many years. Although feelings of distress may decline over time, there is some question about whether survivors of sudden, traumatic death ever recover fully. Thus we prefer to use the term accommodation to recovery when referring to the goal of the mourning processes. As one bereaved mother expressed it, “You don’t get over it; you get

Sudden, Traumatic Death and Traumatic Bereavement

used to it.” In fact, traumatic bereavement can become chronic and debilitating. People may experience such profound and persistent changes as feelings of emptiness and alienation from others, a loss of meaning or purpose in life, and feelings of impending doom. Because friends, relatives, and even therapists are often not aware of the enduring impact of these losses, they may convey to the bereaved that they should be adjusting more quickly than they are. In fact, the bereaved themselves often mistakenly regard their continuing distress as a sign of personal inadequacy or coping failure.

The Need for Integrated Treatment of Traumatic Bereavement

The description of Emily’s traumatic experience at the beginning of this chapter illustrates the importance of addressing traumatic elements of the situation, in addition to those involving loss. Treatment must address integration of the trauma as well as accommodation to the loss. In Emily’s case, the therapists she saw had focused on helping her to mourn – a task that seems like the natural thing to do, and that is in fact an important aspect of the treatment process. Yet, because they did not appreciate that she had been traumatized by what she experienced – overwhelmed by the terrible sights and smells, and helpless in the face of all the horror – a significant aspect of her experience remained unresolved. A survivor who is unable to address the traumatic aspects of a death continues to experience trauma symptoms, and these symptoms compromise the survivor’s ability to mourn the loss fully. Therapy must address the two in combination. Without this dual and integrated focus, survivors may experience continuing emotional pain and distress.

Given the prevalence of sudden, traumatic deaths and the profound disruptions associated with traumatic bereavement, it is essential that effective treatment be available. In our experience, survivors frequently encounter difficulty in identifying treatment options that address their unique concerns and needs. As we describe in Chapter 7, several papers within the clinical literature have discussed the interaction of trauma and grief. For the most part, however, this work has not been integrated into a comprehensive treatment approach. The twin demands for healthy mourning and trauma integration, and the breadth and intensity of traumatic bereavement responses, call for a multifaceted approach.

an overview of our Treatment approach for Traumatic Bereavement

The goal of the treatment approach described in this book is to help an adult survivor address the traumatic stress associated with the death and the way it occurred, so that the survivor can process the grief surrounding her loss. The ultimate goal is to help clients reinvest in their lives in ways that are fulfilling to them. As shown in Table 1.1, this treatment is composed of three core components: (1) building a survivor’s internal and interpersonal resources; (2) processing the traumatic death both cognitively and emotionally; and (3) moving through the processes of mourning. Psychoeducation in these areas is an important element, as are between- session independent activities assigned to clients. A supportive therapeutic relationship is essential as well. This treatment is based on theory as well as on empirically validated practices for treating grief and trauma. We have also drawn from years of clinical experience, and from a pilot study that tested the approach. We describe each of the treatment’s components below and in more detail in Part IV, as well as in the client handouts in the Appendix. In addition, we have provided online supplementary handouts that, while not essential, may be useful to clients. These handouts are available at the website supplement for this book (


Table 1.1. Components of the Treatment Approach

Resource building

  • Self-capacities
  • Inner connection
  • Self-worth
  • Affect management
    • Recognizing affect
    • Tolerating affect
    • Modulating affect
    • Integrating affect
    • Coping skills
  • Breathing retraining
  • Self-care
  • Social support
  • Bereavement-specific strategies
  • Meaning and spirituality
  • Values and personal goal setting

Trauma processing

  • Cognitive processing
  • Cognitive restructuring of cognitive schemas and related psychological needs disrupted by trauma
  • Identifying and challenging maladaptive automatic thoughts
  • Activity scheduling
  • Emotional processing
  • Prolonged (in vivo and imaginal) exposure


  • Recognize the loss
  • React to the separation
  • Recollect and re-experience the deceased and the relationship
  • Relinquish the old attachments to the deceased and the old assumptive world
  • Readjust to move adaptively into the new world without forgetting the old
  • Reinvest

Psychoeducation and independent activities

Therapeutic relationship



resource Building

Clients who have experienced traumatic bereavement need to process the trauma and engage in active mourning. To build the foundation for those two tasks, this treatment approach first focuses on preparing survivors by developing six specific resources. These resources support clients in the therapy process and help them manage day-to-day life. They are woven throughout the treatment; clients are asked to engage regularly in some resource- building activity between sessions. We describe resource- building activities in Chapter 10.

Sudden, Traumatic Death and Traumatic Bereavement


Self-capacities are skills people use to regulate internal states. The three self-capacities essential to internal stability are inner connection (internal bond with positive images and memories of loved ones or other positive attachment figures), self-worth (the ability to feel like a good enough person), and affect management (the ability to recognize, tolerate, modulate, and integrate strong feelings). These “feelings skills” are drawn from constructivist self-development theory (CSDT; Pearlman, 1998) as well as attachment theory (Bowlby, 1969), and are discussed in more detail in Chapters 2 and 10.

coping Skills

Coping strategies are actions people take to manage, tolerate, or reduce the demands of a stressful situation (Folkman, 2001; Lazarus & Folkman, 1984). We can empower our clients by helping them to examine the coping strategies they are using and by educating them about strategies that may be more effective. Two important coping strategies within our treatment approach are breathing retraining and self-care (i.e., adequate sleep, nutrition, and physical exercise).

Social Support

Emotional and instrumental support from family members, friends, neighbors, and coworkers can help to counter the isolation that survivors of traumatic bereavement may experience. The therapist encourages survivors to identify people who can help them when the treatment is challenging. For example, a support provider might accompany the client in exposure activities, such as visiting the deceased person’s grave.

Bereavement-Specific Strategies

Bereavement- specific issues are events or occasions that evoke powerful memories or emotions (“subsequent temporary upsurges of grief”; Rando, 1993, 2013) related to the deceased or to her death. These situations often arise without warning and pose one of the greatest trials for the traumatically bereaved. Our treatment approach addresses these situations directly with clients, helping them to develop constructive strategies for anticipating these challenges whenever possible and coping with them when anticipation is not possible.

meaning and Spirituality

A sudden, traumatic death can assault a survivor’s sense that life is meaningful. An essential aspect of this treatment approach is to help the client create or recover a connection with something that makes her life feel worth living. This connection can serve as an inner resource to be called upon when needed for self- soothing.

values and Personal goal Setting

The purpose of values work with survivors of traumatic bereavement is to help them regain a sense of purpose and direction in their lives by identifying what matters to them most at this point. Values work helps people choose to move forward in meaningful directions and become engaged in activities they view as worthwhile. It can also propel movement forward in a client who seems to be stuck in the mourning process. For example, clients can be helped to realize that despite the loss, they have values that are important to them. These may include nurturing young people, learning new things, or maintaining a relationship with members of their extended family. Therapists can assist clients in developing goals that are consonant with their values. This should encourage involvement in activities that will help the client move forward.

Trauma Processing

When the client has adequate resources, trauma processing can begin. Cognitive-behavioral therapy (CBT) provides the empirically validated underpinning to trauma processing in our treatment approach (see Chapter 7 for a discussion of relevant research and Chapter 11 for a description of how to utilize these treatment elements). Another approach that is widely utilized for the treatment of trauma is eye movement desensitization and reprocessing, or EMDR.[2]

Although our treatment approach relies on techniques from CBT to process the loss, therapists trained in EMDR can use that technique for trauma processing (for a discussion of the use of EMDR to treat complicated mourning and traumatic stress, see Sprang, 2001).

Cognitive Processing

We utilize cognitive processing therapy (Resick & Schnicke, 1992, 1993; Resick et al., 2008) and cognitive techniques such as identifying, monitoring, and challenging problematic automatic thoughts; the downward arrow technique for identifying problematic beliefs; and the behavioral experiments of activity scheduling. These techniques help survivors change maladaptive cognitions that often emerge following sudden, traumatic deaths. Maladaptive cognitions (e.g., “I can’t trust anyone”) often present obstacles to the mourning process. Identifying and changing these cognitions can help the mourning process to proceed. CSDT (McCann & Pearlman, 1990b; Pearlman, 2001; Pearlman & Saakvitne, 1995) outlines five need areas that are the basis for core assumptions and beliefs about self and others within CPT (Resick & Schnicke, 1993). These trauma- sensitive need areas – safety, trust, control, esteem, and intimacy (Pearlman, 2003) – are the foundation for the cognitions targeted in this treatment approach.

emotional Processing

Another aspect of the treatment relies on prolonged (imaginal and in vivo) exposures, drawn from emotional processing theory (Foa & Kozak, 1991; Foa & Rothbaum, 1998; Rachman, 1980). Exposure helps to counter the avoidance of people, places, and things that remind survivors of the traumatic aspects of the death and its aftermath. It also assists survivors by reducing the emotional intensity of traumatic memories and images. Imaginal exposure primarily takes the form of written assignments, the main one being written accounts of the death or of learning about the death. Clients are instructed to write an account of the death three times over the course of the treatment and are asked to read the account daily. For in vivo exposure, a therapist and client create a fear and avoidance hierarchy of avoided or anxiety- provoking situations. The survivor is then supported in moving through the list at his own pace, starting with the least distressing situation. In vivo exposure to situations is primarily carried out as an independent activity. Before initiating trauma processing via exposure, it is important to assess the adequacy of the client’s coping resources. If this step is not taken, trauma processing may result in the retraumatization of the client. Therefore, building or strengthening a client’s self-capacities, in addition to assessing them along the way, is an essential element of this approach.


There is a growing consensus that clients can be helped more effectively by treatments that focus on specific mourning processes, such as recognizing the permanence of the loss, rather than a sequence of discrete stages. In this treatment, we rely on the six “R” processes of mourning developed by Rando (1993, 2013) for conceptualizing healthy mourning. These “R” processes are as follows: Recognize the loss; React to the separation; Recollect and re-experience the deceased and the relationship; Relinquish the old attachments to the deceased and the old assumptive world; Readjust to move adaptively into the new world without forgetting the old; and Reinvest. Healthy mourning is the path to accommodating the many and varied losses that are typically associated with sudden, traumatic deaths. Among traumatically bereaved clients, the mourning process is often impeded by unprocessed trauma. Within this integrated treatment approach, a focus on the individual processes of mourning is interwoven with trauma processing.

Over the years, countless portrayals of the mourning process have appeared in the literature. Two of the most influential are Freud’s (1917/1957) concept of griefwork and Bowlby’s (1969, 1980) and Kübler-Ross’s (1969) stage models of grief. In this book, we examine these models closely and consider their relevance to grief therapy as it is practiced today. In developing our treatment approach, we have drawn from approaches that have for the most part been developed after the griefwork and stages views, and often in reaction to their limitations. In addition to Rando’s “R” processes, these theoretical developments include the stress and coping model (Lazarus & Folkman, 1984), which addresses individual differences in response to the death of a loved one, which stage models cannot; the continuing- bonds approach, which clarifies that it is not necessary to sever all or most ties to the deceased, and that in fact such ties can be beneficial (Klass, Silverman, & Nickman, 1996); research on positive emotions (Folkman, 1997a, 2001), which illustrates the surprising role these emotions can play in facilitating the mourning process and promoting healing; the dual- process model of bereavement (Stroebe & Schut, 1999; M. S. Stroebe, Schut, & Stroebe, 2005), which emphasizes that mourners must focus not only on painful aspects of the loss, but on feelings and behaviors that are restorative, and that provide a respite from intense distress; and the meaning- making approach developed by Neimeyer and his associates (e.g., Holland, Currier, & Neimeyer, 2006; Holland & Neimeyer, 2010; Neimeyer, 2001; Neimeyer & Sands, 2011; Shear, Boelen, & Neimeyer, 2011), who have demonstrated that a search for meaning is a fundamental part of the mourning process.

Psychoeducation, Worksheets, and independent Activities

Psychoeducation – providing clients with information about their symptoms, adaptations, and recovery – is a critical aspect of this treatment. It takes place within virtually all sessions, and is reinforced by informational handouts. Other handouts for clients reinforce and expand upon in- session work; the worksheets and independent activities provided in these handouts support resource building, trauma processing, and mourning. Clients can also use these handouts to support their continuing progress after therapy ends. Purchasers of this book have permission to reproduce all of the handouts, which are located in the Appendix and online (www.guilford. com/pearlman-materials). The handouts that are essential to this treatment approach are in the Appendix and on the website. Additional, supplemental handouts are on the website only.

Therapeutic relationship

We list the therapeutic relationship in Table 1.1 as a separate element of the treatment in order to highlight its importance. As in all trauma therapies, the presence of a compassionate guide on the journey is essential in working with survivors of traumatic death (see, e.g., Pearlman & Courtois, 2005; Pearlman & Saakvitne, 1995).

Treatment structure

The treatment approach described in this book includes a rich array of material that can help traumatically bereaved clients within any theoretical framework, treatment length, or format (structured or unstructured). The therapist can plan the treatment in a variety of ways depending on a client’s needs and resources, as well as on the therapist’s and client’s preferences. In Table 1.2, we list the session topics we have used in implementing the treatment. To provide a more comprehensive overview of our approach, we have expanded this list into a 25-session treatment plan, which is available on the book’s supplemental website at The topics we include, and the way these topics are sequenced, are based on our experience with a series of pilot therapies.

The treatment can be tailored for clients who need only certain elements of the treatment or are only able to participate in a limited number of sessions. One can think of the approach as modular, and select all or any of the three core treatment components (resource building, trauma processing, and mourning) as needed for each client. The sample session format described in Chapter 9 (see Table 9.2) can be used to address any of these topics. In using this approach, it is important to integrate the treatment elements. We recommend that each session contain tasks from one or more of the three core treatment components, as well as psychoeducation about traumatic bereavement. These elements are interwoven over the treatment course, with each session having one or more specific topics as a focus.

Session Topics

People experiencing traumatic bereavement present with a vast array of symptoms, adaptations, and needs, and we would not expect that every therapy would address all of these topics. These topics (see Table 1.2) are sequenced as they would be to address a typical traumatically bereaved client. As we describe in Chapter 9, this approach can be adapted for cases in which the client does not need all aspects of the treatment. However, some of these topics must be addressed before others. Most important, resource building must precede trauma processing, unless you determine the client has the necessary resources to commence with exposure work. In addition, the six “R” processes build upon one another, and the trauma- processing and resource- building work provides the foundation for movement through the six “Rs.” Again, the sample session format described in Table 9.2 can be used to address any of these topics.



Table 1.2. main Topics and subtopics for the Treatment Approach


Session 1. Orientation

Orientation to the treatment

Discussion of sudden, traumatic death and traumatic bereavement (T, M)a

Session 2. Treatment Goals and Growth

Treatment goals and tools

Self-care (R)

Exploring the impact of the death (T, M)

Overview of the six “R” processes of mourning


Session 3. Recognize the Loss; Feelings Skills (Self


The first “R” process (M)

Breathing retraining (R)

Feelings skills (R)

Session 4. Automatic Thoughts

Introduction to the cognitive therapy model for change (T)

Identifying automatic thoughts (T)

Session 5. Automatic Thoughts (Continued) Challenging automatic thoughts (T)

Session 6. React to the Separation; Exposure The second “R” process (M)

First account of the death (T, M)

Session 7. Secondary Losses and Social Support

Secondary losses (M)

Building social support (R)

Second account of the death (T, M)

Session 8. Resource-Building Activities: Social

Support and Values Work

Values work (R, M) and personal goal setting

(R, M)

Third account of the death (T, M)

Session 9. Personal Goal Setting and Psychological


Personal goal setting (Continued)

Psychological needs (T)

Foundation for ending therapy

Session 10. Obstacles to Accommodation Obstacles to accommodation (T, M)

Session 11. Review of Previous Topics

Session 12. Recollect and Re-experience the

Deceased and the Relationship

The third “R” process (M)

Positive and negative aspects of the relationship with the loved one (M)

Session 13. Recollect and Re-experience the Deceased and the Relationship (continued)

Review of the relationship with the loved one (M)

Session 14. In Vivo Exposure

Fear and avoidance hierarchy (T)

In vivo exposure activity (T)

Writing assignment: Relationship with the deceased (T, M)

Session 15. In Vivo Exposure and Guilt

Guilt, regret, and sudden, traumatic death (T, M)

In vivo exposure activity (T)

Session 16. In Vivo Exposure and Anger

Anger and sudden, traumatic death (T, M)

In vivo exposure activity (T)

Session 17. Transforming the Pain

Anger, regret, and guilt in sudden, traumatic death (T)

Letter to the deceased (T, M)

In vivo exposure activity (T, M)

Session 18. Bereavement Challenges

Bereavement-specific issues (M)

In vivo exposure activity (T)

Session 19. The Assumptive World; Relinquish the Old Attachments to the Deceased and the

Old Assumptive World

Discussion of the assumptive world (M)

The fourth “R” process (M)

Session 20. Readjust to Move Adaptively into the New World without Forgetting the Old;


The fifth “R” process (M)

Writing assignment: Meaning of the loss (T, M)

Spirituality (R, M)

Session 21. New Relationship with the Deceased;


Writing assignment: Continuing the relationship with the deceased (M) Ending therapy

Session 22. Self-Intimacy and Identity

Self-intimacy (R)

Identity (R)

Session 23. Other-Trust, Other-Intimacy; Social


Other-trust (R, M)

Other-intimacy (R, M)

Social support (R, M)

Writing assignment: Final impact statement (M)

Session 24. Reinvest; Termination

The sixth and last “R” process (M)


Session 25. Final Review and Termination



aWe have designated subtopics in this table as promoting resource building (R), trauma processing (T), or mourning (M), as appropriate. Some subtopics contribute to addressing more than one of these components. Subtopics without those designations contribute to the development and flow of the treatment. Although the topics are presented according to the sample 25-session treatment plan on this book’s website, therapists may select any topics and subtopics that are relevant to a client’s treatment.


CLiniCAL inTegrATion

“Hi, Emily. I’m glad to see you back this week.” Dr. Sandra Roberts had been working with Emily for just 2 weeks, and she had been unsure whether Emily would return. In their first session, Emily had mentioned being in therapy on several occasions throughout her life and feeling that these therapies had not helped her move through her grief. Why couldn’t she just forget the terrible images and smells that intruded on her days and nights? Sandra was hoping Emily would feel optimistic about this new therapy, but she also understood that Emily might be reluctant to expect further change.

Emily launched right in. “You asked me last week what I saw and what I experienced when I found my father dead all of those years ago. You seemed interested in the details. I think about these details often, even now. But I have rarely talked about it. It just always seemed so taboo, and so gruesome, you know?” Sandra nodded.

“I felt something like relief when you asked me that,” said Emily. “I know there’s fear there – fear about going into these details, but also relief.”

“Well, as I said, I’m glad you’re here, and I think you’re brave for seeking help in the midst of your fear. Today I’d like to talk about what I think we can do together. I’d like to give you an overview of the treatment plan I have in mind. Does that sound OK to you?”

This time it was Emily who nodded. Sandra continued:

“As you know, at a very early age you experienced a traumatic death. You were left to deal with the loss of your father and the grief that resulted from his sudden absence. This is a lot for a little girl to deal with.” Emily was listening attentively as Sandra spoke.

“Mixed in with that was the fact that the experience of finding your father hanging in the garage was traumatic. What I mean by that is that it probably evoked a reaction of shock and horror. It was a scene that was so unexpected – so far outside any framework of understanding that you may have had – that it probably felt pretty unreal. On the other hand, I imagine there was a way in which it was all too real. That is, the sights and smells and your own bodily sensations as you took this in were all in high focus.”

Emily felt a wave in her stomach as Sandra described the scene as being “all too real.” She became more fidgety in her seat and found that her voice cracked as she tried to speak. “I can remember it pretty vividly. I feel anxious hearing you talk about it – anxious in the way I described last week. Sometimes this anxiety comes up out of nowhere. Right now it feels connected to what you are describing.”

“You seem very connected to your experience, and you’re able to articulate it. That’s great, and it will be helpful as we move forward. I think what you have experienced all these years is traumatic bereavement: symptoms, feelings, and a state of being resulting from a combination of loss and trauma, or from a death that was also traumatic in its circumstances. Does that make sense to you?” “It does,” said Emily.

“I think you’ve done a lot of grieving for your dad over the years, and you’ve probably done less work with the traumatic aspects of your experience of his death. If we can work on processing some of the trauma, we may find that the mourning work we do together is different from the work you’ve done in previous therapies. By also focusing on the traumatic aspects of your experience, the process of mourning your father may go deeper or beyond where you’ve been so far, and it may feel more complete. That’s the idea of this treatment approach, and if you’re on board, I will lead you through some exercises designed to process both your thoughts and feelings about the trauma. Along the way, we’ll continue to move through the process of mourning your father in steps that I’ll introduce during our sessions. My hope is that we will be able to assess where there might be obstacles along your path and to address these obstacles in a way that frees you up. At times, it will be difficult to do this work, but I’ll make sure you have the resources and coping strategies to get through it.” Sandra looked directly at Emily and asked, “Do we have a plan?”

“We have a plan,” said Emily, and from there they launched into the therapy.

Concluding remarks

As Emily’s case illustrates, traumatic bereavement differs from the experience of losing a significant other to a death that stems from natural causes. Furthermore, as we have stated throughout this chapter, traumatic bereavement is more than the sum of loss and trauma. It is a unique phenomenon, marked by characteristics that include existential crisis, the taxing of an individual’s resources, and pervasive and persistent symptoms and problematic adaptations.

Based on research with this population, relevant theoretical information, and our own clinical experiences, we have designed a treatment approach to address traumatic bereavement. Emily’s therapist, Sandra, described this approach well: It focuses on assessing obstacles along the path of moving through mourning and addressing these obstacles by first shoring up resources, and then processing the trauma on both the cognitive and emotional levels. This treatment approach addresses the particular obstacles to mourning that a traumatic death presents.

We hope that the theoretical information in Parts I, II, and III paints a comprehensive picture of the experience of traumatic bereavement while pointing to treatment implications, which are then detailed in Parts IV and V. Our intention is to support you, our readers, in your work with traumatically bereaved clients, offering knowledge and tools that you can integrate with your own talents and style of psychotherapy.



Chapter 2. Theoretical Foundations

Eduardo’s twin brother, Jorge, died in a motorcycle accident 2 years ago. He was shocked by the deadly accident, unable to grasp the reality of his brother’s sudden death. They were only 23 years old; this couldn’t be happening. Jorge had saved as much as he could from every job he ever had for that bike. It was brand new, and on the first day out, as he was merging onto the highway, the motorcycle malfunctioned, throwing him onto the dirt shoulder. Breaking his neck, he died instantly. Since that time, Eduardo had been struggling with an array of trauma symptoms, including sleep disturbance, concentration problems, and intrusive thoughts about what his brother suffered that day. In addition, he was experiencing powerful symptoms of grief, such as yearning for his brother and crying at the drop of a hat. His symptoms of grief and trauma were exacerbating one another. At work, crying spells interfered with his concentration on the job. Yearning for Jorge triggered traumatic images of his death and made it more difficult for Eduardo to sleep. He found himself avoiding reminders of their relationship, including childhood memories, even though another part of him wanted to recall fond memories and talk about his sibling and best friend. “When I think of Jorge, my mind always goes to how he died,” Eduardo said.

Throughout this book, we use the terms sudden, traumatic death to refer to the death itself; sudden, traumatic loss to refer to a survivor’s experience of the death; and traumatic bereavement to refer to the enduring problematic reactions that can result from the death. Traumatic bereavement is greater than the experience of trauma plus that of grief. As the case of Eduardo illustrates, people who lose a loved one suddenly and traumatically experience a more complex phenomenon. In this chapter, we lay out the theoretical foundations of our treatment approach – a synthesis of fundamental concepts, definitions, and language. This includes a discussion of loss, grief, and mourning; psychological trauma and trauma processing; and the intersection of loss and trauma, traumatic bereavement. In addressing these issues, our guiding criterion has been the utility of these concepts for clinicians and other treatment providers who must respond to the needs of traumatically bereaved clients.


Loss is ubiquitous in human life. It is a central phenomenon in our existence. Virtually all change involves loss, and all individuals encounter loss repeatedly during their lifetimes.

A friend betrays your trust; a love affair ends; a child leaves for college; your sister develops a chronic illness; you move across the country; your car is stolen; your hearing diminishes; your partner dies. As these examples illustrate, a loss can be physical, referring to the loss of something tangible, or psychosocial, referring to a loss that is abstract or symbolic (Rando, 1993, 2013). A house that burns down, a watch that is stolen, and the death of a significant other are examples of physical losses. A shattered dream, such as being able to retire, is an example of a psychosocial loss. The death of a loved one necessarily involves psychosocial as well as physical losses. As an example, when a partner dies, the surviving partner may experience the loss of the other’s physical presence (physical loss) as well as the loss of the other’s roles in his life, such as lover, confidant, best friend, co- parent, or traveling companion (psychosocial losses).

It is important to distinguish between primary and secondary losses. A primary loss is the initial loss (in this case, the death), and a secondary loss is any loss that goes along with or develops as a consequence of the initial loss (Rando, 1993, 2013). Both primary and secondary losses can be either physical or psychosocial in nature. For instance, when the main breadwinner in a family dies, the family may have to relocate for economic reasons. The loss of the family home is a secondary physical loss; the loss of feeling connected to others in the community is a secondary psychosocial loss.

Some secondary losses refer to things a person no longer has as a result of the death. For example, if Jane’s mother cares for her children during the day, her mother’s death will result in the secondary loss of her day care provider. It is important to keep in mind, however, that secondary losses can also include the survivor’s hopes and dreams for things that, as a result of the death, can never happen. Following her mother’s death, for example, a young woman may mourn her inability to develop a good relationship with her mother while she was alive.

A special case of secondary symbolic, psychosocial losses is the shattering of assumptions, personal constructs, or schemas – known as violation of the assumptive world – which typically occurs in the aftermath of loss. For example, a woman whose husband is scheduled for surgery may believe that most surgeons are capable and can be trusted. If a surgeon makes an error that contributes to the husband’s death, this may shatter her belief. Consequently, she may have great difficulty seeking the care of a physician, even when she is quite ill. If a doctor tells her that she or another close family member requires hospitalization, she is likely to experience intense anxiety. The shattering of one’s assumptive world is particularly relevant to traumatic bereavement, and we address it in some depth in Chapter 3.

In some cases, secondary losses may be as important to deal with as primary losses, if not more so. This was clearly the case with Malcolm, who was 20 years old when his father died in a hunting accident. Malcolm was in college pursuing a degree in accounting at the time. His father’s death forced Malcolm to drop out of school, in order to take over the family dry cleaning store that his father had owned and operated. This sacrifice was necessary to provide sufficient income for Malcolm’s mother and two siblings. In addition to losing his father, Malcolm lost his vocation, his independence (he had to move back home), his day-to-day interactions with his close friends from college, and his role as a carefree young adult (he assumed his father’s role in the family as eldest male and chief provider). Until Malcolm could identify and mourn these secondary losses, he would continue to struggle with the ramifications of his father’s death.

The secondary losses that mourners experience following a traumatic death are determined in large part by the role relationship that was lost. Following the death of a spouse, the surviving spouse may struggle with a loss of identity, feeling as though a part of herself has died. She may also experience the loss of a caring presence day-to-day, the loss of her partner’s participation in childrearing, and the destruction of her hopes and dreams for the future. When a child dies, parents must contend with the loss of their identity as parents, which is centered around caring for and nurturing the child. In many cases, they also lose a sense of meaning and purpose that was provided by the parental role. They can no longer enjoy or celebrate the child’s milestones and accomplishments. In addition, a child often embodies the parents’ hopes and dreams for the future; these are often shattered by the child’s death.

The death of a parent is also associated with a unique set of secondary losses. These may include a lifelong emotionally supportive relationship, recognition and praise for accomplishments and achievements, guidance and advice at important crossroads, and a loving presence in the lives of grandchildren.

In most cases, mourners experience some secondary losses right away. For example, a widow may miss her husband’s companionship immediately after his death. Yet it may take weeks, and perhaps months or even years, for survivors to become aware of the full range of secondary losses associated with the death. When tax season comes around, for example, a widow may recognize that she needs help with a task that her husband had previously handled. She may be confused about whom to contact for assistance.

grief and mourning

Grief and mourning resulting from a traumatic death are both qualitatively and quantitatively different from the grief and mourning that follow nontraumatic death. Although many people use the terms grief and mourning interchangeably, they are different. Understanding the difference is important to being able to help those suffering from traumatic bereavement. Technically, to say grief and mourning is redundant, since grief is the beginning part of mourning. However, they are separated in this book when it is necessary to pay specific attention to particular aspects of the initial period of mourning (i.e., grief), as distinguished from the subsequent action- oriented mourning processes occurring after that grief.


We use the term grief to refer to the psychological, behavioral, social, and physical reactions to the experience of loss (Rando, 1993, 2013). This definition has seven important clinical implications:

  1. Grief is a natural and expectable reaction to an important loss.
  2. People experience grief in virtually all realms of life.
  3. Grief is expressed in a wide variety of ways. There is no right or wrong way to grieve.
  4. Grief is not static, but changes continually over time.
  5. Grief does not necessarily decrease in a linear fashion over time. For example, it may decrease for a while, then increase around the anniversary of the death.
  6. Any important loss, not just death, can trigger grief.
  7. The nature of a person’s grief response depends on the person’s unique perception of what she has lost, as well as on situational and personal factors (these factors are discussed in Chapters 5 and 6, respectively).

Although there is great variability in how people respond to the death of a loved one (Bonanno et al., 2002), there is general agreement about the grief symptoms most likely to accompany a loss. Survivors typically experience shock or numbness, symptoms of depression, and anxiety. Most people report an overwhelming sense of loss, as well as strong feelings of longing or yearning for the person who died. It is common for survivors to feel a profound sense of emptiness and to feel as though a part of them has died. They often speak of pain or heaviness in their chests. Bereaved individuals often lose interest in the world around them and feel hopeless about the future. Things that were once important do not seem to matter much any more. Fatigue, restlessness, irritability, anger, and guilt may also be present.

In the days, weeks, and months immediately following a death, responses such as disbelief, sadness, confusion, rage, and feeling overwhelmed are all common. Each of these reactions has behavioral, interpersonal, and physical correlates, such as withdrawal from social interaction, neglecting one’s own self-care, and sleep difficulties. These natural responses to a significant loss reflect the experience of grief.

By itself, grief is insufficient for dealing effectively with loss, whether it is a natural death or one stemming from potentially traumatic circumstances. This is because, in order to cope successfully with loss, one must do more than merely react to it. This is where accommodation and the active processes of mourning come in. Thus grief is to mourning as infancy is to childhood: It’s the beginning phase, but not the entire experience.

Accommodation and mourning

Ultimately, in order to cope with loss in a healthy way, a person must accommodate it. To accommodate means to make room for something – to adapt or adjust. Accommodation is an active process. It involves reconciling differences in order to integrate one thing with another, for example, old ways of perceiving the world with new realities.

Because loss entails change, it demands accommodation. The death of a significant other is a major change and, as illustrated in our description of secondary losses, brings about numerous other changes as well. A major loss calls for multiple adjustments and a great deal of accommodation on the part of the survivor. When the death is traumatic, mourning will require a more extensive reorientation to life, due to the intensity and breadth of the adjustments required. Grief – merely reacting to the loss – will not accomplish this goal. It is a necessary but not a sufficient condition to do so. This is why the more active processes of mourning must be engaged.

Some have used the term mourning to refer to the cultural or public display of grief (Rando, 1993). As used in this book, however, mourning is the active process of coping with a death. This entails engaging in six processes, described below, that promote the personal readjustments and reorientations required to accommodate the loss of a significant other. These reorientations relate to the survivor’s relationships with the deceased loved one, the self, and the external world (Rando, 1993, 2013).

Essentially, grieving is reacting to the personal experience of loss; mourning goes further and involves actively dealing with that loss. Whereas grieving involves experiencing and expressing one’s reactions to the loss, mourning continues past that to serve the function of adaptation through accommodation. An understanding of this distinction allows a therapist to appreciate how much painful inner work remains after acute grieving subsides. The experience of grief helps people to recognize that their loss is real, and prepares them for the later changes they will need to undertake to accommodate the loss. It is therefore a significant entry into active mourning.

There is an important, if subtle, implication here that is crucial to effective work with survivors of loss. Many survivors will choose, consciously or unconsciously, to remain within the experience of grief and resist moving into mourning. In grief, they feel connected to the deceased. Some survivors may experience the pain of grief as an attachment to the deceased. The active accommodation of the loss in mourning can feel like resignation, accepting precisely that which one wishes to resist. It can feel tantamount to acknowledging that it is “OK” that the loved one is gone. Such acceptance can seem intolerable. Losing a significant other can leave anyone feeling powerless. Resisting acceptance – whether by remaining within grief or by not moving through mourning more fully – can give the illusion of control, even as it ultimately robs the survivor of true empowerment. Our treatment approach facilitates movement from grief into and through the active processes of mourning, resulting in accommodation of the traumatic loss.

An overview of mourning Processes

Knowledge of the processes of healthy mourning provides therapists with a powerful tool to assist clients in moving forward. Below, we provide a broad overview of how healthy mourning unfolds over time to permit accommodation of the loss. In our experience, most survivors’ initial orientation toward mourning is one of avoidance. Over time, mourners typically enter a confrontation phase, in which they begin to deal with the reality of the loss and its implications. An accommodation phase usually follows, in which mourners are able to make a number of changes in how they view their situation, which helps them to move forward. These include their view of the loss, themselves, and the world, as well as their view of their relationship with the deceased. We list these categories of responses in Table 2.1. In describing these categories, we are not proposing that people go through an invariable sequence of responses. Without question, there is considerable variability in the process of mourning losses. However, there are common responses to major losses over time.

When mourning is not progressing toward accommodation, as is often the case in traumatic bereavement, the therapist’s task is to assist the client in moving through these phases in an adaptive and healthy way. This involves successful completion of six specific processes, as described in Chapter 1 (the six “Rs”; Rando, 1993). A major component of this treatment entails facilitating these six processes. We introduce them briefly here and describe them in more detail in Chapter 12. Each “R” operates at a different point in the mourning process. For example, the first “R,” Recognize the loss, is relevant to assisting the client in moving beyond avoidance, while the second “R,” React to the separation, involves confronting the loss.

Below, we provide a brief description of the three broad categories of mourning and the “R” processes that characterize each.


Upon learning of a death, most mourners are overwhelmed. They are unable to comprehend what has happened. They typically feel a strong desire to resist acknowledging the death. Mourners may also experience denial, which can serve as emotional anesthesia as they begin to face the reality of the loss. At this time, many survivors require assistance with the first “R” process, which is Recognize the loss. This is a crucial first step in the mourning process because if the loss is not recognized, there is nothing to mourn. When survivors come to treatment at this stage of mourning, the therapist’s role is to help them to acknowledge the finality and permanence of the death.


TABLE 2.1. The Six “R” Processes of Mourning in Relation to the Three Phases of Grief and Mourning*


Avoidance phase
  1. Recognize the loss
  • Acknowledge the death
  • Understand the death
Confrontation phase
  1. React to the separation
  • Experience the pain
  • Feel, identify, accept, and give some form of expression to all the psychological reactions to the loss
  • Identify and mourn secondary losses
  1. Recollect and re-experience the deceased and the relationship
  • Review and remember realistically
  • Revive and re-experience the feelings
  1. Relinquish the old attachments to the deceased and the old assumptive world
Accommodation phase
  1. Readjust to move adaptively into the new world without forgetting the old
  • Revise the assumptive world
  • Develop a new relationship with the deceased
  • Adopt new ways of being in the world
  • Form a new identity
  1. Reinvest


Note. From Rando (1993). Copyright 1993 by Therese A. Rando. Reprinted by permission. *A slightly reworded, more layperson-friendly version of the same “R” processes appears in Handout 6, The Six “R” Processes of Mourning.




Following acknowledgment of the death, most mourners enter into a painful interval where they confront the loss and gradually come to understand its impact. Three “R” processes come into play during this time. Most clients will require assistance with the second “R,” React to the separation. It is important for therapists to assist their clients in experiencing and expressing the pain associated with the primary loss. To process this loss fully, they will also need help in identifying and mourning their secondary losses. The third “R” is Recollect and re-experience the deceased and the relationship. Therapists can aid clients in reviving and re-experiencing their feelings for their loved ones. The goal is for them to reach a point where they are able to remember the deceased and their relationship realistically, and then to re-experience the feelings associated with what they remember.

The fourth “R” process, which is also important during the confrontation phase, is Relinquish the old attachments to the deceased and the old assumptive world. A therapist’s goal is to help a mourner let go of ties to the deceased that are problematic in light of the death. It is also important for clients to relinquish assumptions about the world that they held prior to the loss but that are not, in fact, true. As noted earlier, the sudden, traumatic death of a child may shatter a father’s assumption that parents can protect their children.


Over time, most mourners come to understand the value of accommodating the loss, and become more receptive to interventions designed to facilitate that process. Still, it is not without struggle. The goal of the fifth process is to help the client Readjust to move adaptively into the new world without forgetting the old. The mourner learns to go on without the deceased, while finding ways to experience a healthy connection with her. For example, the mourner may become involved in a political cause that was important to the deceased. Other changes may involve adopting new ways of being in the world to compensate for the absence of the deceased (e.g., learning new skills).

Reinvest is the sixth and final “R” process. Here the mourner reinvests emotional energy once devoted to the relationship with the loved one in other people, projects, and so on. Ideally, this process of reinvestment will bring about fulfillment, gratification, or satisfaction.

In all of these “R” processes, the therapist works to enable the mourner to learn to live with the loss and its implications in a way that allows for a healthy and life- affirming future. In Chapter 12, we illustrate the role each of the six “Rs” plays as mourning progresses. We also provide guidance, suggestions, and examples of how therapists might utilize the “Rs” in clinical work with traumatically bereaved clients.

No book on grief treatment would be complete without emphasizing the profound role that culture plays in the mourning process. As Rosenblatt (2008) has described, culture defines and influences everyone’s experience of grief, and also shapes (and sometimes limits) its expression.

Although a full account of the role culture plays in traumatic bereavement is beyond the scope of this book, we wish to raise two points. First, many studies on the reaction to traumatic loss have been conducted in other countries and with respondents from other cultures. This is the case, for example, for studies reviewed in Chapter 5 about the impact of war and disasters in Bosnia and Kosovo. Although such studies were not designed to address cultural differences, they elucidate the responses specific to each culture. This information could be useful to therapists working with people from cultures different from their own.

Second, the few studies that have focused on bereaved individuals from particular cultural groups in the United States have provided important information about the vulnerability of those groups. For example, McDevitt- Murphy, Neimeyer, Burke, Williams, and Lawson (2012) conducted a study among African Americans to examine the impact of losing family members to homicide over the previous 5 years. These losses took an enormous toll on the study respondents. The authors reported that nearly half of the sample screened positive for depression, complicated grief, PTSD, or anxiety, even though for most respondents it had been several years since the incidents occurred. The authors emphasized that this group would benefit from treatment tailored to their unique vulnerabilities. (In our judgment, the treatment approach described in this book has considerable relevance for this population.)

For those interested in learning more about culture and grief (in particular, information that has direct application to clinical practice), we recommend a book chapter by Klass and Chow (2011), which addresses, among other things, how culture “polices” the expression of

Theoretical Foundations

grief; the book on African American grief written by Rosenblatt and Wallace (2005), which describes the ethnically specific challenges faced by African Americans, and also discusses cultural institutions of central importance to many African Americans, such as the Black church; and the book by Houben (2012), which provides a rich account of the values and traditions of Hispanic individuals, a cultural group increasingly seeking mental health treatment.

Psychological Trauma

A survivor who experiences the sudden death of a loved one as shocking or overwhelming is likely to suffer psychological trauma along with loss. We define psychological trauma as the experience of threat to life or to bodily or psychic integrity that overwhelms an individual’s capacity to integrate the threat. In addition, the survivor feels as if she were going to die or disintegrate (Pearlman & Saakvitne, 1995). The events or experiences that give rise to psychological trauma following the sudden death of a loved one include aspects of the death and the context in which it occurs. As described in Chapter 1, survivors are particularly likely to experience deaths as traumatic if they are sudden, untimely, perceived as preventable, regarded as unjust, and/or viewed as resulting from an intentional act such as murder. Other important factors include whether the death involved violence or mutilation of the body, and whether a survivor believes that her loved one suffered during his final moments (see Chapter 5 for a comprehensive discussion of these characteristics). For example, upon witnessing the death of her partner in a motor vehicle crash, a woman may experience shock, terror, and helplessness. She may feel as if she is in a slow- motion horror movie from which she cannot escape. It is this experience (and not the crash or the death) that is the psychological trauma.

By definition, a traumatic experience often remains unassimilated within the survivor. Many people think of PTSD when psychological trauma is mentioned. Survivors who are unable to integrate overwhelming experiences may develop PTSD symptoms related to the event, such as intrusive thoughts or images or avoidance of reminders; negative changes in thoughts and mood; and changes in arousal and reactivity. Greater integration of the experience leads to symptom reduction.

Whereas PTSD is the diagnosis most commonly associated with the experience of trauma, or traumatic bereavement, it is certainly not the only one. Nor do these PTSD symptoms constitute a comprehensive description of psychological trauma. Survivors of sudden, traumatic loss can exhibit a broad range of problematic responses. Major depression, generalized anxiety disorder, panic disorder, acute stress disorder, substance abuse, and dissociative disorders are examples of other disorders that can be associated with traumatic stress (see, e.g., Kristensen, Weisaerth, & Heir, 2012). In some instances, problematic reactions to traumatic events and experiences may not fit any diagnostic category at all.

Another way of understanding problematic responses to potentially traumatic events focuses on the self rather than on symptoms. CSDT (McCann & Pearlman, 1990b; Pearlman, 2001; Pearlman & Saakvitne, 1995), mentioned in Chapter 1, elucidates both the domains of the self most vulnerable to traumatic experience and the process by which these vulnerabilities are activated. It gives clinicians a tool for understanding their clients’ unique experiences of traumatic bereavement, and thus provides the link among survivors’ experiences, their symptoms, and their specific treatment needs. Events in and of themselves do not lead directly to specific psychological responses. Every individual experiences and processes those events, attributes meaning to them, and integrates them into existing frameworks (or is unable to do so). With its focus on the self, the CSDT framework augments and enhances understandings offered by diagnostic categories. In addition, CSDT offers a framework for potential therapeutic intervention that grows out of its delineation of the domains of self most likely to be disrupted by traumatic bereavement. With its focus on early development and attachment, CSDT suggests the importance of a developmental perspective on how a person is affected by traumatic experiences. Finally, the theory emphasizes a relational orientation in any treatment designed to address traumatic attachment experiences, including traumatic loss.

Disrupted Domains of the Self

CSDT describes five domains of the self that are most vulnerable to disruption through severe attachment losses, including sudden, traumatic death (see Table 2.2). An individual who experiences the sudden, traumatic death of a loved one may suffer injury or disruption to particular domains of self – for example, the need for safety, the ability to use sound judgment, or the capacity to tolerate strong feelings.



TABLE 2.2. CSDT: Domains of the Self Affected by Traumatic Life Experiences

Frame of reference: Frameworks for understanding life

  • Identity: Perceptions and experience of self
  • Worldview: Life philosophy, notions of causality, moral principles
  • Spirituality: Awareness of intangible aspects of experience; meaning and hope

Self-capacities: Abilities that allow for navigation of the intrapersonal or inner world

  • Inner connection with benign others: Internalized positive experience of others
  • Self-worth: Sense of one’s value
  • Affect tolerance: Ability to experience, tolerate, manage, and integrate strong feelings

Ego resources: Abilities that allow for navigation of the interpersonal world (e.g., judgment, boundary management, foreseeing consequences)

Psychological needs and related cognitive schemas: Motivating factors and related beliefs

  • Safety: Oneself (self-safety) and loved ones (other-safety) are generally safe and secure
  • Trust: One can trust one’s own perceptions and judgment (self-trust) and most other people can be trusted (other-trust)
  • Esteem: Oneself (self-esteem) and others (other-esteem) are worthy of respect
  • Intimacy: One can be aware of one’s thoughts and feelings (self-intimacy) and experience deep connection with others (other-intimacy)
  • Control: One can manage one’s behavior (self-control) and can be effective in the world (other-control)

Body and brain: Physiological and somatic effects

Note. The social and cultural context – including traditions, mores, and norms – shapes the survivor’s and others’ responses to potentially traumatic events. From Saakvitne, Pearlman, and the Staff of the Traumatic Stress Institute (1996). Copyright 1996 by the Traumatic Stress Institute/Center for Adult & Adolescent Psychotherapy LLC.

theoretical Foundations


Trauma symptoms are the more visible signs of those invisible domains of self that have been disrupted. Examples of symptoms and, in parentheses, the corresponding disrupted domains, include the following: a decreased ability to tolerate strong feelings of anger, and a related feeling of anxiety because the emerging anger would be unacceptable (self-capacity/affect management); a sense that the world is meaningless, leading to withdrawal from one’s spiritual community (frame of reference/spirituality); difficulty believing that loved ones are safe, resulting in fears about their whereabouts (psychological needs/safety); and questioning one’s judgment, resulting in difficulty with decision making (ego resources). Individuals experiencing traumatic bereavement often present with such symptoms when they come for treatment. The symptom picture of traumatic bereavement is discussed in detail in Chapter 3. The domains of self-relevant to this treatment approach, based in CSDT, are discussed below.


Self-capacities are inner abilities that allow individuals to manage their psychological world and regulate their internal states. The three self-capacities within CSDT are internalizing benign others (those who care for a person), maintaining positive self-worth, and regulating emotion. A person who can practice these skills effectively is better equipped to manage the internal states that mark traumatic bereavement, and therefore to process the experience of the loss. In other words, in order to process a traumatic loss effectively, a survivor needs to be able to experience intense feelings, memories, and sensations over time, without avoiding or dissociating from them. The survivor needs to remain connected to her experience. For these reasons, the above named self-capacities lay the groundwork for processing the traumatic loss within this treatment approach. Because a traumatic event can disrupt the very capacities needed for healing and recovery, effective treatment must attend to the strengthening of those capacities.

Effective treatment must take into account a person’s developmental history as well. There is clear evidence that vulnerability to potentially traumatic experiences is shaped by a person’s attachment history – particularly attachment experiences that occur during the first years of life, when the brain is developing most rapidly (Allen, 2013). Healthy attachment interactions provide the foundation for the skills to tolerate, modulate, and integrate feeling states and emotional experiences (Bowlby, 1969, 1988; McCann & Pearlman, 1990b; Schore, 1994; see Chapter 10 for a more detailed discussion). A person’s developmental history is therefore relevant to his capacity to manage the inner experiences that mark traumatic bereavement. If a person did not have positive attachment experiences while growing up, then effective treatment requires attention to the development of these capacities. Treatment with a person who evidenced well- developed capacities before the traumatic death will still need to attend to buttressing those capacities, which may have been diminished by the traumatic death. Again, because such capacities are crucial to managing traumatic bereavement, an assessment of developmental history is essential, as is an assessment of post-loss capacities, regardless of developmental history. We discuss such assessment in Chapter 8.

ego resources

Ego resources are the basis for those skills that support a survivor as she negotiates external demands and her interpersonal world. In the aftermath of traumatic death, such tasks can be extremely taxing, rendering these skills indispensable. Being able to trust one’s judgment when deciding when to return to work after a loss, setting appropriate boundaries in order to get increased rest and engage in more self-care, and assessing available avenues of social support are examples of ego resources that treatment can address to help a person move through traumatic bereavement. As is the case with self-capacities, though, a traumatic death can compromise these skills at a time when they are most needed. Moreover, such skills often work hand in hand with self-capacities. When a survivor’s internal experience feels intense and out of control, it is more difficult to call upon resources that were once available but now seem out of reach.

Some traumatic bereavement symptoms are expressions of disrupted ego resources. Understanding this can help clinicians to empathize with clients and to intervene effectively. For example, a mourning, traumatized mother reports almost falling asleep at the wheel while driving her children to school. Rather than interpreting this as “self- destructive behavior,” we can instead recognize that she needs help with accessing good judgment and asking for help from others. Like self-capacities, ego resources are a domain of the self-affected by traumatic bereavement. They form a background for understanding survivors’ behaviors and are therefore a significant foundation of our treatment approach. The treatment addresses strengthening ego resources in its attention to developing coping skills, social support, bereavement- specific strategies, and values and goal setting, as discussed in Chapter 10.

Psychological needs, Schemas, and automatic Thoughts

We all have physical and psychological needs that must be met as we move through life. These needs motivate our behavior, and their fulfillment influences our well-being. The following five psychological needs are particularly sensitive to the effects of traumatic events, including traumatic loss: safety, trust, esteem, intimacy, and control (Pearlman, 2003). We experience each of these needs in relation to ourselves and to others. For example, we generally need to believe that both we and those we care about are safe in the world in order to move through our day-today lives unencumbered by anxiety. When these needs are for the most part fulfilled, we tend to take them for granted and pay little attention to them. When they are disrupted, they can take the form of automatic thoughts, which may contribute to an array of symptoms.

Cognitive and cognitive- behavioral theorists, drawing upon information- processing theory, suggest that we gather interrelated information in the form of schemas, or belief systems. Our schemas guide our attention, expectations, interpretations, and storage and retrieval of memories (Janoff- Bulman, 1992), as well as our social interactions (Pearlman, 2003). Distress can occur when people encounter information that is incongruent with a schema or when conflicting needs give rise to problematic schemas (e.g., the need for connection or intimacy can conflict with the need for control). As mentioned earlier, traumatic bereavement symptoms that stem from disrupted schemas will often reflect one of the five psychological need areas listed above. A father may view the death of his child as incongruent with the schema that good parents should be able to protect their children (reflecting needs for other-safety and other- control). In this case, an event has occurred that is schema- discrepant. The bereaved father may extrapolate from this discrepancy and decide that his poor parenting was the cause of the child’s death. This belief is likely to result in self-blame, as well as intense anxiety about the safety of his other children.

Our schemas present themselves in our daily lives in the form of automatic thoughts. “My keys are hanging by the door” is an example of a benign automatic thought that occurs, mostly outside of awareness, for the woman who always leaves her keys on the same hook when she enters her home. Automatic thoughts often help us move through the world efficiently. We can also have automatic thoughts that reflect harmful, negative, or disrupted schemas. These may also occur without our awareness and can have a powerful impact on our moods, behavior, or physical sensations. Automatic thoughts in the wake of a sudden, traumatic death range from the existential (“I asked God to protect him, and He did not”) to the everyday (“I will never be able to maintain the house without her”).

An understanding of trauma- sensitive psychological needs is important for a comprehensive framework of traumatic bereavement. Problematic schemas can interfere with trauma processing and accommodation to loss. Cognitive therapy techniques, including those we draw upon in this treatment approach, help people to recognize these thoughts, to name the schemas underlying them, and then to challenge the thoughts that are associated with psychological distress (Lichtenthal, 2012). By listening to clients’ language and narrative of events for disruptions within the five need areas outlined above, therapists can hone in on maladaptive beliefs common to traumatic experience that may be interfering with clients’ progress. Clients can learn to do this for themselves as well. By identifying and challenging their automatic thoughts, they can remove some of the obstacles that are preventing them from accepting and processing the traumatic loss and from moving forward in their lives. Clients can also benefit, therefore, from knowing these categories of needs as they listen for their own problematic automatic thoughts. Handout 23, Psychological Needs (in the Appendix and online at, describes each of the five needs in detail and is useful for therapists and clients alike. In Chapter 11, we provide detailed information about identifying and challenging automatic thoughts.

Frame of reference and assumptive World

As human beings, we all hold assumptions and beliefs pertaining to “big- picture” issues, such as how we define ourselves, why things happen in the way they do, and whether something like a higher power exists. We may believe that there is a meaningful trajectory to our lives, or not. We may assume that things happen for a reason, or not. We may believe that there is reason to hope for something we desire, or not. We may define ourselves according to certain roles, accomplishments, or ways of being. Taken together, our assumptions and beliefs constitute what CSDT refers to as our frame of reference. Frame of reference includes a person’s identity, worldview, and sense of spirituality.

Like psychological needs, a person’s frame of reference is articulated as a set of schemas and expressed in automatic thoughts. The schemas can be helpful or maladaptive, accurate or exaggerated, explicit or implicit. And as is the case with psychological needs, traumatic experiences usually violate aspects of a survivor’s frame of reference. In fact, disrupted meaning and loss of hope are hallmarks of psychological trauma (Pearlman & Caringi, 2009).

Following the traumatic death of her husband, for example, a woman may feel unanchored in her identity as wife, partner, companion, and co- parent. When the traumatic death of a loved one shatters such roles and their associated meanings, the psychological and relational foundations of a person’s life can be demolished – and, as we have mentioned in Chapter 1, a survivor may experience an existential crisis. So much of what the survivor assumed to be true about the world can be turned on its head, and this can happen in an instant. Traumatic death can evoke a violation or shattering of a person’s assumptive world (Janoff-Bulman, 1992), or everything a person holds to be true about herself and the world. Awareness of this process is essential to a comprehensive understanding of traumatic bereavement.

Theoretically, the concepts of frame of reference and assumptive world overlap. For our purposes, we use these concepts interchangeably throughout the text. The delineation of frame of reference as including identity, worldview, and spirituality can help a therapist listen for particularly sensitive aspects of a person’s assumptive world in any given therapy. Empathic attunement to a client’s existential crisis is itself a therapeutic stance. Appreciating the specifics of such a crisis for any given individual also allows a therapist to address the last three “R” processes in an effective manner, and to address the work of reestablishing goals and values in the wake of the loss.

Brain and Body

At any given time, no matter what else is going on in our lives, our bodies are our vehicles for navigating the world. Our bodies are fundamental aspects of ourselves; some would say that we are our bodies. Any comprehensive understanding of the traumatized self must therefore include the body. In delineating domains of the self-most vulnerable to traumatic experience, CSDT calls attention to the body. As a theory of trauma treatment, CSDT suggests intervention targeting the physiological effects of traumatic bereavement, with particular attention to affect regulation.

We have drawn upon research findings about the neurobiological correlates of the psychological experience of extreme stress and PTSD. This research informs our understanding of the experience of the body in traumatic bereavement (Bremner, 2006; Bremner et al., 1995, 1999, 2003; Heim & Nemeroff, 2009; Shin, Rauch, & Pitman, 2006; van der Kolk, 2006). Much of this research has been conducted with individuals diagnosed with PTSD and/or with survivors of childhood abuse or neglect. We include this information because, in our judgment, survivors of traumatic bereavement often suffer from physiological dysregulation.

Describing the clinical implications of clinical neuroscientific research, van der Kolk (2006) suggests that clients with PTSD “lose their way in the world” (p. 280) because of their diminished capacity to be engaged in the present. Trauma therapy, he concluded, ought to facilitate self- awareness and self- regulation, helping clients to regain their capacity to respond more fully in the present moment. The emphasis on building and strengthening self-capacities within our treatment approach may effect greater self- awareness and emotional regulation among traumatically bereaved clients. Ideally, this will address the possibility of over activated, hyper aroused, and/or sensitized central nervous systems. Within our treatment approach, breathing retaining and drawing on an internalized benign other are examples of interventions that can help clients to regulate their emotions.

Engaging mourners in active coping behaviors, goal setting, and narration of the traumatic death (all elements of this treatment approach) may have the effect of stimulating cortical activity. (Such activity may be diminished in trauma survivors, potentially resulting in impaired judgment or difficulty with goal setting, for example.) These strategies also offer clients experiences of empowerment and mastery. Furthermore, because survivors often experience their symptoms viscerally, clinicians can strengthen the therapeutic alliance by understanding the physiological processes underlying their clients’ symptoms and articulating this understanding to clients as appropriate.[3]

symptoms as Adaptations

CSDT establishes an approach to symptoms that respects their adaptive qualities. Throughout the text, we sometimes describe the manifestations of traumatic bereavement as adaptations rather than as symptoms. This term is intended to emphasize that the visible signs of disrupted domains of the self-represent survivors’ best efforts toward managing or adapting to overwhelming internal states. The term adaptations conveys the positive implication that survivors are doing the best they can under the circumstances. Symptoms conveys pathology, which can lead to victim blaming or failure to appreciate survivors’ strengths. Of course, adaptations may result in negative consequences, even as they represent attempts to cope. For example, a mother struggling with painful and intense affect following the death of her child may begin overusing alcohol to help dull the pain. While creating problems, this response is an understandable attempt to manage agonizing feelings.

Understanding the varied expressions of traumatic bereavement as adaptations to an overwhelming event and the corresponding internal states that the person has been unable to integrate reduces the likelihood of pathologizing common and natural responses to unexpected terrible events. For example, one bereaved wife talked with her therapist about seeing her deceased husband every night and having conversations with him. It would be most useful for the therapist to create a shared understanding of this experience as an adaptation to the loss. In this case, the survivor’s intense longing for her husband’s companionship might have led to her envisioning that she was conversing with him. Identifying this perception as a hallucination and treating it with antipsychotic medication would be counterproductive. Not only might this be a misunderstanding of a particular adaptation, but it could block an opening for exploring this client’s particular experience of adapting to the inner emptiness left in the wake of the loss. This treatment approach understands symptoms as adaptations and supports healthy, adaptive coping strategies.

Processing Psychological Trauma

As noted in Chapter 1, our treatment approach draws heavily on cognitive processing theories and CBT. These models combine cognitive techniques with behavioral applications. One goal of our integrated approach is to assist clients in addressing those posttraumatic stress and post-loss symptoms that most interfere with the tasks of mourning. CBT techniques assist in (1) locating the disruptions to particular domains of the self as described above, because such disruptions often show up in a person’s automatic thoughts; (2) addressing avoidance of trauma material, including emotional and other internal responses to the traumatic death; and (3) implementing and practicing adaptive behaviors that support a survivor’s movement forward in his life.

Our use of CBT techniques within the treatment approach is based in the notion that a person’s mood, thoughts, and behaviors all affect one another (Beck, Rush, Shaw, & Emery, 1979), as described by the model shown in Figure 2.1. The multidirectional arrows in the figure signify that the cycle can begin anywhere in the loop, and that addressing one aspect of the loop (e.g., thoughts) can affect the other aspects (e.g., mood). Cognitive- behavioral theories focus on mechanisms of change in thoughts (cognitions) and behaviors. Some theories also address related physical sensations.


Processing the trauma entails addressing the disruptive and distressing elements of the thought – mood – behavior loop as they are manifested for a particular client. Leading a client through this process requires that the therapist understand something about how the various elements relate to one another for the client. For example, a man whose spouse died may believe he failed his partner. This belief may make it impossible for him to move forward with meeting new people and dating, which may reinforce his belief that he is an inadequate person.

One important aspect of CBT that is relevant for this treatment approach involves avoidance behaviors and how these relate to disrupted schemas. For instance, the painful consequence of touching a hot stove makes us likely to avoid touching hot stoves in the future. This type of learning, conditioning, plays an important role in some traumatic experiences. An event as significant as a sudden, traumatic death can condition a survivor to avoid anything related to the painful feelings associated with the loss. Our brains naturally create quick associations, and an emotional reaction prompts us to avoid potentially painful situations.

Behavioral conditioning can occur over time with repeated “trials” of learning. A person who has experienced traumatic bereavement may have learned from successive trials, or real-life experiences, that expressing emotion about the loss to others will result in a painful, awkward silence. The survivor therefore begins to withdraw and to avoid talking to people about the death. People can learn other associations in a single instance when a sufficiently powerful emotion accompanies the trial. For example, a survivor may become very distressed at the sight of planes because his loved one died in a plane crash. Survivors often avoid internal, emotionally painful states as well, thereby preventing them from experiencing their feelings and from emotionally processing the loss. Of course, avoidance of external and internal stimuli usually go hand in hand.

We can begin to see the dilemma. Traumatically bereaved clients often attempt to avoid feeling their emotions about the death and the way it happened. They avoid thoughts that evoke emotion, as well as people, places, and things that remind them of the loss. Although this avoidance may temporarily ease their pain, the longer- term consequences contribute to the experience of being “stuck” in their grief and mourning, unable to move through the “R” processes described earlier. It may be particularly difficult, for example, to Recollect and re-experience the deceased and the relationship when doing so brings up painful affect or traumatic memories. Survivors may successfully suppress emotions in the short term, but these emotions may later surface unexpectedly. Such behavioral patterns tend to reinforce maladaptive schemas. Withdrawal from life means that bereaved survivors do not have experiences that might challenge their maladaptive schemas. And disengagement from emotions means that they miss the opportunity to mourn in healthy ways. Disengagement from others further eclipses opportunities to receive much- needed social support. Chapter 11 details the specific use of CBT techniques for processing the traumatic loss on both a cognitive and an emotional level.

A relational Treatment Approach

Understanding personal development in the context of an attachment paradigm allows us to appreciate that individuals develop within relationships, can suffer injuries within relationships, and can heal within relationships as well. The loss of a significant other will call a person’s attachment system into play (see, e.g., Fraley & Shaver, 1999; Parkes, 2001). The survivor’s attachment paradigms (or internal working models; Bowlby, 1988) and experiences will mediate responses to traumatic loss, which in turn will affect those paradigms. This may be particularly true in the case of a sudden, traumatic death; the survivor does not have an opportunity to say goodbye. Sensitivity to the therapeutic relationship, including its eventual end, is an important element within this treatment approach.

The sudden death of loved ones can reinforce survivors’ beliefs that relationships will likely end traumatically, placing them at greater risk of a poor outcome. Yet, without relationships, the essence of human experience is diminished. In addition to whatever therapists do or say, their predictable, compassionate presence serves as a balm to painful attachment losses from the past. Thus, in this treatment approach, we regard a therapist’s commitment to respectful connection with a client as an intervention of significance.

integration in The Traumatic Bereavement Treatment Approach

There are two key aspects to the role of integration in our treatment approach: integrating mourning and trauma resolution, and integrating theory and practice. First, integration refers to the fact that a survivor of a traumatic death must deal with the dual tasks of mourning the loss and resolving trauma – tasks that both overlap and interfere with one another. In creating an effective treatment for individuals grappling with both loss and trauma, we have recognized the importance of integrating trauma resolution into the work of facilitating adaptive mourning. We have further recognized that it is essential to help clients build and access the resources needed to engage successfully in such processing work. Research has affirmed the importance of developing self-capacities, or the ability to regulate one’s emotions, before providing too much emotional challenge (e.g., Cloitre, Koenen, Cohen, & Han, 2002; Korn & Leeds, 2002; see Chapter 7 for a discussion of this research). This recognition is also the basis for the widely utilized phase- oriented treatment for psychological trauma, which recommends building an internal foundation for the challenging work of processing memories of traumatic experiences. Various clinical approaches to addressing psychological trauma reflect this model (Allen, 2001; Briere, 1996a, 1996b; Cloitre, Cohen, & Koenen, 2006; Korn & Leeds, 2002; Linehan, 1993; McCann & Pearlman, 1990b; Saakvitne, Gamble, Pearlman, & Lev, 2000).

Throughout our treatment approach, the development of self-capacities supports the necessary regulation of arousal. This, in turn, assists with the processing of traumatic imagery and memories (Cloitre et al., 2006; Korn & Leeds, 2002; McCann & Pearlman, 1990b; Pearlman, 1998), which further facilitates mourning. In addition to the development and strengthening of self-capacities, the treatment approach emphasizes attention to those ego resources that promote effective coping in the world. Clients are guided to practice a variety of activities and strategies, which are generally referred to as resource building. These strategies help them to access and utilize their ego resources and to engage with the world in adaptive ways.

The treatment approach integrates three core components, described in Chapter 1: the development and strengthening of self-capacities (McCann & Pearlman, 1990b; Pearlman & Saakvitne, 1995) and other resources necessary for the effective, safe engagement with traumatic bereavement material; trauma processing, largely accomplished through CBT interventions and exposure to traumatic bereavement material (Foa & Rothbaum, 1998); and the tasks and trajectory of mourning based on Rando’s work, as described earlier in this chapter (Rando, 1993). Supported by an empathic therapeutic relationship and a client’s own commitment to healing, practically carried out through independent activities, these three core components work together to facilitate moving forward with life in fulfilling ways.

The treatment approach also integrates theory with practice. We realized early that we could not create a one-size-fits-all treatment for this population. Rather, we offer an approach that includes a flexible trajectory, necessary tasks and interventions, and topics likely to require attention. In order for therapists to utilize this approach well, and to target particular clients’ needs, a comprehensive understanding of mourning, the traumatized self, traumatic bereavement, and CBT techniques is required. Thus our use of integration to describe this treatment approach refers to the fact that foundational theoretical concepts inform the implementation of the therapeutic approach, and that therapists need to be familiar with these concepts in order to utilize the treatment effectively. Of particular relevance is a firm understanding of the domains of self-most vulnerable to disruption by a traumatic loss. Such an understanding affords therapists a means of assessing the self-capacities necessary for trauma processing, a framework for identifying problematic adaptations and existential injuries, and a means of connecting visible symptoms with a client’s inner experience.

One potentially useful way of conceptualizing a traumatic bereavement therapy is to think about it as a journey through the “R” processes. In collaboration with the client, the therapist assesses supports for this journey and works to develop those resources as needed. Also in collaboration with the client, the therapist assesses obstacles to the journey. Some of these obstacles will be related to disruptions to domains of the self-resulting from the traumatic loss. It is useful to think of responses to these disruptions as adaptations and to ask whether a particular adaptation is helping a client to accommodate his particular loss, or not. In other words, is this adaptation assisting a client through his journey? If not, how might the client adapt in a different way? This treatment approach is designed to help therapists and clients answer this question together.

Two people may endure the death of a loved one that looks similar, yet may have two very different sets of reactions. In a community tragedy such as a terrorist attack, some individuals may struggle most with the sudden, unexpected violation of their community. Others may focus on the lack of preparedness demonstrated by their community agencies. Some may withdraw from loved ones, while others cling desperately to family and friends. Some may struggle with self-trust needs, while others are challenged more by other- safety needs. Each of these responses has different treatment implications in terms of the types of resources that must be developed and the specific nature of interventions used. In this chapter, we have laid out the theoretical concepts that inform the approach. In Parts II and III, we describe living with traumatic bereavement as well as risk factors before moving into the specific interventions of the treatment approach in Parts IV and V.

Clinical integration

Pauline walked into the break room after her session with Eduardo. She was glad to see her clinical supervisor, Erin, sitting there with a cup of coffee. “Do you mind if I join you?” she asked Erin.

“Of course not. Have a seat. How’s it going?”

“Well, I think,” remarked Pauline, noticing the tone of doubt in her own voice. “I just met with that new client I’ve been seeing – the one whose twin died in a motorcycle accident a couple of years ago.”

Erin nodded. “You’re using that new traumatic bereavement approach with him, right?”

“Yeah. It’s been useful to think about the therapy in this way. It’s helped me not to minimize the traumatic aspects of his experience, not to focus solely on the loss.”

“That’s interesting,” said Erin. “I imagine the traumatic aspects of a sudden death might be overwhelming – not just to him, but to you, too. What are you doing differently as a result of being mindful of the trauma?”

“I’m not sure,” said Pauline. “We’ve only met three times so far. Eduardo seems to be really stuck on how unfair the experience was, and is. He’s pretty young. Prior to this, he had never experienced any sort of tragedy or major loss. His life was going well, and he believed life was fair – that people get what they deserve. Eduardo also thought the world of his brother. His death shook him to his core, in large part because he believed Jorge, maybe more than anyone, deserved a good life. Eduardo hasn’t been able to reconcile this.”

“Don’t you think such a death would shake anyone to his core?” Erin wondered aloud.

“Well, yes and no. Eduardo has had lots of trauma symptoms, as well as those of grief. Jorge was his best friend, and he misses him terribly. He feels empty without his twin, and yet he cannot remember the times they had together in any way that brings him comfort. He just imagines Jorge lying on the roadside, dead. Two years later, he is still experiencing disturbing imagery and a predominant feeling of emptiness. I’m now thinking his attachment to the idea that life should be fair gets in the way of processing all of this. Does that make any sense?”

“Yes,” said Erin. “Can you say any more about his attachment to fairness?”

“It’s as though Eduardo needs this to be true – that life is fair. There’s this impasse within his psyche, and for as long as it’s there, I don’t think he’ll be able to move forward with his life. Eduardo lost not only his brother, but also his whole frame of reference, and assumptions about how the world works. It feels to me like his very identity is built upon this idea of fairness.”

“That belief or frame of reference sounds like a good focus for your work with him,” Erin said.

“Yes, I think you’re right,” Pauline answered.

Concluding remarks

Throughout this chapter, we have laid out foundational and theoretical information related to the phenomenon of traumatic bereavement. Rando’s (1993) work describes mourning as an active process that ideally promotes the personal adjustments necessary for a person to accommodate his loss. When a death is traumatic, as Jorge’s death was for Eduardo, a survivor’s abilities to make such adjustments and accommodate the reality of the loss can be compromised in specific ways. CSDT, based in attachment theory, points to those aspects of the self that are most vulnerable to disruption by traumatic experience, including a traumatic death. In doing so, CSDT provides a framework for possible targets of intervention.

Cognitive- behavioral theories further inform the various mechanisms of intervention that we discuss more completely in Part IV. We believe that a survivor needs to confront, rather than avoid, the death and its circumstances; work to accommodate the new reality; and work through the obstacles to doing so that are often related to maladaptive schemas or beliefs. The working- through process as described in this book fosters the awareness and confrontation of these beliefs.

Pauline understood that Eduardo needed help addressing obstacles to mourning his brother’s death – obstacles that were related to both the traumatic nature of Jorge’s death and the resulting trauma symptoms, as well as Eduardo’s own belief system. Her foundational understanding of the phenomenon of traumatic bereavement allowed her to listen for those obstacles, or places where Eduardo was stuck in his mourning of Jorge. Her ultimate goal was to assist Eduardo in moving through his mourning, so that he could reinvest in his life without the physical presence of his twin. We hope that the information provided throughout this book will assist you, our readers, as you work with clients to develop adaptations that best assist them with their tasks of mourning.



Part II. Living with Traumatic Bereavement






Chapter 3. Psychological Dimensions

James lost Raphael, his partner of 7 years, when Raphael died in a manufacturing accident. Upon learning of the accident, James rushed to the plant, where he saw the aftermath. Images of blood, broken machinery, his partner’s body, and Raphael’s coworkers, who were themselves in shock, were etched into his mind. In the months following the accident, James spent a lot of time trying to find out what happened and who was to blame. He spoke with employees who had witnessed the incident, as well as the manager in charge, but found no one who could explain it. Given the nature of Raphael’s death, James also found himself preoccupied with the question of how much his partner had suffered and with his own associated feelings of powerlessness. These disturbing thoughts interfered with his sleep. When he did manage to fall asleep, it was a restless experience, marked by nightmares revolving around themes of Raphael’s death. He wanted the intrusive imagery, the loneliness, and the pining to stop.

The monumental impact of Raphael’s death on James is striking. “It is as though the wrath of God has been unleashed on me,” he said. Similarly, a man who lost his son said, “Even if someone had dropped an atom bomb in the middle of our community, we could not have been more affected” (Dyregrov, Nordanger, & Dyregrov, 2003, pp. 149, 151). Survivors often experience a traumatic death as a wound to their fundamental sense of self; the injuries are deep and far- reaching.

The material presented in this chapter and the next three offers a comprehensive description of traumatic bereavement, in order to give clinicians a framework of possibilities for working with traumatically bereaved clients. This chapter and the next present the phenomenology of traumatic bereavement, describing what it feels like to the survivor. This chapter describes common psychological responses to sudden, traumatic death, which often complicate the mourning process. We link the common symptoms or adaptations to their source: the violation of the assumptive world, which includes disruptions in underlying psychological needs and frame of reference.

symptoms and Adaptations

As we have discussed in Chapter 2, many symptoms of traumatic bereavement are adaptations to this extraordinary event and the inner experiences it evokes. Many strategies that start out as adaptive eventually become problematic, prolonging distress and pain. For example, initially avoiding painful feelings can help clients get through the day, and can keep them from becoming completely overwhelmed. If it continues over time, however, such avoidance can become an obstacle to moving through the mourning process.

Table 3.1 provides a comprehensive list of symptoms that survivors of sudden, traumatic death may experience. We include this list to illustrate the wide range of ways in which traumatic bereavement manifests itself. Many of the symptoms fit into multiple categories. Readers will recognize some of these symptoms as hallmarks of grief, and others as those of trauma. However, they cease to be easily separable within the experience of traumatic bereavement. They are all expectable responses to sudden, traumatic death, and one of our important tasks as clinicians is to normalize them as appropriate for our clients. We encourage therapists to consider each client’s particular constellation of symptoms as that person’s experience of, and adaptation to, traumatic death.

shattering of The Assumptive World

Survivors of traumatic death must contend with the shattering of their most basic beliefs and understandings about the world. This is termed violation of the assumptive world (Janoff- Bulman, 1992). This disruption in beliefs is one process that gives rise to the symptoms of traumatic bereavement outlined in Table 3.1 on pages 42 – 43. When the survivor can no longer trust her perceptions of the world, of other people, or of herself, a multitude of problematic adaptations can result.

As described in Chapters 1 and 2, CSDT (Pearlman, 2001; Pearlman & Saakvitne, 1995; Saakvitne et al., 2000) outlines five psychological need areas that are particularly vulnerable to assault from a traumatic experience: safety, trust, control, esteem, and intimacy (Pearlman, 2003). Within each need area, people hold beliefs related to self and others (e.g., self- esteem, or valuing oneself, and other- esteem, or valuing others). The experience of a traumatic loss is likely to influence assumptions, beliefs, or internal working models (Bowlby, 1988) related to these five need areas. We refer therapists who want to provide clients with more information about these needs to Handout 23, Psychological Needs.

In addition, traumatic experiences usually violate survivors’ frame of reference, or big- picture ways of understanding themselves and the world. These include identity, worldviews, and spirituality (particularly meaning and hope). After the traumatic death of his wife, for instance, a man may feel that his roles as husband, partner, companion, and co- parent have been shattered. The loss of these roles and their associated meanings can shatter the psychological and relational foundations of his life.

Listening for these need- related themes in a client’s statements reflects empathic attunement and helps the client to feel understood. When the therapist accurately identifies critical needs – for example, control or intimacy – the therapeutic relationship grows stronger, the therapist knows how to guide the work, and the therapy moves forward more effectively.

Sudden, traumatic deaths are likely to evoke intense fears that something else bad is going to happen. A survivor may feel that danger is lurking everywhere, and that there is no way to protect loved ones from harm (other- safety). As one bereaved mother expressed it, “You’re always waiting for this other shoe to drop” (quoted in Finkbeiner, 1996, p. 81). From this place of fear, individuals understandably may become rigid, overprotective, and avoidant in their attempts to defend against another traumatic loss (other- control). Of course, in some instances, the client not only feels unsafe but also is actually at increased risk of harm. An example would be a case of homicide in which the perpetrator is still at large and/or has threatened other family members.

The events that bring about traumatic death frequently undermine a survivor’s ability to trust. Problems with trust are particularly likely in those situations where the life of the deceased was in the hands of another person. As noted above, survivors of medical malpractice typically have great difficulty trusting doctors or other health care professionals in the future (other-trust). Deaths that occur when a child is at school or with a babysitter are also likely to damage the survivors’ assumptions about trusting others. Losses of this sort also lead survivors to question their own judgment (self-trust). For example, a man who lost his infant son because the doctor failed to diagnose and treat pneumonia blamed himself for choosing that particular doctor.

Moreover, traumatic deaths affect survivors’ desires to be close to others (other- intimacy) – even members of the immediate family. As one father stated following the death of his son in a motor vehicle crash, “I just couldn’t get that involved with my other son after the first one died.” Individuals often have a difficult time with self- intimacy (being aware of and familiar with their own internal states) as well; they may deny their feelings and needs in an effort to avoid the associated pain.

In some cases, the death shatters the client’s assumptions about the deceased. Information that was previously unknown may surface following the death. For example, parents may learn for the first time that their child was involved in destructive or illegal activities. This may shatter their assumptions that she was a well- adjusted person who used good judgment. Deaths of this sort can leave parents with the painful realization that they did not really know their own child.

In addition, survivors of a traumatic death may develop new beliefs that can generalize in ways that promote or prolong painful affect (Pearlman, 2003). For example, Arthur allowed his teenage daughter to go out with a young man whom he did not know very well. While driving, the young man was speeding and failed to negotiate a turn. Arthur’s daughter was killed instantly when the car struck a tree. Consequently, Arthur developed a belief that “I must monitor my children’s behavior at all times in order to keep them safe.” He became a harsh disciplinarian with his son, restricting his activities, controlling his choice of friends, and imposing a strict curfew. As a result, his son became extremely angry and resentful. He avoided his father as much as he could, and lied to his parents about his social activities and relationships. Their previously warm and loving relationship was transformed into one characterized by conflict and mistrust. Such disruptions contribute to prolonged suffering, as they often separate survivors from their loved ones at a time when they have a deep need for connection and support.

In addition to the disruption of an assumptive world, a survivor may experience the stirring of long-held beliefs that were problematic even before the significant other’s death. For example, throughout her childhood, Joan’s father had told her that she was “no good.” When her son committed suicide, the belief that she was no good (self- esteem) emerged as a significant element of her grief.

The shattering of their worldviews has profound implications for how survivors think about and process the loss. In most cases, survivors will try to make sense of what has happened, but may be unable to do so. They may have trouble reconciling the death with their religious views, and may feel betrayed or let down by God (other-trust, worldview). Many survivors are preoccupied with thoughts about causality and responsibility (self-trust, worldview) and accountability (other-trust, worldview). It is also common for mourners to be tormented by feelings of guilt and questions of whether and how much the deceased may have suffered. We discuss these issues in more detail below. Each adds to the challenges of accommodating the death and moving constructively into the future.

Core issues Created by violated Assumptions

Difficulty accepting the Loss

As noted above, it is common for survivors of sudden, traumatic deaths to experience difficulty accepting that their loved one is actually dead. As Rando (1993) has explained, many people state that they accept the death, but it is clear from their remarks that they do not fully comprehend the finality of the loss and all of its ramifications. Consequently, it is difficult for the mourning process to commence. In the study by Lehman and colleagues (1987), described in Chapter 1, the respondents were interviewed 4 – 7 years after losing a spouse or child in a motor vehicle crash. Nearly 40% of the bereaved spouses and parents indicated that they sometimes felt the death was not real and that they would wake up and it would not be true. In addition, 32% of the bereaved spouses and 41% of the bereaved parents indicated that, even though they realized it was not possible, they sometimes imagined that their spouse or child was coming back.

In cases where the deceased’s body is not recovered, such as in an airplane crash or a terrorist attack, it may be particularly difficult for the survivor to accept the death. Even when the body is present, problems accepting the death may make it hard to part with the loved one’s possessions. In addition, these problems may make it difficult to deal with tangible reminders that the loved one is gone, such as the gravesite. “When I visit my child’s grave, it confronts me with her death in a way that is almost too painful to bear,” said one mother.

grappling with meaning

Most survivors of traumatic loss report that at some point, they attempted to make sense of, or find meaning in, their loved ones’ deaths. According to Davis (2001), the search for meaning may take many forms, such as finding emotional meaning (e.g., believing that one’s loved one is with God and is no longer suffering); developing new goals or a new purpose; experiencing transformative personal growth; or finding benefits or redeeming features in the loss.

However, available evidence does not support the belief that, over time, most survivors are able to make sense of what has happened and move forward with their lives (see Wortman & Boerner, 2007, for a review). In our experience, survivors frequently comment that now that their loved ones have died, life holds no meaning. For example, parents are likely to view the death of a child as a violation of the natural order. As one father indicated, “You’re not supposed to bury your children” (Rosof, 1994, p. 17). Survivors of traumatic death typically make statements like these: “Tomorrow comes and tomorrow comes,” and “I don’t care what happens to me” (quoted in Finkbeiner, 1996, p. 191). In the Lehman and colleagues (1987) study described previously, the majority of the respondents (68% of bereaved spouses and 59% of bereaved parents) said that they had not made any sense of, or found any meaning in, the deaths 4 – 7 years afterward. In addition, 85% of spouses and 91% of parents had asked the question, “Why me?” or “Why my spouse/child?” Of these people, 60% of the bereaved spouses and parents said they were unable to answer the question.

Cleiren (1993) found that 14 months after the loss, 74% of those who had lost a loved one in a motor vehicle crash could not find meaning in what had happened. Murphy, Johnson, and Lohan (2003b) obtained similar findings in a study that focused on parents who had lost a child as a result of homicide, suicide, or a fatal accident. They found that 43% of the respondents had not found any meaning in their child’s death by the end of the 5-year study. In the case of homicide, 66% of respondents were unable to find meaning. Evidence is clear that survivors are more likely to have difficulty finding meaning after a sudden, traumatic loss than after a loss stemming from natural causes (see Neimeyer & Sands, 2011, for a review).

These and other studies have demonstrated that the mourning process is especially painful for people who search for meaning but do not find it (Davis, Wortman, Lehman, & Silver, 2000). For example, Lehman and colleagues’ study (1987) reported that of the respondents who were unable to find meaning in the loss, 73% of the bereaved spouses and 81% of the bereaved parents reported that it was painful for them not to have found meaning in the loss. Moreover, among those who seek meaning, the inability to find it is a significant predictor of poor post-loss adjustment in the majority of these studies. Neimeyer (2001) has suggested that sudden, traumatic losses impair the ability to create meaning, and that this may be the mechanism through which traumatic loss can bring about intense and prolonged distress.

Questioning One’s Faith

Among practitioners and laypeople alike, it is believed commonly that a deep religious or spiritual commitment may facilitate coping with loss. Park and Halifax (2011) have noted that for many individuals, “religion or spirituality underlies their general approach to life and forms the system of meaning through which they experience and understand the world” (p. 358). Religious or spiritual beliefs may mitigate threats to meaning, since most faiths have doctrines that explicitly address the meaning of death. Such beliefs may help people make sense of the traumatic loss by providing a framework for incorporating negative events (Pargament & Park, 1995; Park & Cohen, 1993). For example, a religious doctrine may emphasize that a traumatic incident was the will of God (see, e.g., Dull & Skokan, 1995). Specific tenets of a faith, such as the belief that the loved one is in a better place or that the mourner will be reunited with the loved one someday, may also reduce the likelihood of an existential crisis.

Whereas some people may find solace in their religious beliefs, it is also common for survivors of traumatic loss to question faith-related beliefs, and sometimes to abandon them altogether. A woman who had lost her son in an accident several years previously found that the loss triggered a powerful and long- lasting crisis of faith. Although she had been actively involved in her church before the loss, her views toward God shifted dramatically following her son’s death: “If there is a God, [He is] not a loving God and I want nothing to do with him… If He has no control over our lives, why bother to pray to Him?… the hell with you, God” (quoted in Finkbeiner, 1996, pp. 167 – 168).

Wilson and Moran (1998) maintain that following a major traumatic experience, “God is viewed as absent from a situation which demanded divine concern, divine protection, and divine assistance. The God in whom one once believed no longer deserves devotion. Consequently… in these situations, faith becomes impossible” (p. 173). Like many of a person’s fundamental beliefs, those related to spiritual and/or religious practices may be subject to abandonment, renegotiation, or recreation. The task for clinicians working within this treatment approach is to help clients develop a perspective on these issues that contributes to their healing.

Preoccupation with causality, responsibility, and Blame

In the wake of a traumatic death, it is common for a mourner to become preoccupied with the question of why the loved one died and who should be held accountable for the death. Typically, this preoccupation represents the mourner’s attempt to rework his worldview and to regain a sense of order, control, and justice in the world following the destruction of his basic assumptions.

Particularly after deaths that are unexpected or perceived to be preventable, survivors often experience a need to learn everything about what happened. They may obtain copies of police reports, autopsies, and other documents in order to gain as much information as possible. Many survivors feel conflicted about reading such documents, since they recognize that the information often includes traumatic content and that it may confirm the death, which they still have not fully accepted. In fact, many survivors find that the information included in the documents is more disturbing than they anticipated. One woman, whose husband died in an explosion at his job site, was determined to review the autopsy report so she could understand more about how her husband died and whether he had suffered. “His bosses told me that he died instantly, but how can they know?” she said. The report provided no definitive information about how long he lived once the accident had occurred. However, it did reveal that his injuries were far more extensive than she had been led to believe. Even in cases where mourners are not exposed to traumatic content, these documents are rarely definitive. In some cases, they are inconsistent with information about the tragedy from other sources, such as eyewitness testimony. In other cases, the information may be incomplete. Consequently, such documents often raise more questions than they answer, adding to the mourners’ distress.

In cases where deaths were caused by identifiable individuals, it is common for survivors to experience a desire for retribution. Following a homicide, for example, mourners are often determined to ensure that the legal system holds the perpetrator accountable for what happened. As we discuss below, it is natural for survivors to believe that the person who brought about the loved one’s death should receive punishment commensurate with the heinous act. In our experience, negative feelings toward the perpetrator are likely to intensify if he fails to show remorse for his actions. This perspective is supported by observations from the South African Truth and Reconciliation Commission, which revealed that when perpetrators confessed their guilt without remorse, the bereaved were left feeling insulted, angry, and dissatisfied with the process (Payne, 2008; Weiner, 2006).

Survivors are especially likely to struggle with the need for accountability, as well as a desire for revenge, in cases involving homicide. As Rando (1993) has indicated, these mourners typically experience anger that knows no bounds, as well as accompanying thoughts of retaliation and revenge. They may develop elaborate fantasies regarding ways to hurt, degrade, or even torture a perpetrator. As one mourner indicated, “I want him to experience the terror and physical pain that my daughter experienced.” Most mourners are very frightened by the emergence of such feelings.

In therapy, clients may be reluctant to bring up these strong feelings and revenge fantasies, fearing that their clinician may be repelled or judgmental. These survivors are typically not aware that such thoughts are normal following this type of loss. Feeling angry can also be very empowering for survivors, and may represent a preferable alternative to the vulnerability and despair that may underlie the anger.

Feelings of guilt

Many survivors of traumatic death experience powerful and disturbing feelings of guilt. Guilt feelings frequently emerge in cases where they would appear to be completely unwarranted. For example, one woman relocated her family from Denver to Chicago because she had an excellent job offer there. After they had been living in Chicago for about a year, her 13-year-old son was struck and killed while riding his bicycle. “Johnny did not want to move to Chicago, but my husband and I thought it would be best for the family,” she said. “If we had not moved, he would still be alive.”

Evidence from the motor vehicle study discussed earlier indicates that it is extremely common for survivors to experience self-blame and guilt even when they are not at fault (Davis, 2001). For example, many of the respondents lost a loved one when another motorist, either speeding or drunk, collided with the car occupied by their loved one. Not one of the respondents reported thinking, “If only the other guy wasn’t drunk,” or “If only the other guy had driven more carefully.” Virtually all of the respondents offered explanations for what happened that implicated their own behavior – for example, “If I had taken my son to the ballgame that night, rather than letting him drive with a friend, it would not have happened.”

Most parents have deep feelings of responsibility for the safety of their children, and these feelings are readily transformed into guilt after a child’s traumatic death. As Rosof (1994) has put it, “Your job as a parent was to protect your child, and you could not” (p. 15). In attempting to understand what happened and why, survivors often question themselves mercilessly about things they did, as well as things they believe they should have done but didn’t. Self-blame serves the purpose of shoring up the belief that there is some controllability in the universe and that what happens is not completely random (Janoff- Bulman, 1992). Rosof has emphasized that, despite the anguish that typically accompanies feelings of guilt, it is easier for survivors to find themselves guilty of some sin of omission or commission than to acknowledge how helpless they truly are.

In our experience, feelings of guilt are particularly pronounced after a suicide (see Chapter 5). It is common for survivors to experience intense anguish because they did not recognize the depth of their loved one’s distress, or because they could not prevent what happened. However, feelings of guilt are prevalent among survivors of other kinds of sudden death as well. A college student whose father dies in a crash when driving drunk may feel guilty for not confronting him about his alcohol use. A mother whose infant dies as a result of sudden infant death syndrome (SIDS) may feel guilty because she was not watching the baby closely enough. A woman whose husband dies of a heart attack may experience guilt because she did not encourage him to alter his diet or to get more exercise.

Guilt often causes survivors of sudden, traumatic loss to scrutinize their behavior during the days and weeks before the death. It is common for them to focus on any sign of conflict and exaggerate the role this may have played in the death. For example, shortly before his mother left for work, a teenage boy had an argument with her about attending a party at his friend’s house. When his mother was killed in an accident on the way to work, he could not help feeling that she was distracted by the argument and therefore less attentive to road conditions.

In addition to their own feelings of guilt, survivors often worry that those in their social network will blame them for the tragedy. Indeed, it is common for friends and acquaintances to make remarks insinuating that a survivor is to blame, even when such an assessment is unwarranted (see Rudestam, 1987). In our experience, such remarks are particularly likely be made after the death of a child. For instance, an elderly driver struck and killed a 12-year-old boy who had run into the street to retrieve a baseball. A neighbor berated the boy’s mother because she did not have a fence around her yard. While such direct and unwarranted blaming of survivors is prevalent, it is even more common for people to deliver such remarks in more subtle form, which can make them more difficult to refute. A friend of this same woman asked her, “Where were you when your son was killed?”

Sometimes survivors’ beliefs about others’ judgments may be projections of their own feelings of guilt or shame. Survivors’ sense that others are judging or criticizing their behavior typically leads them to withdraw from social contact. Social withdrawal can contribute to feelings of isolation and estrangement, which make it difficult for the healing process to begin.

Litz and colleagues (2009) have used the term moral injury to refer to the state that military service members can experience after “perpetrating, failing to prevent, bearing witness to, or learning about acts that transgress deeply held moral beliefs and expectations” (p. 700). Although these occurrences are expected parts of the combat experience, they can nonetheless lead to social withdrawal, self- harming behaviors, re-experiencing (in the form of painful recall), helplessness, hopelessness, and enduring changes in beliefs about oneself and others, among other difficulties. The concept of moral injury is relevant to service members who may seek treatment for trauma- or bereavement- related challenges, and it may also be relevant to others who similarly struggle with moral aspects of the deaths of their loved ones.

Preoccupation with the Deceased’s Suffering

Most survivors of sudden, traumatic deaths are preoccupied with questions about whether and how much their loved ones suffered. Many agonize about what their loved ones experienced during the final moments of life. Did they know they were going to die? Did they see it coming? Did they experience intense fear or terror? Ruminations about suffering appear to be most prevalent following deaths that are violent or mutilating, or that involve homicide. As one father expressed it, “I have nightmares about how my son struggled with his killer.” Such ruminations are also prevalent in cases where the death was not instantaneous. Concerns about the deceased’s suffering can tap into a person’s other- control needs.

In 95% of violent deaths, loved ones are not with the deceased at the time of death (Rynearson, 1987, 2001). Hence the vast majority of survivors struggle with questions about exactly how their loved ones died. Furthermore, many survivors of traumatic deaths are deeply troubled that their significant others died alone. They are distraught that there was no one available to comfort their loved one in his final moments of life. “I wish I could have been there to hold his hand, stroke his face, and tell him how much I loved him,” said one woman whose husband died in a motor vehicle crash.

Clinical integration

James’s sister, Pamela, had been worried about him for some time. She decided to talk to him about her concerns. “I know you had a bad experience with that therapist a year ago, but maybe someone else would be more understanding and could actually help you. I’m worried that I’m going to lose my brother forever.”

Pamela was referring to his extreme withdrawal since Raphael’s death 2 years earlier. James no longer socialized with friends; he had stopped going to the gym; he didn’t spend time with his nieces and nephews as he used to; and, as far as his sister knew, he had quit playing guitar. Pamela not only missed her brother, but was deeply concerned for his health and well-being. As she and James spoke, he saw the look of concern on her face and considered what she had said. Still, he couldn’t seem to get past the question the first therapist asked him almost a year ago: “Have you been able to find a silver lining in your experience of losing Raphael?”

The memory made him want to scream. “Silver lining?!” he thought. “There is no silver lining here! My life is over! My love is lost forever.”

Although he had felt initially supported by that therapist, James never returned after she asked that question. He found it deeply offensive and took it as proof that the therapist couldn’t understand what he was going through. What the therapist didn’t fully understand, and what James himself found difficult to acknowledge, was that he was struggling with the utter meaninglessness of Raphael’s death. After a year-long investigation of the accident and of working conditions at the manufacturing plant, no liability was apparent. There was no one to blame and no way to make sense of what had happened that dreadful day. Neither did James have a way of making sense of the death from a broader perspective. For James, there was no spiritual belief, no worldview, and no actual experience that imbued Raphael’s death and his own loss with any meaning at all. If he were to give therapy another try, he would need the next therapist to understand this. He needed a therapist who could tolerate the radical uncertainty that now defined his existence. If he couldn’t make sense of Raphael’s death in some way, how could he continue with his own life? This was the question that James now needed some help exploring.

Concluding remarks

Throughout this chapter, we have described traumatic bereavement as an extraordinary experience marked by disintegration of worldviews, depletion of resources, and disruption of basic psychological needs. Survivor clients need clinicians to convey understanding of and respect for their symptoms and struggles. Sound, ethical clinical practice requires that we know something in general about our clients’ condition while remaining open to learning from them about their particular experience. In other words, we should not leave it to the clients to teach us what we need to know about traumatic bereavement; neither should we assume that we know how the clients experience traumatic bereavement in the context of their lives.

James’s first therapist made a mistake by asking about a possible “silver lining.” We can characterize the question as a mistake because in this case, James was struggling with a sense of meaninglessness that was just the opposite of what his therapist wondered about. James’s experience can help us appreciate that knowing something about the role and nature of blame attribution, guilt, rage, and spiritual loss will be helpful in working with traumatic bereavement clients. At the same time, we can best help our clients if we also remain open to learning whether and in what ways these aspects of traumatic bereavement manifest themselves for each individual client.



chapter 4. Domains of Life affected

Kyle’s younger brother, Jeff, died in a plane crash on his way to visit friends in the Midwest. At the time of the incident, both Kyle and Jeff were college students and were extremely close. Now that Kyle has returned to college following Jeff’s death, he feels numb and as if nothing matters any more. Thoughts about Jeff’s accident go through his mind, and he finds it difficult to sleep. Concentration problems plague him, particularly in his math and science courses, and Kyle is terrified that he will lose his scholarship and disappoint his parents.

Kyle is also worried about his parents. Before Jeff’s death, Kyle looked forward to visits home during the school year – enjoying his mother’s great cooking, shooting hoops in the backyard with Jeff and his dad, and watching sporting events as a family. Since Jeff’s death, he instead has felt sadness and despair as soon as he enters his parents’ home. His father is more withdrawn. It seems as though his mother’s vitality has drained away. Her boundless energy was one of the things he admired most about her. Now she appears to be a shell of her former self. Cold cuts from the deli or pizza delivery have replaced family dinners. His friends at school have expressed sympathy, but they also tend to keep their distance because they don’t know what to say. For Kyle, Jeff’s death has changed everything. No matter where he turns, he confronts the painful consequences of what happened.

A sudden, traumatic death can impinge on virtually every aspect of a mourner’s life. A comprehensive understanding of the domains of life it affects, including possible legal involvement, is crucial to successful treatment. As illustrated above, disruptions in these domains bring about additional assaults on mourners and their capacity to integrate and accommodate their losses. In this chapter, we describe the sorts of difficulties that survivors may encounter in the various domains of their lives.

Survivors of traumatic loss seek solace in a variety of places, including interactions with others or involvement in work, leisure activities, and faith communities. For a variety of reasons, their quests for comfort and support are often unsuccessful. Indeed, in many cases, survivors continue to accumulate painful and alienating experiences.

Survivors of natural deaths may also have trouble in many of the domains we discuss below. In most cases, however, survivors of traumatic deaths encounter situations that are more problematic. For example, upon returning to work, a woman whose husband killed himself is more likely to experience stigma and greater social discomfort than is a woman whose husband died of cancer. Following the death of a spouse by suicide or homicide, intrusive thoughts and concentration problems are common and can interfere with the survivor’s ability to meet responsibilities at work and at home. Such problems are less prevalent following a natural loss. In fact, survivors of natural deaths rarely encounter some of the problems that bring about great distress for survivors of traumatic deaths. For example, these survivors are more likely to question their religious faith. They may also experience anguish at the hands of the criminal justice system. For example, the system may bring them into contact with a perpetrator who shows no remorse, or who receives a suspended sentence. Encounters of this sort give rise to further complications of mourning, beyond those the survivors have already sustained.


interpersonal relationships

The nuclear family

In considering how a nuclear family may be affected by traumatic loss, it is important to keep three factors in mind. First, the particular stressors associated with any role (e.g., work) are likely to be more intense and prolonged following a traumatic death than one that has occurred through natural causes (Rando, 2013; Wortman & Boerner, 2011). Second, reactions to a given loss are importantly influenced by the role relationship each family member had with the deceased – for example, whether one has lost a spouse or a child. People viewing the loss through the lens of one role may have difficulty understanding aspects of the loss associated with other roles. Finally, within a particular family, there are typically dramatic differences in whether and how individuals express their grief and cope with their loss. Each of these factors is likely to contribute to family members’ distress and can undermine relationships that were previously close and rewarding.

Unlike those who lose their loved ones through natural causes, survivors of sudden, traumatic deaths have no time to make a transition into the new roles required of them. If a woman experiences the traumatic death of her partner, she may suddenly have to take on responsibilities for unfamiliar roles, such as handling the family finances. In fact, she is likely to be confronted with a host of financial matters almost immediately after the death. These include issues pertaining to Social Security benefits, life insurance, and estate taxes, among others. These may exceed her abilities, particularly while she is in the throes of acute grief. In contrast, if a person loses his spouse to cancer, he will have weeks or months to prepare for taking over such tasks. Moreover, this process is most likely to proceed with input from the spouse.

Consider a case in which a man is killed in a helicopter crash, leaving behind a wife and an adolescent son. The son may be devastated because he can no longer turn to his father for support or advice. In addition, he may deeply miss his father’s involvement and encouragement regarding his music activities. He may be troubled by the fact that, although his parents always attended his concerts together, his mother has rarely attended performances since his father’s death. Over time, he may resent his mother’s apparent lack of interest in him; he may sometimes feel that, in effect, he has lost both parents.

In many cases, one family member may be unaware of the issues that are most troubling to another. For instance, the mother in the example above may assume that her son understands that she will become more engaged in his activities as soon as she is able. She may also assume that her son is aware that she is struggling with complex issues surrounding her husband’s estate that she must handle now.

It is difficult to correct such erroneous assumptions because most survivors try not to say or do things that will upset other family members. This adolescent boy may believe that if he talks candidly with his mother about how upset and disappointed he has been, she may become even more distraught. It is also unlikely that his mother will talk with her son about the enormous pressure she is experiencing in regard to financial issues. Yet it may be beneficial for him to have a better understanding of the burdens she is carrying, as this may lead him to judge her behavior toward him less harshly. In addition, open discussion about their respective losses may help each facilitate the other’s mourning by diminishing their sense of isolation.

Survivors may also mourn differently because they have distinct styles of emotional expression. Whereas some mourners may benefit from discussing their feelings about the person who died, such discussions may increase others’ distress. Mourners within the same nuclear family may also differ in their views regarding the value of displaying feelings. A bereaved parent may conceal his feelings in order to be strong for his partner. Similarly, parents may feel that it is inappropriate to express feelings of grief and distress in front of their children. They may feel that in the face of this tragedy, children need to believe that their parents are strong and capable. Finally, regardless of their attitudes about emotional expression, mourners are likely to differ in their ability to regulate and control the emotional distress they are experiencing. Such divergent responses can complicate the mourning process within the nuclear family and between immediate and extended family members.

Most people report a dramatic change in the atmosphere at home. As one mother explained following the death of her teenage son, “He would always walk through the door laughing and joking, often with some of his friends. Now all I hear is silence, and it kills me.” Family members may also become more irritable and tense following the loss – a common result of the disrupted ability to manage strong feelings or express grief or anger directly. One man who lost his daughter stated, “The anger and frustration from what happened to our daughter seem to spill over into my relationship with my wife. We are far more irritable with each other now.”

Some family members may interpret others’ different approaches to mourning as indicating something negative. For example, a wife may fail to understand why her husband shows no emotion following his sister’s death. She may question whether he really loved his sister. In addition, as family members struggle with their own anguish, there may be a contagion of negative affect that can intensify each person’s grief. After a relatively good day at work, for example, one husband plummeted into despair when he returned home to find his wife sobbing.

In most cases, the home and yard contain many reminders of the loved one. Such reminders can intensify the pain of the loss. For example, one man had helped his wife plant daffodils along the side of their home the fall before she died. The next spring, when the flowers bloomed, he became distressed that she was not there to see them.

marriage or Primary Partnership

Following the death of a child, members of a couple are sometimes able to pull together and provide some measure of support for one another, reflecting other-trust and other- intimacy. In fact, a mourning parent may feel that the partner is the only person who truly understands who and what was lost, and the couple may develop a closer relationship as a result of what happened. The notion that divorce after the death of a child is almost inevitable has been shown to be a myth (Murphy, Johnson, & Lohan, 2003a) – one that puts an unnecessary additional burden on bereaved parents. It is true, however, that divorce becomes more likely following the death of a child. Evidence suggests that the death of a child places strain on even the best partnerships. As discussed in Chapter 1, parents who had lost a child in a motor vehicle crash 4 – 7 years previously were more likely to divorce than parents who had not lost a child (Lehman et al., 1987).

As described above, a potential source of discord may be that the members of a couple have different mourning styles. For example, one partner may feel a powerful need to talk about what happened or about their child. The other partner may prefer to keep feelings inside. One partner’s discussions about the loss may intensify the other’s torment. As one husband explained it, “When my wife talks about what happened the day our daughter died, I know she is only trying to make sense out of it. But it literally makes me nauseated, and I have to leave the room.” If one partner gives cues that he doesn’t want to hear about the other’s feelings, the other partner is likely to feel disappointed and hurt. Such feelings can diminish communication between partners and change the tenor of everyday tasks they previously enjoyed, such as preparing dinner or gardening together. As a result of living with these dynamics, it is common for each member of the couple to feel estranged from the other. According to Mehren (1997), spouses often report that they feel “shut out,” and are at a loss as to how to establish the closeness they enjoyed previously.

It is common for partners to have difficulties negotiating their sexual relationship following the death of a child. Either person may experience a lack of interest in sexual intimacy after the loss. For example, one may feel that it is wrong to experience pleasure in light of what has happened. In some cases, however, the desire for intimacy may increase following the death of a child. As one man explained after the death of his only child, “Sexual intimacy helped me feel close to the only other person who meant anything to me.” In cases where partners differ in their desires for intimacy, tension can arise. When both members of the couple lose interest in sex, their sex life may become yet another casualty of their child’s death. (For more on the impact of child loss on sex and other aspects of a couple’s relationship, see Rando, 1986, 1993.)

A couple may also have difficulty coping with other losses, such as the death of a parent, sibling, or close friend. If the loss affects one partner more deeply, the other may have a difficult time understanding what the first one is feeling. This is particularly likely to occur when one member of a couple loses a parent. People typically believe that the death of a parent should not cause an adult a great deal of distress. Hence, one partner often reacts with irritation when the bereaved partner appears distraught about such a loss. The bereaved spouse may feel unsupported by the partner, and both are likely to report a decrease in marital quality (Umberson, 2003).

For a same-sex couple, the loss of a loved one may pose an additional set of challenges in coping. For example, the surviving member of the couple may feel unwelcome at her partner’s funeral. If sexual orientation has alienated the survivor from her extended family, she may also lack that potential source of social support.


The death of either a partner or child leaves a surviving parent with a number of specific problems. Some problems in parenting are unique to people who have lost their partners. For instance, Marlene, the mother of four young children, lost her husband in an airplane crash. Prior to his death, Jon had participated fully in parenting and household activities. In addition to his role as primary breadwinner, Jon had assumed responsibility for paying the bills, planning for the family’s long-term financial needs, and maintaining the house and car. The two of them shared driving the four children to different schools and attending their activities. Jon’s death thrust Marlene abruptly into single parenthood.

Other difficulties are experienced both by survivors who have lost a partner and by those who have lost a child. When a person is in deep mourning as a result of such a loss, it is hard to be emotionally available to surviving family members. In many cases, it is challenging for bereaved parents to provide physical care for their children. Like many others, Marlene had difficulty with sleep after her husband’s death. She would typically fall asleep around 4:00 A.M. She was often unable to get up at 7:00 A.M. to get her children ready for school. She was afraid to take sleep medication because she wanted to be sure she would hear the children if they cried out in the night.

Marlene felt that her children would benefit from continuing the family activities that they had enjoyed before Jon’s death. Prior to the loss, they went skiing every other weekend during the winter, and took regular trips to the beach in the summer. However, she recognized that without her husband’s income, these pastimes were not affordable. In fact, the financial constraints resulting from a loved one’s death can prove devastating, and can greatly increase the distress associated with the loss itself. In Marlene’s case, an immediate consequence of her husband’s death was that she lost health insurance for herself and the children. This was particularly stressful in Marlene’s case because one of her sons had a congenital birth defect that required regular treatment.

About 6 months after her husband died, Marlene recognized that she and the children could no longer afford to live in the family home. Clearly, such a loss has profound ramifications for all family members. In addition to everything else, Marlene had to get the house ready to sell and find a real estate agent. She also had to locate a suitable new home and deal with such issues as mortgage rates and closing costs. The children were faced with the loss of their many friends from the neighborhood. They also had to adjust to a new school.

In addition, it can also be difficult for surviving parents to enforce consistent discipline. Because of symptoms such as depression, lack of motivation, fatigue, and inability to concentrate, bereaved parents are sometimes lax in maintaining structure, boundaries, and routines for their children. At other times, chronic feelings of anger and frustration may result in frequent arguments. Children may find that sometimes the surviving parent does not notice indiscretions, while at other times she responds harshly.

Alternatively, a parent may realize that the child is having a difficult time, and provide gifts as a way of comforting him. Members of the extended family may also provide an excessive number of gifts. These diverse responses to the child, which often bear little relationship to his behavior, can lead to confusion and insecurity.

It is also common for parents to become overprotective following a traumatic death because their safety needs – for themselves and others – are likely to be affected by the sudden death. Survivors typically live in fear that something bad will happen to other family members. As one bereaved woman stated, “When my daughter was late coming home, and I could not reach her on her cell phone, I became hysterical.” Parents often place many new restrictions on the behavior of their children. A 9-year-old girl who lost her brother complained, “I used to be allowed to go to sleepovers at my friends’ houses, but now I’m not. I’m the only kid who’s not allowed to go.” Parents are likely to question teenagers relentlessly about where they are going and what they are doing. Such behavioral restrictions and increased scrutiny often contribute to feelings of animosity and resentment. These responses can also interfere with the development of autonomy in adolescents and young adults, which typically evolves in response to consistent guidance and age- appropriate regulation by parents.

Some bereaved survivors express deep concern about how children of the same gender as the deceased parent will fare without a role model to assist with gender role socialization. One man who lost his wife in an industrial accident was concerned about raising his two young daughters alone. “She used to take them shopping for clothes and talk to them about their feelings about boys,” he said. Such concerns may also adversely affect the surviving parent’s feelings of self- esteem, self-trust, and adequacy to parent alone.

Parents may be unaware that young children express their grief differently from adults. Very young children may simply be unable to comprehend the permanence and irreversibility of death or the concept of an afterlife. One grandmother who had lost her adult daughter was taken aback when her 4-year-old grandson asked at the funeral, “When is Mommy going to wake up?” She added, “He thinks heaven is an actual place you can visit, like McDonald’s, and says we should go to heaven and pick Lucy up.”

Young children are also likely to exhibit aggression, anxiety, and regressive behavior – evidence of setbacks in affect tolerance. Bedwetting is common following the traumatic loss of a parent or sibling. Unfortunately, many parents are unaware of the link between the loss and such regressive behaviors and consequently may react punitively to the child. Other common symptoms are stomachaches, headaches, difficulty tolerating separation from the surviving parent or other loved ones, and acting in ways that test (or may be designed, even if unconsciously, to elicit) limits.

Many times, teenage children become more rebellious and uncooperative around the house. They may perform more poorly at school and experience an increase in problematic behaviors. One of Marlene’s sons began cutting classes and bullying classmates. Parents might have difficulty determining to what extent certain changes stem from the loss, and to what extent they stem from the fact that the child is now an adolescent. Such behavior can be particularly difficult for the surviving spouse if the deceased spouse handled discipline prior to the death. In any case, the surviving parent must now manage these challenging behaviors without the benefit of consulting with the partner.

Children often go out of their way to be “good” so as not to upset or disappoint the surviving parent. When parents are unable to function, surviving children may be forced into a caregiving role. In these cases, it becomes more difficult for such children to separate from the parent and become independent.

Parents often struggle with what to tell their children about the death, and about how to respond to a child’s questions or comments. For example, the driver of a moving van was talking on his cell phone when he plowed into a car that was stopped at a red light. The 32-year-old driver of the car was killed on impact. The trucker received minimal punishment for this crime. As his wife stated, “Our 8-year-old son, Bobby, asked me why the trucker is not in jail and why he is still driving a truck. What am I supposed to tell him?” In another case, a 10-year-old boy whose father was killed by a drunk driver announced to his mother, “When I grow up, I’m going to kill the man who killed my daddy.”

The extended family

Following a traumatic death, an adult survivor typically expects to receive emotional support from parents, siblings, and other relatives, particularly if they enjoyed good relationships prior to the loss. Sometimes this expectation is fulfilled, and mourners are able to establish a nurturing relationship with one or more family members. However, many bereaved survivors encounter unexpected problems in their relationships with members of their extended families.

One problem frequently mentioned by mourners is extended family members’ refusal to acknowledge and talk about the deceased. As one mother expressed it, “They act as though my daughter never existed. This really hurts.” Some family members avoid mentioning the deceased for fear of upsetting surviving members of the nuclear family, whereas others do so because they worry that they themselves will become emotionally overwrought if they bring up the topic. Still others simply feel at a loss for the “right” thing to say.

Whereas failure to acknowledge the deceased can be problematic, intense and repeated displays of distress can be equally difficult for survivors. As one woman indicated after the death of her daughter, “I used to enjoy going over to my mother’s. But now all she does is cry about Cassie. I wish she would support me, but instead I feel that I have to take care of her.”

Following the death of a spouse or partner, it is common for conflict to develop between the survivor and her in-laws. In-laws may begin to offer unsolicited advice about many topics, including how the surviving parent should raise the children and handle investments. Such behavior may reflect the in-laws’ desire for control stimulated by the loss of their child. Of course, concern for the young family may also motivate such comments. Advice is most helpful when tempered by attunement to the young family’s expressed needs and responses to advice.

Conflict may also emerge regarding particular possessions of the deceased. In the case of a natural death, the dying person has the opportunity to decide how to distribute his possessions. Following a sudden, traumatic death, however, family members must sort this out for themselves. For instance, a man who killed himself had an extensive coin collection. His parents believed that they should have the collection, while his wife wanted to keep it to pass down to their children. In such disputes, each party may be looking for ongoing connection with the deceased.

Because of the aforementioned difficulties, the tenor of family gatherings may change. When attending a family gathering, both immediate and extended family members may feel as though they must “walk on eggshells” to avoid upsetting anyone. If survivors do lose their composure on such occasions, they may not receive much sympathy. One woman who had lost an infant son was attending her sister’s baby shower. Although she worked hard to maintain her composure, her eyes welled up with tears a few times. After the shower, she overheard her mother say, “It’s too bad Peggy can’t be happy for Susan, instead of just focusing on herself and her own loss.”

Finally, the fact that all family members are bereaved may affect the degree of support any family member can offer to another. When Jon was killed, Marlene naturally turned to his parents, who lived nearby, for help with the children. However, Jon’s father was so deeply affected that he was unable to assist Marlene and required substantial support from his wife, who then was less available to support Marlene and the children.

structures of daily Life

Following sudden, traumatic deaths, most people will need to attend to their obligations and the basic requirements of daily life. These demands may include such tasks as maintaining the household, paying the bills, and bringing home a paycheck. It can be excruciatingly difficult to engage with such tasks when it feels as though one’s world has been ripped apart. These burdens can also compromise people’s ability to participate in therapy. Alternatively, a survivor may appear to become excessively involved in daily activities, to avoid facing the painful affect associated with the loss. One husband and wife found themselves at odds shortly after the death of their adult son in military combat. Almost immediately after their son’s death, the wife threw herself into dismantling his condominium to prepare it for sale. Although her husband wanted to spend some time reviewing their son’s art collection, she insisted on selling it, even though they did not need the money. In either case, clinicians and clients together must explore the psychological needs the clients’ behavior is serving, and whether it is in fact adaptive for healthy mourning and accommodation.


For many survivors of traumatic deaths, work is a means of maintaining a routine, structuring their time, and feeling competent. They hope that their jobs will help them focus their attention away from the loss, and perhaps fill the emptiness they feel. In many cases, mourners are fortunate to have supportive coworkers. Nonetheless, it is typical for survivors to have experiences at work that add to their distress. Particularly in the first several months after the loss, mourners may have difficulty keeping their emotions under control. They may become tearful when they encounter a reminder of the loss, such as a customer who has the same name as the deceased. They may also feel self- conscious around others. As one woman indicated, “I felt that my presence was making people uncomfortable. They kept some distance from me, probably because they did not know what to say or do.”

Upon returning to work, many survivors face serious difficulties with concentration and memory. These common symptoms of traumatic bereavement can dramatically reduce a mourner’s ability to function at work. If he is experiencing intrusive imagery, concentration difficulties may be even more pronounced. One survivor said, “My boss keeps asking me for the sales projections for next year. But how can I finish them when I keep seeing images of the accident?”

These problems manifest themselves in different ways, depending on the nature of the job. Those who work in sales may be unable to remember the names of their customers or what products they need. Those who work in management or service fields may find it extraordinarily difficult to listen to the work- related problems of their clients or their subordinates. People who work with heavy machinery may be concerned that a lapse in concentration will result in an injury for themselves or someone else.

The deficits in motivation that often accompany traumatic bereavement can also erode survivors’ ability to perform well at work. Many people report that because of the death, they no longer find their job as satisfying or interesting as they once did, and that they have to force themselves to perform tasks that they completed easily before the loss. In many cases, previously held plans or goals for professional advancement no longer seem possible. As one mourner indicated following the death of her sister, “I was planning to start taking classes toward my master’s degree this summer. But at this point, there is no way I can handle work and school.”

Physiological changes – including hyper arousal, an increase in headaches or stomachaches, and sleep difficulties – can also lead to lowered productivity. A reduced sense of physical wellbeing can make work feel more onerous.

Because of the problems described above, most mourners show a dramatic decline in work attendance. In addition to such factors as sleep disturbance and a decrease in motivation to complete the work, the ability to go to work on significant dates may affect attendance. Common impediments to work attendance include the anniversary of the death or the birthday of the person who died; the necessity of dealing with children who are ill (particularly if a survivor is a single parent); and the decision to be present in the courtroom if a (criminal, civil, or both) case is being tried. Dealing with these factors can also affect performance in many ways, such as enhancing the likelihood that a survivor will make errors, or will fall behind schedule by taking more time to complete job- related tasks. Survivors of sudden, traumatic deaths may experience a great deal of anxiety about their work performance. As one woman indicated, “I was always worried that I would let down my coworkers or my boss.” Another man said, “Before my mother’s death, I gave 150% at work. Now I can only give around 50%.”

The factors that contribute to absences at work are also likely to result in tardiness. As one employee expressed it following the death of his partner, “For the last 16 years, I was only late on one occasion. Since Bob’s death, I have been late about three times a week.” In addition to anxiety, it is common for survivors to feel embarrassed or ashamed about their absences and tardiness. Moreover, many mourners have indicated that after the first month or so following the loss, their coworkers do not show much sympathy for their situation. “My boss told me flat out that she thought I was taking advantage of Jessie’s death by missing so many days and coming in late all the time,” said one mother who had lost her daughter.

In many cases, survivors also report difficulty with the day-to-day banter of colleagues. It is hard for some mourners to endure coworkers’ comments about their families. One father lost his son shortly before the son was scheduled to begin college. When he heard a coworker mention that he was planning to take his daughter to college, the bereaved father suddenly started sobbing. Another survivor who lost his wife had difficulty showing sympathy for a colleague who complained that his wife was out of town for a week. Because of their discomfort with such conversations, many survivors minimize their contact with coworkers. As one mourner stated, “I used to eat in the lunch room, but now I eat at my desk.”

Leisure and recreation

For most people, recreational activities are enjoyable pastimes, providing relaxation and replenishment. After a traumatic death, however, it is often difficult for survivors to participate in leisure activities that they enjoyed with the deceased. One father said, “As my son was growing up, I taught him everything I know about fishing. We went fishing together on countless occasions and always had a great time. Since his death, I have no interest in fishing whatsoever. My friends have invited me to go, but I have declined. It would be too painful to be out there without him.”

Vacations also present challenges to those who have experienced a traumatic death. Family members often struggle with whether they should return to a regular vacation spot or try a new destination. If they return to a destination they have enjoyed in the past, the trip is likely to trigger bittersweet memories. If they choose a new destination for a vacation, they may experience profound sadness that their loved one is not present to enjoy the trip. One couple lost their toddler when his condition was misdiagnosed in the emergency room and he did not receive the appropriate treatment. The following year, they took their surviving children to Disney World. It was painful for them to encounter Mickey Mouse, who had always been their toddler’s favorite character.

These feelings are likely to emerge not only around vacations, but also around a host of activities family members enjoyed before the tragedy. Camping trips, sporting events, and religious and school functions are but a few examples. As one widow explained, “Every year we went to the annual charity ball at my workplace, and it was always a lot of fun. I have no desire to go by myself.”

Following a traumatic death, it may also be difficult for survivors to enjoy television and movies as much as they did before the loss. Many mourners find it hard to relax while watching TV or films because they never know when they will encounter vivid reminders of their loss. For example, a couple who lost a blond toddler may find it difficult to witness the endless series of blond toddlers who appear in diaper and cereal commercials. Sometimes, out of a need to guard against the potential confrontation with such reminders, mourners remain in a constant state of hypervigilance. At other times, they may elect to quit watching TV altogether so as to avoid exposure to these cues. One man whose twin sister was shot in a robbery said, “I can hardly watch anything any more. Shootings occur all the time on TV and in the movies. I can’t even watch the evening news.” Even if the media do not expose survivors to images that evoke their loved ones’ deaths, newspapers and magazines frequently carry stories that exacerbate survivors’ distress. For example, a woman whose daughter was killed in a gun accident may find it painful to encounter an article about a recent mass shooting or about the easy availability of guns. In addition, watching TV or movies can bring about discomfort if mourners feel guilty when they enjoy these pastimes or momentarily forget about their loved ones.

In most cases, the distress associated with watching movies or TV is exacerbated when a mourner is in a social situation. In one case, a man was at the home of friends, and they were watching an action movie together. Near the end of the movie, there was a violent explosion. This man’s father had died in an explosion the previous year while working on a pipeline. “The movie ended and they asked me if I wanted coffee and cake, and I was sitting there crying,” he said. “Witnessing that explosion brought everything back.”

spiritual or religious Community

As we have discussed earlier, the traumatic death of a spouse/partner or child can evoke a crisis of faith. Feelings of disillusionment may undermine survivors’ motivation to participate in their faith- related activities or communities. Without their faith communities, survivors lose an important source of support and comfort.

Among those who continue to attend religious or spiritually oriented services, this experience may change dramatically after the loss. One woman who had gone to church with her husband for many years found it jarring to attend alone. Often the music played can stimulate great emotion, as can certain parts of the service. One Catholic widower remarked, “I cry when I hear the hymns at Mass, and I really lose it when I have to give others the Sign of Peace.” A place of worship can also trigger disturbing memories if the funeral service took place there. As one woman indicated, “Whenever I go to the synagogue, I think about my son’s funeral.” Survivors also report feeling self- conscious in religious institutions, since these communities are defined in part by concern for others. “I found it hard when people asked me how I was doing,” said one mother who lost a child. “I knew they wanted me to say I was doing OK, or that I was doing better. But that would have been a lie.”

In some religious communities, survivors may also become the recipients of support attempts that are based on an assumption of God’s omnipotence. As one father expressed it, “If one more person tells me that God needed my son more than I did, I’m going to throw up.” Survivors are commonly told that what happened was God’s will, that it was for the best, that their loved ones are in a better place, and that they will see their family members in the next life. Many people find such comments offensive. In addition, common responses to a traumatic death (e.g., questioning God’s will) may elicit disapproval from members of a mourner’s congregation, who may view such responses as blasphemy or demonstrating a lack of faith.

In some cases, members of a congregation may regard a mourner’s decision to enter treatment as reflecting a lack of faith. As a result of these kinds of responses, it is common for survivors to distance themselves from their religious communities. Some change churches or temples so that they can practice their religious faith without constant scrutiny; others quit attending religious services altogether. As one former churchgoer stated, “Following my son’s death, I began to question religious beliefs that I had held all of my life. I could not understand why God would allow my son to die. I thought attending church would be comforting, but every few minutes there was a reference to God’s omnipotence or God’s goodness.”

The Legal system

If the death of a loved one was caused by another person, the perpetrator may be prosecuted criminally for causing the loved one’s death. The death may have come about through murder, manslaughter, or criminally negligent homicide. In such cases, the local, state, or federal government, which seeks to determine the perpetrator’s guilt or innocence and impose an appropriate sentence, may initiate legal action.

Individuals may also become involved with the legal system if they decide to file a civil suit, or a wrongful- death suit, on behalf of their deceased loved one. The most common causes of wrongful deaths include motor vehicle accidents, medical malpractice, use of defective products, and construction accidents. Unlike criminal trials, which are initiated by the government, civil suits are initiated by the loved one’s surviving family members. In a criminal case, the penalty imposed is a sanction, such as a fine or imprisonment. In a civil case, a monetary judgment is entered against the perpetrator. In some cases, the perpetrator may be prosecuted in both a criminal action and a civil action.

In either a criminal or a civil case, survivors are typically motivated by a desire for justice. They want to see the perpetrator held accountable for what has happened. At the onset of a trial, survivors may be optimistic about receiving an acknowledgment from the legal system that what happened to their significant other was wrong. Many mourners have a fervent wish that as a result of the legal proceedings, what happened to their loved one will be less likely to happen to someone else. Consciously or not, they may also believe that they will experience some relief or healing if the perpetrator is found guilty.

People commonly hold beliefs and assumptions related to justice and fairness within their worldviews, and a traumatic death can deeply disrupt these beliefs. It is common for family members of individuals who have been murdered to express dissatisfaction with the legal system. In one study, dissatisfaction with the criminal justice system was highly correlated with respondents’ ratings of anxiety and depression (Amick-McMullan, Kilpatrick, Veronen, & Smith, 1989).

It is most unfortunate that what begins as a search for justice or healing often ends in disillusionment and heartbreak. Disillusionment may stem from going through the legal process, facing an unfavorable outcome, or both. Parties can experience a number of delays during the judicial process, for which most people are ill prepared. Postponements, continuances, and appeals can prolong a legal battle for several years. In one case, a woman witnessed her husband being struck and killed while he was on the shoulder of the highway changing a tire. The perpetrator’s blood alcohol level was three times the legal limit. She felt strongly that the perpetrator should be held accountable for this crime. Each time the matter was scheduled to be heard in criminal court, she took a day off work and drove to the courthouse, which was 50 miles away. The case was continued six times over a 2-year period. Many defense attorneys are motivated to continue such cases because it is a way to keep their clients out of prison. Such practices can be heart- wrenching and infuriating for survivors.

If a case does go to trial, survivors may experience considerable anxiety about the prospect of testifying in front of the judge and jury. Many bereaved survivors cannot imagine expressing their innermost thoughts and feelings in such a public forum. It can feel as though they are the ones on trial, and that they must prove how much they are suffering. In most cases, they are also fearful about what they will be asked during cross- examination. One mother was terrified that she would be questioned about how often she visited her son’s grave. One aspect of the judiciary process that can be upsetting to survivors is that the defense attorney may attempt to shift blame from the perpetrator to the survivors or to the deceased. For example, a man was struck and killed while he was attempting to assist a distressed motorist on the side of the highway. In court, the defense attorney argued that he should have recognized the danger of stopping to assist another motorist.

It is also common for the alleged perpetrator’s attorneys to scrutinize every aspect of the survivor’s past. A single parent who lost her only son in a motor vehicle crash was shocked when the defense attorney unearthed her traffic violations from 15 years earlier, and when he berated her in front of the jury for accepting food stamps when her son was young. Defense attorneys are often intent on obtaining information about the plaintiff’s behavior that will weaken the case. In one case where a woman’s husband died because of medical malpractice, the defendants hired private investigators to determine whether she had begun dating again. She frequently saw them lurking outside her home and was frightened and intimidated by these tactics.

During legal proceedings, survivors often encounter information about their loved one or the manner of death that is shocking and disturbing. One woman was pushing her baby in a stroller when a drunk driver drove onto the sidewalk, hitting the stroller and killing the baby. The woman was horrified when she entered the courtroom and saw the mangled stroller, which the defense attorney planned to use as an exhibit. Another woman learned in the courtroom for the first time that when her brother’s accident occurred, his body was dragged along the pavement for 200 yards.

Yet another troubling aspect of the judicial proceedings is that they bring survivors into contact with the perpetrator, usually for the first time. For most survivors, this encounter evokes powerful and unsettling emotions. As noted above, it is common for survivors to harbor seething rage toward the perpetrator. They hope that the perpetrator will recognize the magnitude of the loss she caused and show some remorse. In our experience, this almost never happens. One man whose mother was shot in a holdup attempt said, “He acted so nonchalant, as if he did not have a care in the world. He even smiled on some occasions. I was so angry, I could have killed him with my bare hands.”

It is typical for survivors to feel that what happened to them and their significant others was profoundly unfair. They often believe that they have received a life sentence of pain and loss. It is rare for perpetrators to receive sentences that mourners view as commensurate with their crimes, especially in cases of vehicular homicide. In one case, a couple lost their teenage daughter when her car was struck by a vehicle traveling over 150 mph. The driver was returning from a bachelor party and was legally drunk. Her parents were infuriated that the perpetrator was not sentenced to any jail time; he was not fined; and, in fact, he didn’t even get a traffic ticket. In those cases where the perpetrator receives a minimal sentence or no sentence, the survivors may feel that the value of the loved one’s life was not acknowledged or recognized. As one father expressed it, “It was as if they said, ‘Your daughter was killed, so what!’ ” Similarly, such an outcome can leave the survivors feeling as though their own pain and suffering do not matter.

In our experience, many bereaved individuals harbor a strong wish to convey what they have been through to the perpetrator. Since the 1990s, survivors have been able to make statements regarding the emotional suffering they have experienced as a result of their loved one’s death. Such a statement is called a victim impact statement, and is used at sentencing. This information can be provided orally, in writing, or both. In our experience, the vast majority of bereaved people who have given such statements consider them to be meaningful and worthwhile.

social support

Social support is generally regarded as one of the most important resources for dealing with stressful life experiences. As we discuss in Chapter 10, supportive interactions with others help people to feel loved, cared for, valued, and understood. A survivor who is engaged in any of the domains described above, such as being at work or attending church, has the potential for receiving support. Unfortunately, available research indicates that survivors of traumatic loss rarely receive effective support. Studies on social support among the bereaved suggest three reasons why support may not be forthcoming. The first, which we have touched on above, has to do with the impact of a death on the support providers to whom a mourner has typically turned in the past. The second stems from survivors’ strong inclination to withdraw from others after the tragedy, thereby cutting themselves off from interactions that are potentially healing. The third set of reasons results from the social ineptitude of those in the social environment, leading them to offer support that is ineffective or even harmful. We discuss each of these reasons below.

impact of the death on Potential supporters

It can be especially hard on a survivor if the person who died was his major source of social support. This often occurs in the case of spousal loss, particularly for men. Many heterosexual men in our culture rely almost entirely on their wives for support and have few close friendships outside the marital bond. In addition to removing a major source of support, the traumatic death can render other potential supporters less effective, since the tragedy may also affect them, as discussed previously in the section “Interpersonal Relationships.” mourners’ Tendency to Withdraw

Studies have shown that people who have experienced the traumatic death of a loved one often choose to avoid or minimize contact with others. Research indicates that it is common for survivors to withdraw from others. In a study of how older adults coped with the death of their adult child, Malkinson and Bar-Tur (1999) noted that many of these parents inhabit “an emotional territory that is inaccessible and isolated, by building a fence between themselves and others” (p. 414). Dyregrov and colleagues (2003) assessed parents of children who had died as a result of SIDS, an accident, or suicide, an average of 1½ years after the deaths. Approximately 50% expressed agreement with the statement “I withdraw from others.” Self- isolation was by far the most important factor associated with health problems, PTSD symptoms, and complicated grief in all three samples.

Survivors may withdraw for several reasons. Some mourners may feel too helpless, confused, or depleted to initiate social contact. As one woman expressed it following the suicide of her son, “When you experience such a disaster, you are not capable of asking for anything. You are completely lost” (quoted in Dyregrov, 2002, p. 656). These feelings may also make it difficult for survivors to respond to social overtures from others. Some people do not like to go out, especially at first, because they feel self- conscious. As one person indicated after the loss of her child, “I felt that everyone was looking at me and trying to figure out how I was doing.” A woman who lost her spouse felt that she did not “fit in” with her former couple friends. As she expressed it, “I feel like a fifth wheel.” In addition, she found it painful to realize that at the end of the evening, she would be going home alone. Some avoid socializing because they are afraid that they will make others uncomfortable, or that they will be “wet blankets” and ruin the gathering for others. Still others prefer to stay at home because they never know when they will encounter a reminder of their loss that will trigger distress. For example, a widower whose spouse loved lasagna became visibly upset when he went to a dinner where the host served lasagna.

In addition, mourners often have difficulty engaging in the types of interactions that typically occur at social gatherings. After experiencing a traumatic death, a mourner may find almost any subject trivial and meaningless. In our experience, mourners have particular difficulty with people who complain about relatively insignificant issues. For example, a woman whose husband died in an accident may become annoyed when her colleague complains because someone dented his car in the parking lot.

Parents who have lost a child may find it heartbreaking to hear others discussing their children’s activities, accomplishments, or plans. Bereaved parents may also have difficulty when exposed to parents who are critical of their children. “At work today,” one bereaved parent indicated, “I had to listen to my supervisor go on and on about how upset he was that his son didn’t make the basketball team.” For all of these reasons, survivors of traumatic deaths often feel more comfortable at home.

others’ social ineptitude

Research indicates that in many cases, survivors perceive remarks that people intend to be supportive as disappointing or hurtful. Dyregrov (2003 – 2004) conducted a study of the support difficulties encountered by parents who lost a child to SIDS, suicide, or an accident. She used the term social ineptitude to describe the responses that the bereaved often received from members of their social network. Problematic responses fell into three main categories. The first was anticipated support that failed to appear – for example, when people who were close friends prior to the loss did not contact a survivor after a death. The second category was avoidance of the bereaved (e.g., friends or acquaintances crossing the street or looking the other way when they caught sight of a bereaved person). As one mother stated after the traumatic death of her daughter, “I felt like I had the plague.” Rando (1993) has noted that among those who have lost a loved one, bereaved parents are the most stigmatized and avoided because “their loss represents the worst fears of others” (p. 624).

The third category of social ineptitude Dyregrov identified was offering advice or support that recipients viewed as unhelpful. These included attempts to block discussions about the loss or displays of feelings (e.g., “You need to be strong for your children”), minimizing the problem (e.g., “At least he’s not a vegetable”), invoking a religious or philosophical perspective (e.g., “She’s a flower in God’s garden”), giving advice (e.g., “You should not be going out to the cemetery every day”), and identifying with feelings (e.g., “I know how you feel – I lost my second cousin”). One might expect unhelpful remarks to be more prevalent among strangers or casual acquaintances than among the survivors’ relatives or close friends. However, this does not appear to be the case (Lehman, Ellard, & Wortman, 1986). In one study, the bereaved consistently rated family members as less helpful than friends (Marwit & Carusa, 1998).

Survivors have reported that they experience such responses as deeply wounding. They leave the bereaved feeling that no one understands what they are experiencing. Such comments also contribute to survivors’ discomfort at social gatherings. The bereaved typically find it helpful when others convey a supportive presence (e.g., “I’m here for you”); when they express concern (e.g., “I care what happens to you”); or when they offer tangible assistance, such as help with errands or meals. Most survivors also value interactions in which they can talk about the loss if they choose to do so (Lehman et al., 1986; Marwit & Carusa, 1998).

Some survivors elect to stay at home to avoid the difficult questions that others may direct toward them. People in a survivor’s social network may ask insensitive questions about such matters as how the death occurred (e.g., “How fast was your husband driving?”), about financial issues (e.g., “How are you going to spend the insurance money?”), or about the loved one’s possessions (e.g., “What are you going to do with his tools?”) (Wortman, Battle, & Lemkau, 1997). Such questions or remarks can contribute to the survivor’s tendency to withdraw from others.

Clinical integration

It’s been about 9 months since Kyle lost his brother, Jeff, to a plane crash. Now in his senior year of college, Kyle has been working with a psychotherapist, Xiu, in the counseling center on campus. During their ninth meeting, the following conversation takes place.

Xiu: Hi, Kyle. How did you do with your independent activities this past week?

Kyle: Um, you know how we talked about bringing a friend home with me for the long weekend? Jeff and I both used to do that a lot. Our friends loved coming to our home when we had some time off at school because we have a comfortable house and our dad’s a big sports fan and a really good cook. My friends always loved my mom, too, and she’s an even better cook. When you’re used to eating college cafeteria food and pizza, two chefs in the family is a big deal.

Xiu: (smiling) Yes. And I know that going home is one of the things you’ve missed since Jeff’s death.

Kyle: Yeah. I wasn’t sure if Al would be able to have a good time because my parents aren’t like they used to be. It took all the nerve I had, but I finally asked Al if he wanted to come home with me because his family lives too far for a weekend visit and he had nowhere to go. I thought that a sad house was better than staying in the dorm alone.

Xiu: You were concerned about Al’s feelings?

Kyle: Yeah, I guess so. He’s one of the guys who know about what happened and all, so that made it a little easier. I called my girlfriend before I talked with Al; she really helped me get up the nerve to ask him.

Xiu: That’s great, Kyle. Do you see how calling Trish was an example of calling on social support and building those resources we’ve been talking about?

Kyle: Yeah, I guess so. For the most part, it’s easier to rely on her, but I’m afraid of overwhelming her and pushing her away.

Xiu: OK – I’m going to jot that down: Your fear of overwhelming Trish. It’s something we may want to go back to and examine more closely. For now, can you tell me what happened when you talked with Al?

Kyle: Well, he was really cool about it and all. He’s been to my house before, and so he was looking forward to it. But the next day I changed my mind. I canceled the trip. I disappointed Al and myself, and maybe even my parents.

Xiu: OK. Let’s go back a few steps and maybe learn something about the blocks you’ve been talking about. Do you remember how you felt, or what was going on inside of you, right after Al said he would come home with you for the weekend?

Kyle: I wanted to feel proud of myself; I thought I might, but I didn’t. Instead, I felt that pit in my stomach that I always feel.

Xiu: Always? That’s a strong word. Do you always feel the pit? Did you feel it after talking with Trish?

Kyle: No, not always, and not after my call to Trish.

Xiu: OK. So you did feel the pit after talking with Al. Are you aware of any thoughts you were having at the time?

Kyle: I’m not sure.

Xiu: That’s OK. What is your best guess about what you may have been thinking?

Kyle: I think I started imagining me and Al shooting hoops in the driveway. What if my mom was looking out the window while we played?

Xiu: What if? What do you imagine would happen?

Kyle: (choking up) It’s… it’s like I’d be hurting her. She would see Al and me and think of Jeff and me, and… well, you know?

Xiu: I think I do know, but I want to make sure I understand. What’s the “and”? You said she would think of you and Jeff and – ?

Kyle: Um. And she would think it’s wrong if I was having a good time. (Xiu remains silent for a few moments, allowing space for Kyle to be with his inner experience. Kyle looks up at Xiu, then quickly looks away.)

Xiu: Kyle, what did you notice just then? What was happening inside?

Kyle: I just felt sad, but also some relief. Well, that’s not the right word. It’s like I was aware of how heavy everything is, and somehow I felt lighter or something; I don’t really know.

Xiu: Sometimes when we can give a name or some expression to an inner experience, it does feel lighter. As though a small piece of the burden is lifting.

Kyle: (softly) Yeah.

Xiu: You’ve said some important things today, Kyle. You were worried about Al having a good time. You didn’t want to disappoint him. You were worried about being a burden to Trish. And you were concerned with possibly hurting your mom, and worried about disappointing her – not wanting to disappoint her. Not wanting to disappoint her with your happiness! That’s all quite a burden, isn’t it?

Kyle: Yeah, I guess it is.

Xiu: And the part about disappointing or hurting your mom with your happiness, that’s quite a dilemma: “If I’m happy, then I’ll hurt Mom.” It’s especially a dilemma now, as you’re trying to get through the last semester of your senior year, when there are a lot of opportunities for some happiness, or just a bit of fun.

Xiu again allows some silent space between words. He then asks, “What about Kyle?” Kyle’s posture changes on hearing this question. He sits up straighter, indicating some interest in this question. He is vaguely aware that this issue is a theme they have touched on before, and on some level, he is grateful to have someone asking, “What about you?”

ConCLuding remArks

When working with this treatment approach, we can address the domains of life affected by the traumatic death in various ways. We will want to assess which domains of life have been most disrupted or are most problematic as a result of the client’s loss. For Kyle, the dynamics within his nuclear family, his relationships with friends, and his ability to experience pleasure and leisure have all been dramatically affected by Jeff’s death. As Xiu has demonstrated in his work with Kyle, we also want to explore the client’s inner experience in relation to these situations. What are his reactions? What is he telling himself about the situation? Which psychological needs are being activated? How are the client’s self-capacities being tapped or challenged? Furthermore, are these elements of inner experience helping or hurting him in his ability to cope, adapt, and move forward, both in general and within specific domains of his life? Finally, we’ll want to explore how best to assist clients in adapting to and accommodating the changes they now face. In other words, we want to help clients develop healthy adaptations – those that support rather than inhibit the evolution of their mourning. Xiu again demonstrated how this can be done through examining Kyle’s inner experience and helping him to confront difficult situations and practice coping strategies.



Part iii. risk factors and related evidence






chapter 5. event-related Factors

Just as she did most other afternoons, Suzanne, a single mother, walked into her house at about 4:00 P.M., threw her bag and keys on the credenza, and called out to let her teenage daughter know she was home from work. Unlike other afternoons, there was an eerie silence in the house; once she entered the kitchen, Suzanne felt a chill throughout her body. She hadn’t heard her daughter answer in her usual fashion. Suzanne would later describe this as “a feeling deep down in my bones that something was wrong.” Suzanne doesn’t remember the rest of that afternoon in any detail. She knows that she became more frantic when she entered her daughter’s empty room and then began searching the house for clues to her whereabouts. They had spoken just hours before, as they did every afternoon, to confirm that her daughter would be home. Suzanne remembers that Sarah’s voice had sounded strange, but she had chalked that up to adolescent moodiness. Suzanne also remembers her own horrific screams – although at the time she experienced them as though they were coming from someone else – when she descended to the basement to find Sarah dead. An empty prescription bottle for oxycodone lay next to her.

In this chapter, we continue a comprehensive description of traumatic bereavement. We focus on two sets of factors that influence how individuals experience and express traumatic grief: the characteristics of the death, and the type or mode of death. These dimensions are referred to as risk factors, since they typically affect the survivor’s risk of a poor outcome. Each mode of death (e.g., accident, homicide) incorporates one or more of the characteristics of deaths (e.g., violence, randomness) described below.

Awareness of risk factors can provide a framework for understanding each client’s thoughts, beliefs, emotions, behaviors, and vulnerabilities. Such information is invaluable in identifying specific issues that clients who have endured a particular type of loss often face. Following the violent death of a child, for example, it is common for the surviving parent(s) to struggle with intrusive thoughts about the unfairness of the death. Such images are usually less common following other kinds of losses, such as a spouse’s fatal heart attack. Therapists who have a keen understanding of these issues will be in a better position to validate their clients’ feelings, enhancing the likelihood that clients will feel heard and understood.

Characteristics of The death

In Chapter 1, we defined a sudden, traumatic death as one resulting from a precipitating event that is abrupt and occurs without warning. In this chapter, we discuss many characteristics of a death that, when present either individually or in combination, are likely to add to the impact of suddenness and lack of anticipation, and to precipitate traumatic bereavement in a survivor. There is empirical support for some of these elements, such as violence. Other factors, such as multiple deaths, have yet to be investigated systematically. In such cases, our discussion is based primarily on clinical observations – our own and those of other treatment providers. In discussing these elements, our goal is to elucidate the specific ways they can traumatize the mourner. Such knowledge can be indispensable to therapists in developing a treatment plan tailored to their clients’ unique concerns.

Evidence suggests that the impact of the risk factors discussed below is cumulative. However, the intensity of a mourner’s response to any specific risk factor depends on his subjective assessment or cognitive appraisal of the situation. Sometimes one factor (e.g., how much the loved one suffered just prior to death) brings more distress than others. This is why the therapist must focus not only on the array of event- related factors that are present in the situation, but on the client’s unique responses to particular factors.

In exploring the impact of characteristics of the death, it becomes clear that some characteristics overlap with others. For example, unnatural deaths are usually violent. We have elected to discuss each characteristic individually, despite the overlap. This enables us to paint a more complete picture of the potential ramifications of the different kinds of death.


An unnatural death is markedly different from natural dying and typically prompts more extreme responses in a mourner (Rynearson & Geoffrey, 1999). In almost all cases, violent deaths are unnatural. The more unnatural the death, the more difficult it is for the survivor to integrate it into his inner life. There is a lack of any comfort that could be taken if this were a death that was anticipated and regarded as an appropriate exit from life. As Rynearson (1987) noted, “the peaceful dying of someone ringed by nurturing relatives is categorically distinct from the brutal dying of someone who is stabbed repeatedly by an assaultive thief or someone who is hit in a crosswalk by a drunk driver, or someone who is partially decapitated by a self- inflicted gunshot wound” (p. 78). The more unnatural or grotesque the specific circumstances of the death (such as a dismembered body), the more it breaches the survivor’s sensibilities, and the more it interferes with healthy mourning (Rynearson, Schut, & Stroebe, 2013). In addition, mourners are more likely to view an unnatural death (e.g., one resulting from suicide or an accident) as “a senseless and wasteful loss of life” than a natural death (e.g., one resulting from illness) (Bailley, Kral, & Dunham, 1999, p. 267).


A large majority of sudden, traumatic deaths involve at least some violence. Mutilation or destruction often accompanies deaths involving violence. They are particularly traumatic because of the feelings they typically engender in the survivors: shock, horror, helplessness, vulnerability, anxiety, violation, and victimization (Rando, 1993). In most cases, such reactions lead to significant physiological hyper arousal, anger, guilt, and self-blame. Violent deaths rupture mourners’ senses of invulnerability, security, predictability, and control, viciously violating their assumptive worlds (described in Chapter 3). In addition, they tend to undermine the mourner’s ability to think or speak about the experience coherently. This, in turn, makes it far more difficult to process the loss and come to terms with what has happened (Currier, Holland, & Neimeyer, 2006). Consequently, there is a high risk of mental health problems following the violent death of a loved one (see Hibberd, Elwood, & Galovski, 2010, for a review; see also Rynearson & Salloum, 2011).

In most cases, violent deaths bring about posttraumatic stress symptoms (Green et al., 2005; Rynearson, 1987, 2001). Clients typically experience traumatic imagery that can be overwhelming and unresponsive to treatment. Of course, violent deaths result not only in intense and prolonged trauma symptoms, but in grief symptoms as well (see, e.g., Kaltman & Bonanno, 2003; Zisook, Chentsova- Dutton, & Schuchter, 1998). Kaltman and Bonanno (2003) found that, in contrast to people whose spouses died of natural causes, those who experienced the violent death of their spouse manifested significantly more PTSD symptoms during the 2-year duration of the study. Those who lost their spouse through natural means showed a decline in depressive symptoms over time, whereas those who lost their loved one through a violent means showed no drop in depressive symptoms over the course of the study (see Currier et al., 2006, for similar findings).

In some cases, a survivor may have harbored aggressive thoughts or fantasies toward a deceased person prior to the death. For example, upon learning that her husband is having an affair, his wife may have recurrent fantasies about harm befalling him. If so, his actual death may bring about feelings of guilt (Raphael, 1983), perhaps more so if the death is violent. Similarly, Raphael (1983) has asserted that violent deaths evoke primitive destructive fantasies and reawaken basic death anxiety and fears of annihilation, leaving survivors with these additional stresses to master. Horowitz (1997) maintains that in some cases, violent deaths evoke a powerful desire for retaliation. As we have noted earlier, survivors often imagine killing or torturing the perpetrator, and feelings of guilt sometimes follow these thoughts. Moreover, such deaths inevitably conjure up images of whether and how the deceased may have suffered. These images add enormously to the mourner’s distress.

As noted in Chapter 3, in 95% of violent deaths from suicides or homicides, the persons die alone, in the absence of loved ones (Rynearson, 2005; Rynearson & Salloum, 2011). Survivors of such a death are at risk for being stuck in what Rynearson terms the reenactment story of the death. According to Rynearson (2005), survivors piece together this story from the media and from police and witness descriptions. It is common for survivors to replay this reenactment repeatedly in their minds.

Physical or emotional suffering before death

Sometimes there is evidence that a loved one suffered, as when witnesses at the scene heard screams of anguish prior to the loved one’s death, or when the medical examiner provides evidence that the death was not instantaneous. In other cases, a mourner may strongly suspect that a loved one suffered because of the way the death occurred. Regardless of how the events leading up to traumatic deaths unfolded, most survivors are concerned that their loved ones may have suffered. Thoughts about suffering are distressing because of the mourners’ helplessness in the face of what happened (a challenge to schemas about control), the anger and guilt that result from the helplessness, and the associated imagery. As noted above, it is common for mourners to have elaborate and detailed thoughts about their loved ones’ final moments, focusing on such things as whether they died in a state of fear or terror, experienced physical pain, or called out for the mourner as they were dying. As noted previously, some survivors become trapped in a repetitive cycle of imagining the suffering and death of their loved ones. Others may avoid thinking about the death to such an extent that the third “R” process of mourning (Recollect and re-experience the deceased and the relationship) does not take place.

human-induced events

Although few comparative studies exist, available evidence suggests that it is more traumatic for people to contend with a human- induced tragedy than a natural one, such as an earthquake or tsunami. An exception to this occurs when humans cause a “natural” event, as was the case when poorly constructed levees gave way during Hurricane Katrina in 2005. The lack of an adequate response to an emergency or disaster, as with Hurricane Katrina, can also contribute to its psychological effects. A truly natural event usually brings forth relatively less anger and fewer violations of the survivors’ assumptive world, although there still can be challenges, such as being left without a specific target for blame and anger (Rando, 2013). Two types of human- caused deaths create particular difficulty for survivors: those that survivors regard as preventable, and those that they view as intentional. Each of these types of deaths poses unique issues for the mourners.

Deaths regarded as Preventable

Once a mourner receives information about a death, she may conclude that it occurred because of the negligence or carelessness of someone else. For example, there may be evidence that the pilot of a small plane was talking to co- workers and not paying attention, resulting in a fatal crash. Or a doctor may breach the standard of care by failing to prescribe needed antibiotics to a young boy who visits his office, resulting in seizures that prove fatal. Mourners are likely to view such deaths as senseless and unnecessary – in other words, as preventable. The fact that a mourner perceives a death as avoidable can cause him to ruminate about how someone, including himself, could have prevented it. For most survivors, such deaths raise issues of responsibility and accountability. They also affect the survivors’ ability to trust and depend on others. For example, a man whose partner dies because of medical malpractice may want the physician to be held accountable for what she did. He may be devastated to learn that she will not be penalized and will still be allowed to practice medicine. It is typical for survivors to experience profound anger that such deaths occur, as well as feelings of anger and bitterness at the persons perceived to be responsible (Kristensen et al., 2012). It is also common for mourners to struggle with the injustice and unfairness of what has happened.

Complications following the loss may be greater in those cases where the behavior of the person(s) perceived as having caused it is more imprudent and/or unreasonable. In one case, a pedestrian was killed by teens who were joyriding in a parent’s car. If the accident had occurred because an elderly woman temporarily lost control of her car, traveling just far enough onto the shoulder of the road to kill the deceased, fewer complications might have ensued for the survivors. The death of a loved one may also be more difficult to process in those cases where the perpetrator’s negligence occurred on a regular basis and/or resulted in financial gain. This might occur in a death brought about by a trucking accident. If the trucking company routinely cut costs by hiring unqualified and inexperienced drivers, survivors may have great difficulty coming to terms with the loss.

In some cases, the deceased’s own behavior contributes in some way to her death. For example, a teenager may sneak out of the house to take a ride with her boyfriend, and then die when he loses control of the car. In such cases, her parents’ feelings of intense anger toward their daughter, as well as feelings of guilt, are likely to add to their distress because they view the accident as preventable. The perceived preventability of the death has violated their control schemas.

Deaths caused by a Perpetrator with intent to Harm

As noted above, psychological symptoms are particularly severe and long- lasting when the cause of death is of human design and conscious intention, as opposed to being a natural event or an accident. Homicide and suicide are examples of such deaths, and each type presents mourners with more potentially traumatizing elements than preventability alone. In addition to violating the mourners’ assumptions about predictability, safety, and control, such elements are likely to undermine their trust in other people (Janoff-Bulman, 1988). In many such cases, the mourners view such deaths as evidence for the existence of evil forces in the world. According to Janoff- Bulman, an exaggerated sense of powerlessness and helplessness, along with a sense of “losing” a loved one to another human being, can elicit humiliation, shame, and a loss of self- respect. Outrage at the audacity of someone who takes a loved one’s life can also be difficult to manage. We discuss homicide and suicide in more detail below.


In some cases, survivors believe that their loved one died because she was in the wrong place at the wrong time. For example, Gretchen was scheduled to fly back to her home town following a business meeting in another city. The meeting ended early, so she was able to book an earlier flight. She was killed when the plane crashed. It was agonizing for her husband and parents to recognize that if she had taken a different flight, she would still be alive. Random events are frightening because they are uncontrollable; individuals cannot protect themselves from such events. For this reason, survivors sometimes assume blame for random events. It is easier for mourners to cope with such an event by taking responsibility for it, believing that they are in control of their lives, than to contend with the fact that they had no control. In such situations, the assumption of blame and of the consequent guilt is the price one pays to maintain the needed perception that the world is controllable. For example, Gretchen’s husband might assume responsibility for her death because he had asked her to get home as soon as she could.

A related set of dynamics operates in a phenomenon called blaming the victim (Ryan, 1976). Here a survivor attempts to remove the event from the realm of a random occurrence by identifying what the deceased should have done or not done so that the event would not have taken place. Beliefs that contribute to victim blaming can be held not only by a survivor, but by acquaintances, friends, and family members of the deceased. For example, people may assert that “If she hadn’t gone out alone at night, she wouldn’t have been raped and murdered,” or “If he’d worn his seat belt, he would not have been killed in the car crash.” They derive some illusions of predictability and control by claiming that if they act differently than the deceased did (e.g., not going out alone at night), then they can avoid future tragedy (e.g., not being raped and murdered). Victim blaming by others can complicate the survivor’s loving attachment to the deceased, creating ambivalence and guilt in the survivor, who does not want to hold blame toward the deceased loved one.

multiple deaths

We use the term multiple deaths to refer to cases where two or more loved ones die in the same event. Such deaths may stem from a natural or human- induced disaster, from a motor vehicle crash, from a murder – suicide scenario, or in cases of mass violence (such as a shooting episode in a public setting). In most cases, multiple deaths create a state of bereavement overload (Kastenbaum, 1969; Rando, 1993, 2013), and are consequently more difficult to handle than the death of a single loved one or even two sequential deaths. The process of mourning for one person often compromises the process of mourning for a second person. A vicious cycle often exists wherein the survivor is unable to mourn the death of Person A in the best way because of the emotions, unfinished business, and remaining reactions connected with Persons B and C. Each of these deaths, in turn, cannot be mourned adequately because of the incomplete mourning and stress associated with the death of Person A.

Situations involving multiple deaths raise a number of challenges. Multiple deaths are often associated with such a deluge of pain that a survivor is unable to function. Multiple deaths can also engender psychic numbing (Lifton, 1976), which can interfere with engagement in mourning processes. The mourner may also experience survivor guilt because she did not die. She may come to believe that her continued existence has been purchased at the cost of the loved ones who died. In addition, multiple deaths may have an adverse effect on the mourner’s social support system. In many cases, one or more persons to whom the mourner would ordinarily turn for support have also been killed. Others in the social support network may also be incapacitated by grief and trauma symptoms, and thus may be less available. For all of these reasons, multiple deaths are likely to interfere with the six “R” processes of mourning. Such processes as facing the pain, mourning secondary losses, and relinquishing attachments are far more difficult when the survivor is mourning the deaths of two or more people.

Multiple deaths can also be complicated for survivors who lost only one loved one, but also acquaintances, neighbors, or other community members. This instance includes shootings in public settings such as schools (as in Newtown, Connecticut, in 2012) and movie theaters (as in Aurora, Colorado, also in 2012). In such a case, a whole community will be affected. An individual mourner’s private grief becomes part of a larger narrative. Such events also tend to attract major media attention, including anniversary commemorations. Although mourners may experience additional support in such cases, they alternatively may find that their mourning is taken over by the community, which may choose ways to mourn or commemorate the deceased that do not meet any individual mourner’s needs or style.

Threat to one’s own Life; Confrontation with the deaths of others

In some cases, a mourner’s own life is threatened during the incident in which a loved one dies. For example, a couple may be involved in a car crash in which the husband dies, while the wife sustains serious injuries but survives. A scenario of this kind faces the survivor with a host of coping challenges. These often include watching the loved one suffer and die, and then struggling with subsequent gruesome images of the scene of the accident. If the loved one dies instantly, the survivor may feel heartsick that she was unable to tell him that she loved him and to say goodbye. The survivor may also experience guilt that she was not able to take some action that would have prevented the accident. In such situations where there was a threat to survival, the more the survivor experienced this life threat and thought she was going to die in the situation, the more emotional reactions, traumatic stress symptoms, and potential long-term problems she may have.

Being present at the scene of the loved one’s death has the potential to bring the survivor into contact with the deaths of many people. One’s presence at the scene typically results in a highly aversive sensory bombardment in terms of sights, smells, sounds, and kinesthetic feelings. Examples of such situations include air crashes, natural disasters, and war (Rando, 1993). Common responses include shock, horror, terror, helplessness, anxiety, and fear. Such factors as the sheer number of dead bodies encountered, as well as the extent of damage or mutilation to the loved one’s body, can increase the horror of the situation. These stimuli can evoke overwhelming traumatic stress responses, including hyper arousal, numbness, intrusive images, flashbacks, avoidance, and extreme vulnerability.

As Kristensen, Weisaeth, and Heir (2009) have noted, those who are directly exposed to a disaster and experience a threat to their own lives are far more likely to develop PTSD than those who are not directly exposed to the disaster. This will be the case for those who survive shootings in schools and other community gathering places. Such survivors may need to review and re-experience the event in their thoughts, as well as to defend against it by avoiding it or shutting it out. Clearly, such personal confrontations with death, which raise the deepest questions about the meaning and value of one’s life, can have a profound impact on the process of coping with the death of an important other (Rando, 1993).

According to Rynearson (2010), approximately 5% of violent deaths are witnessed by survivors. This may occur in a variety of different situations. For example, those who are present at the scene of a mass shooting at a school or movie theater may witness others’ deaths. Or, following a motor vehicle crash, the driver may witness the passenger’s death (or vice versa) while they are waiting for help to arrive. Evidence suggests that witnessing the death results in a significant increase in PTSD symptoms (see Kristensen et al., 2012, for a review). For example, Brent and colleagues (1992) found that survivors who witnessed the suicides of their loved ones or found the bodies had more PTSD symptoms than those who did not.


When a young person dies, we typically feel that he has not had the opportunity for the kind of fulfillment in life to which he was entitled. It is a death “out of turn with nature” because it happens at an inappropriate stage in the natural life cycle. Such deaths violate many of our assumptions about the world, particularly those related to our worldviews. Losses of this sort are often associated with powerful feelings of injustice, intense anger, and anguish because of the termination of a life that had unrealized potential. Because of the person’s youth, survivors may experience more numerous and poignant secondary losses, such as seeing the person taken from life before achieving important goals (e.g., seeing his business succeed) or before fulfilling responsibilities that were important to him (e.g., raising his young children). Moreover, bereaved persons are also likely to mourn for other survivors who are dealing with the death of the same person. As one woman commented following the death of her husband, “I grieve for my husband, but I also grieve for my son. He was hoping to get a baseball scholarship to college. My husband coached his team for many years and practiced with him every weekend. Now there is no one to fill this role, and my son is thinking of dropping out of baseball. The loss to my son is incalculable. He has not only lost his father; he lost the confidence he had that he would make it to the top.”

Additional factors

Many additional characteristics of the death can exacerbate a mourner’s distress (Rando, 2013). Some of these have to do with the perpetrator’s behavior. If it is clear that the death resulted from the actions of a specific person, survivors typically become angry if he does not acknowledge what he did. Survivors also find it deeply troubling when the perpetrator expresses no remorse for what has happened. In many cases, perpetrators’ lawyers may have advised them not to admit responsibility or blame for the incident that resulted in the loved one’s death. Survivors may not be aware of this, and may believe that the defendant is “getting away with murder.” As one mother expressed after her son’s car was sideswiped by a truck driver high on amphetamines, “If he would have just looked me in the eye and said he was sorry for what he did, it would have brought me a lot of comfort.”

Sometimes the survivor will encounter the perpetrator somewhere in the community – the grocery store, the movie theater, the park. One woman lost her 7-year-old daughter when the dentist administered too much anesthesia. “He killed my daughter, and is still practicing dentistry. But today at the park, I saw him pushing his own daughter on a swing, without a care in the world.”

Other characteristics of the death that can complicate the mourning process include waiting for confirmation of the death; failing to recover the body; finding the injured or dying person still alive; and being notified about the death insensitively. Additional experiences that can exacerbate grief include having upsetting encounters with police, emergency medical staff, doctors, or nurses at the hospital, or personnel at the medical examiner’s office or the funeral home. These experiences can become part of the survivor’s narrative of the death, and are therefore legitimate targets for intervention in the therapy.

The process of identifying the loved one’s body or viewing the body for the first time can result in long-term traumatization of the bereaved. When people receive notification that a loved one has died, several scenarios may ensue. In some cases, survivors are told that a member of the family must identify the body. In other cases, survivors are strongly discouraged or even prohibited from viewing the body, even if they have a strong desire to do so. This directive may come from officials at the police department or coroner’s office, who usually prohibit contact with the body when there is an ongoing criminal investigation. There are also cases in which one or more family members may strongly advise a mourner not to view the body. As one father explained following the death of his daughter in a shooting accident, “Jennifer’s skull was shattered by the impact of the bullet. Nonetheless, my wife expressed a strong desire to be with Jennifer. I did everything I could to dissuade her. I wanted her to remember our daughter the way she was.” Alternatively, a family member may encourage another to view the body, even if that person does not wish to do so.

Available research suggests that there are strong individual differences in survivors’ desire to view the body, and in the impact of viewing the body on later adjustment (Chapple & Ziebland, 2010). Particularly after the death of a child, parents often have an overwhelming desire to be with their child’s body, and to retain their role of caring parents. As one researcher described it, “We were surprised that so many expressed such an intense need to see, touch, hold, talk, or sing to the body” (Bower, 2010, p. 10). Many parents appear to draw comfort from such activities as washing and dressing their child. Survivors also value being with their loved one’s body because it provides an opportunity for them to say goodbye. Still others felt that they would not be able to accept the reality of the death unless they view the body.

In many cases, survivors are extremely distressed that officials or other family members do not permit them to have time alone with the deceased. Instead, they are required to endure the presence of a police officer or someone from the coroner’s office.

The first time bereaved persons encounter their loved one’s body is usually at the funeral home. Even in cases where there is little visible damage, it is common for survivors to feel disconcerted by their loved one’s appearance, frequently commenting that “It didn’t look like him at all.” In cases where there is more damage to the body, many are unprepared for the shock they experience when they view the body. As one mother indicated, “The funeral director did a good job, but there was only so much he could do. I brought my daughter’s favorite dress, but we couldn’t use it because it did not hide the bruises on her neck and arms, or the autopsy scar on her chest.”

In cases involving sudden, traumatic loss, survivors typically benefit from viewing the body, even in cases where the body is badly damaged (Bower, 2010; Chapple & Ziebland, 2010). Those who decided to view the body had better outcomes and were less likely to regret their decision than those who chose not to view the body, who were more likely to regret their decision.

Overall, evidence suggests that the determining factor about whether viewing the body is ultimately a good idea may have to do with whether the survivor is encouraged, or at least permitted, to do what she chooses. Those who choose to view the body are likely to believe that they made the right decision, especially as time passes. Regrets are more often experienced by individuals who decide not to view the body. A central dynamic of trauma is loss of control, so when survivors are able to resume control following a terrible event or experience, recovery can begin. Being thwarted in one’s preferences about viewing the body or spending time with the deceased continues the experience of loss of control.

In our experience, no matter how upset a survivor may be about what happened when he viewed the body, he is unlikely to raise these issues with members of his support network. Consequently, creating space in therapy where these issues can become legitimate topics of discussion and intervention can be highly beneficial to the client.

mode of death

How does the mode of death influence the impact of a traumatic death? Are mourners who lose loved ones to suicide, for example, likely to experience more intense and prolonged distress than those who lose loved ones in motor vehicle accidents? Most of the studies assessing mode of death have focused exclusively on parents who lost children (Dyregrov et al., 2003; Murphy et al., 1999; Murphy, Johnson, Wu, Fan, & Lohan, 2003), although a few have examined survivors who lost spouses, siblings, parents, or friends (Cleiren, 1993; see Sveen & Walby, 2008, for a review). Those studies that have compared the impact of different modes of death have found fewer differences than they expected.

A study by Murphy and her associates compared parents who lost a child through homicide, suicide, or accident. They assessed parents four times over a 5-year period. Parents of children who were murdered reported a significantly higher number of PTSD symptoms than parents whose children committed suicide or died in accidents. Otherwise, there were very few differences in parents’ psychological reactions as a function of the mode of death. These investigators found that 5 years after the loss, parents’ responses on objective measures of mental distress and trauma were two to three times higher than those from normative samples of adults, regardless of the children’s mode of death (Murphy et al., 1999; Murphy, Johnson, Chung, & Beaton, 2003; Murphy, Johnson, Wu, et al., 2003).

Dyregrov and colleagues (2003) studied parents who lost children to suicide, accident, or SIDS. They interviewed parents 1½ years after the deaths. They found that the majority of these bereaved parents evidenced severe psychosocial distress on virtually all measures used. Parents bereaved as a result of suicide or accidents evidenced significantly more problems than those who lost infants to SIDS. In particular, parents whose children committed suicide or who died in accidents were more likely to experience intrusive thoughts. Dyregrov and colleagues noted that the results of the study do not support the idea that loss of a child by suicide is worse than loss by other modes of death. In addition, they emphasized that although distress scores were reliably lower for parents of infants dying of SIDS than for the other groups, they nonetheless manifested very high distress. Taken together, the results of these two studies indicate that the sudden, traumatic death of a child brings about enduring distress among surviving parents, regardless of the cause of death.

Despite these findings, we believe it is important to provide information about the psychological ramifications of distinct modes of death. This material will help practitioners to respond to clients with greater awareness of the issues they are facing. Below, we highlight issues that affect the mourning process in response to acute natural death, accidents, disasters, military combat, homicide, and suicide. Each mode of death incorporates one or more of the characteristics of deaths described earlier in this chapter.

Acute Natural Death

Deaths brought about by acute natural causes, such as heart attack, stroke, aneurysm, acute illness, or infection, confront survivors with an unanticipated loss. For example, a spouse may suddenly die of a heart attack, or a child may die because of meningitis. Although survivors of such losses usually experience fewer intrusive, disturbing memories than do survivors of other kinds of traumatic deaths, this is not always the case. For instance, if the loved one is hooked up to tubes and gasping for breath during his final moments of life, these images can return to the mourner as intrusive reminders.

In deaths that result from acute natural causes, clinicians and other providers must be sensitive to whether the survivors view the deaths as preventable, since such perceptions can complicate the mourning process. Some mourners may believe that a loved one is responsible for the death – for example, when a person failed to take necessary medication, exercise, or eat a healthy diet. Others may place responsibility on members of the medical staff who they believe did not do enough to save their significant other. In these situations, some survivors may struggle with powerful feelings of anger after the loss. Still others may blame themselves. For example, a mother may blame herself for her child’s death if the child had a high fever but she did not take him to the emergency room. In such cases, feelings of guilt are likely to plague the survivor.

Event-Related Factors


Motor vehicle crashes are the most prevalent cause of traumatic death. Survivors may also face such deaths as a result of firearms, falls, drowning, fires, choking, animal attacks, hazards at the workplace, and medical malpractice, among numerous other types. Most, but not all, of these accidents occur suddenly and without warning. Accidents occur at disproportionately higher rates among children, adolescents, and young adults (Heron, 2012), enhancing the likelihood that accidental deaths will be perceived by survivors as untimely. Motor vehicle crashes are more than twice as likely to claim the lives of African American or Hispanic male teenagers as those of European American teens (Armour, 2006). Accidental deaths are often associated with violence, mutilation, and destruction. In many cases, those who lose a significant other in an accident struggle with gruesome images of what happened, as well as fears that the deceased may have suffered.

We normally think of an accident- related death as constituting a sudden loss. Yet, as Armour (2006) has indicated, over half of those who die in motor vehicle crashes dieen route to the hospital or during the first few weeks of hospitalization. In such cases, what does or does not take place in the hospital often becomes a critically important part of the dying-and-death story with which the survivor must contend (Rando, 2013). A survivor often finds the hospital experience to be profoundly disturbing. The traumatic event may have bruised and battered the loved one. He may be hooked up to tubes, ventilators, and other life support machines. The family members may have difficulty obtaining medical information. They may have agonized about whether health care providers are doing everything possible for their loved one. In many cases, the hospital staff is not able to control the patient’s pain or keep him comfortable. Witnessing their loved one’s suffering in such a setting not only exposes mourners to intense emotional distress, but can also provide an additional source of disturbing images, smells, and sounds that can resurface later. Depending on what they are told, family members may alternate between hope and despair. In a case where heroic measures such as cardiac paddles are used, survivors may experience anguish if the deceased had to endure these procedures but dies anyway (Rando, 1993).

Another potential source of traumatization is that family members are often required to make a decision about is taking a loved one off life support. Regardless of the extent of their loved one’s injuries and their implications for future quality of life, most people find it agonizing to take someone they love off life support and watch him die. It is also common for survivors to experience doubts in the future about whether they made the right choice.

Decisions about donating the loved one’s organs can also be unsettling and retraumatizing. “I kept thinking about them cutting out her organs,” said one father who lost his daughter in a bicycle accident. “I know it was for a good cause, but I still found it horrifying” he said. At this point in time, most survivors have not yet accepted their loved one’s death, so assaults on the loved one’s body are difficult to endure.

In a case where an accident comes about in part through the deceased’s own behavior – for example, if she has been drinking and driving – survivors may experience intense anger toward their significant other. Such feelings may be accompanied by guilt over this anger, as well as guilt that the survivors were unable to influence the deceased’s behavior and hence prevent the fatality. Such feelings are common among parents of teenagers or young adults, who often feel that if they had been more effective as parents, the tragedy would not have occurred. As one father indicated, “Our son had problems with alcohol and drugs. We tried to get him into treatment, but he was very resistant. One night after drinking several beers, he took the family car without our knowledge and was killed when the car went off the road. If we had been successful in getting him into a treatment program, this never would have happened.”

In cases where the surviving mourner was also injured in the accident that caused the death, it may be very difficult to commence the mourning processes. If injuries are permanent, they may serve as a perpetual reminder of the other’s death. Of course, there are also cases in which the death of a loved one comes about because of the mourner’s behavior. For example, a father might decide to purchase a gun and keep it in his night stand. His decision could prove fatal if his 10-year-old son discovers the gun and is accidentally killed when it misfires. As discussed in Chapter 3, mourners typically experience powerful feelings of guilt even in cases where they played no role in their loved ones’ deaths. Such feelings are paramount when a death comes about because of a survivor’s poor judgment. Research shows that feelings that one could have done something to avoid the death are associated with increased PTSD risk and prolonged feelings of grief and depression (Kristensen et al., 2012).

In some cases, mourners perceive accidents as preventable. As Armour (2006) has indicated, the police classify a large percentage of deaths from motor vehicle crashes as due to the negligence of other drivers, suggesting that such deaths were preventable. Crashes in which perpetrators were speeding, driving under the influence of alcohol or other substances, or driving while using cell phones or texting are just a few examples. In such instances, the perpetrators may be arrested and face criminal prosecution. However, as described in Chapter 4, people who cause motor vehicle accidents are rarely held fully accountable for what they have done. They may receive small fines, or their licenses may be revoked for a few months, but in our experience they are almost never sent to prison.

In other cases, survivors may perceive an accident as a random event, in which the loved one was “in the wrong place at the wrong time.” One man was killed in a motor vehicle crash on his way to work. He proceeded into the intersection when the light turned green, and was struck and killed by a driver who was trying to run the light. On the day of the accident, his boss had asked him to come in to work 10 minutes early. “If that request had not been made, my husband would still be alive,” his wife said. As noted above, the belief that the death was random is painful, because survivors feel that they have no control over their lives and are at the mercy of fate or other people.

Survivors’ struggles may relate very specifically to particular aspects of a death. Those who lose a loved one in a motor vehicle crash may develop profound anxiety about driving. If their loved one died in a crash caused by a truck driver, they may experience intense fear when a truck comes up behind them on the highway. They may also become particularly fearful when other loved ones are traveling by car. As one young man expressed it, “After my dad was killed in a car crash, my mom wanted me to transfer from the college I am attending now, which is about a 4-hour drive from our home, to a college in our home town. She told me that if I don’t transfer, she doesn’t want me to come home on weekends any more.” Similarly, if the deceased loved one drowned, survivors may fear the water and refuse to go swimming or to accompany others to a beach or pool.


Disasters are usually classified as one of two types: natural disasters, such as hurricanes or earthquakes; or human- induced disasters, such as the terrorist attacks against the United States on September 11, 2001. In most cases, survivors view natural disasters as unavoidable, although they may feel that attempts to warn them about the disasters or to contain the ensuing destruction were insufficient. Survivors are likely to view human- induced disasters as due to human callousness or malevolence, and perhaps preventable as well (Kristensen & Pereira, 2011). Consequently, they may experience feelings of rage and bitterness toward those they perceive to be responsible (Christ, Kane, & Horsley, 2011). Attributions of malevolence often challenge survivors’ beliefs about the inherent worth of others.

Regardless of how disasters come about, they pose a unique set of issues for the mourners. Following a disaster, there is usually an agonizing period of waiting before survivors learn that their loved one has died. At that point, most mourners experience an overarching need to gain possession of their significant others’ body. They may encounter many obstacles, such as bureaucratic processes of the county, state, or nation, as well as coroners’ inquests. It can take weeks, or even months, to recover the body. Depending on the nature and magnitude of the disaster, the body may never be found, or it may not be found in recognizable form. In cases where the body is not intact or is not recognizable, survivors often struggle with intense anguish about whether their loved one suffered in her final moments. In those cases where there is no opportunity to see and recognize the body, it is harder for survivors to accept the reality of the death. Understandably, the absence of the body is likely to fuel disbelief, making it extremely difficult for the mourning process to begin.

In the course of a disaster, bereaved survivors may experience threats to their own lives or may witness gruesome scenes involving the deaths of others. Survivors who are exposed to the disaster that claims their loved one’s life show more PTSD and prolonged grief symptoms than do those who were not exposed (Johannesson, Lundin, Hultman, Frojd, & Michel, 2011).

Following a disaster, survivors are also likely to encounter many secondary losses in addition to the death of their loved ones. As a result of Hurricane Katrina, the tsunamis of 2005 and 2011, the 2010 earthquakes in Chile and Haiti, and the 2011 earthquake in Japan, for example, many people faced multiple enormous losses – their homes, neighborhoods, possessions, money, and/or jobs. These losses typically bring the mourners into contact with insurance companies, federal agencies, and/or relief and assistance agencies, which they may experience as nonresponsive and highly bureaucratic. The lack of an adequate or appropriate response can cause a “second injury” (Symonds, 1980) that may exacerbate survivors’ distress and must be addressed as well. A recent book on treatment for survivors of disaster (Dass-Brailsford, 2010) provides helpful information about what survivors experience and how they can be assisted.

A major disaster is also likely to be covered in the mass media for months and sometimes years following the event, as well as commemorated or at least noted annually, evoking painful and disturbing thoughts and images. Following the 9/11 catastrophe, for example, images of the collapse of the Twin Towers were televised repeatedly. Moreover, the attacks have been commemorated on a yearly basis. Finally, in those cases where the disaster affects the entire community, survivors can be overwhelmed by the loss of many individuals who played an important role in their lives. This was true in 9/11, when surviving firefighters and their family members faced the deaths of dozens of their friends and co- workers. Many firefighters reported that attending multiple funerals and commemorative events was extraordinarily difficult (Christ et al., 2011). It was also the experience of the Newtown, Connecticut community, when numerous funerals of young children and their teachers followed the horrific school shooting. As described earlier, this type of situation can result in a state of bereavement overload, in which the sheer number of deaths makes it difficult to mourn any one death. Opportunities for social support are often limited in such settings, since most of a person’s usual support providers are either deceased, or stretched to the breaking point as they try to deal with their own losses.

military Combat

Surprisingly few studies have focused on the impact of losing a loved one as a result of military action. Much of what we know about how such losses affect survivors comes from studies conducted in Israel (see, e.g., Rubin, Malkinson, & Witztum, 1999). For the most part, these studies have focused on Israeli parents who lost a son in a war. An interesting feature of this work is that it has examined the long-term impact of war deaths. For example, Rubin (1990) studied parents who had lost a son in a war on average 9 years earlier and compared these respondents to parents who had lost a 1-year-old son to illness (see also Malkinson & Bar-Tur, 1999; Rubin, 1992). Parents who had lost a son in a war manifested higher levels of grief, and they remained attached to their sons despite the passage of time. This body of research suggests that the emotional ramifications of war deaths can last for years. In these studies, parents rarely discussed their feelings with others and typically bore their grief alone. Of course, it is not clear whether these findings will generalize to those who have experienced the death of a loved one in other military conflicts, such as the wars in Iraq and Afghanistan. The generalizability of these findings may depend in part on the nature of each war and the extent of public support for it.

A recent study by Morina, von Lersner, and Prigerson (2011) focused on how young adults were affected by the deaths of their fathers as a result of fighting in the Kosovo War. These investigators interviewed a large number of bereaved young adults and nonbereaved young adults. Interviews were conducted a decade after the war. Bereaved participants scored higher than the nonbereaved on several indicators of mental distress, including depression, anxiety, and PTSD.

How do war deaths differ from other kinds of losses, and what are some of the unique stressors survivors face? Harrington-Lamorie and McDevitt- Murphy (2011) conducted an excellent review of the information available on these questions. As these authors explained, the U.S. Department of Defense categorizes war deaths as resulting from hostile action, accidents, homicide, illness, suicide, terrorist attack, or undetermined. Over the past 10 years, the leading causes of death in the Iraq and Afghanistan wars have been hostile actions and accidents.

It is clear that factors known to enhance the negative psychological impact on survivors characterize the majority of war- related deaths. Combat deaths as well as accidents are likely to involve violence and mutilation. In addition, such deaths are almost always untimely. The average age of soldiers killed in combat is 24 years. Consequently, deceased soldiers who were married are likely to leave behind young families. Surviving military spouses, typically in their 20s, are unlikely to have experience dealing with death (George, Elliott, Jennings, Cleland, & Brown, 2009). Moreover, it may be difficult for them to identify other young people who have experienced the death of their spouses. This contrasts markedly with the situation facing older people who lose their spouses. Even if a spouse dies unexpectedly and under traumatic circumstances, the surviving spouse has the opportunity to spend time with members of her cohort who share some similar concerns. This isolation may be offset to some degree by the military community, which can provide important support to spouses and families whose loved ones die in combat- related incidents. One important resource for such families is the Tragedy Assistance Program for Survivors (

Several complicating factors are typically present for a spouse or family following a wartime death (Harrington- Lamorie & McDevitt- Murphy, 2011). In most cases, a lengthy period of separation precedes such a death. The separation itself may include stressful elements, such as the necessity of serving as a single parent and living under the constant threat that the loved one may be killed. These chronic stressors become the backdrop against which the death occurs and must be mourned.

After the death, those who lose a loved one in combat go through many of the same experiences as those who lose loved ones in disasters or terrorist attacks, such as dealing with the notification, waiting for information about whether the body has been recovered, and if so, learning the condition of their loved one’s remains.

After the funeral, survivors of wartime deaths immediately face a multitude of hurdles (George et al., 2009). The bereaved spouse must navigate a complex bureaucratic system in an attempt to obtain government benefits, as well as the return of personal property. These matters may take considerable time to be resolved, which can make it difficult for mourning to proceed. Other issues that require attention in the immediate aftermath of the death include decisions about housing, relocation, and employment (Harrington- Lamorie & McDevitt- Murphy, 2011). A particularly challenging issue for a surviving spouse involves the formation of a new identity.

As Harrington- Lamorie and McDevitt- Murphy (2011) have indicated,

Spouses often feel the loss of an identity as a “military spouse,” loss of a way of life as a “military family,” loss of housing (if on a base or post), loss of friends through the unit or command, and a loss of feeling connected to the greater military community… Many were afforded little opportunity to develop their own careers, hobbies and support networks outside of the military due to frequent moves and the demands of the military occupation on the family. (pp. 267 – 268)

The survivor’s attitude toward the war or mission constitutes another set of issues that can complicate the mourning process. Did the surviving spouse, parent, or child agree with the deceased’s decision to enter the military and to participate in this war? If not, the survivor may harbor resentment toward the deceased for putting himself in such a dangerous situation. If the war was unpopular, this may also reduce the likelihood that a survivor will receive social support outside military circles. Attitudes toward how the military treated her loved one can also play an important role. Some survivors may feel resentful that the military did not do everything it should have done to protect the decesaed. Others may feel that the sacrifice made by their loved ones was not appropriately acknowledged or appreciated.

Feelings of resentment that the military could and did not protect their loved one are likely to be paramount in cases of military suicide. In 2012, the number of suicides among active duty troops was 349. This number exceeded the 229 soldiers who were killed in combat that year in Afghanistan (Londono, 2013). In addition to feeling betrayed by the military for failing to keep their loved ones safe, survivors may also feel betrayed by the deceased. Whereas some soldiers kill themselves while in combat, others take their lives while they are making the transition to civilian life. One widow stated, “My husband chose death over coming home to me and the kids. That is hard for me to forgive.”

It is virtually impossible for survivors of military deaths to escape ubiquitous reminders of a continuing war because of media coverage. In addition to serving as a trigger for their distress, the content of a news story may be deeply disturbing. For instance, a parent may be sickened to hear that additional troops, equipment, and supplies are being shipped to fortify resources in the area where her son was killed.

In Chapter 3, we have mentioned the notion of moral injury (Litz et al., 2009). This experience of having violated one’s own moral code is relevant to military service members. They may be mourning the loss of fellow combatants for whose death they feel some responsibility or other moral involvement.

As noted above, there is frequently a delay in notification following the loss of a loved one in military conflict. Powell, Butollo, and Hagl (2010) conducted a study to determine the psychological impact of having a loved one who is missing but has not yet been declared dead. These investigators studied two groups of wives who had survived the war in Bosnia and Herzegovina: those whose husbands’ deaths were confirmed, and those whose husbands were still listed as missing because of the war. The wives with unconfirmed losses had higher levels of traumatic grief and severe depression than those whose husbands were confirmed dead. The authors indicate that many health care providers may not be aware of the extreme vulnerability of mourners with unconfirmed losses.


Homicide differs from other modes of traumatic death with regard to the depths of rage, horror, and vengefulness it typically unleashes in survivors. As Armour (2006) has stated, homicide “violates every norm about what a civilized society stands for” (p. 67). It is typical for survivors to be frightened and confused by the intensity of their rage and their preoccupation with vengeance. As noted above, there is some evidence that those bereaved by homicide exhibit higher levels of PTSD and grief symptoms than do survivors of suicide or accidents (see Kristensen et al., 2012, for a review). Parents are also more likely to show declines in marital satisfaction, and to have the most difficulty accepting their child’s death (Murphy, 2008; Murphy, Johnson, Wu, et al., 2003). Rynearson and McCreery (1993) found that homicide survivors were more likely to experience frequent and intense replaying of the events surrounding a murder, even if they were not present when the murder occurred.

Armour (2006) has emphasized that, as is the case with motor vehicle crashes, homicide is far more prevalent in some groups than in others. For example, African American males are six times more likely to be victims of homicide than European American males. If the survivors are also African Americans, their mourning could well be complicated further by the effects of racism in our society. Minority groups may find mainstream resources such as support groups more difficult to access. In addition, resources such as books and websites may be less relevant to their experiences and needs.

The murder of a loved one also results in even more negative views of the world among survivors than losing loved ones in an accident (Wickie & Marwit, 2000 – 2001). Those whose loved ones are murdered also experience powerful feelings of betrayal and alienation (Riches & Dawson, 1998). Because of the intensity of their emotions, it is common for homicide survivors to feel helpless and out of control. As one daughter described the situation her family faced, “[We] are all in this deep hole… we are just getting deeper and deeper and there is nowhere to go but down” (Armour, 2006, pp. 69 – 70).

Another prevalent problem following homicide is that mourners live with pervasive anxiety and fear. Survivors often become hyper vigilant, determined to avoid violence for themselves and their remaining loved ones. They typically feel extremely vulnerable to potential assaults, and restrict their contact with people and situations with which they are not intimately familiar.

Homicide survivors often experience an endless number of intrusions and frustrations at the hands of the criminal justice system. As we have discussed in an earlier chapter, survivors are often initially hopeful that the system will hold a perpetrator accountable for his actions. They believe that the judicial system exists to protect the rights of the murder victim and surviving loved ones. Because murder is a crime against the state, it is the state that prosecutes alleged murderers. This means that the survivors will have virtually no control over the court proceedings. In many cases, the court will withhold from them the very information they are seeking so that they can understand what happened. For example, the court may regard as evidence information about the crime as well as the extent of their loved one’s injuries, and therefore withhold it from the survivors until after the trial (Armour, 2006).

In an eloquent discussion of these issues, Redmond (1989) described the profound difficulties that she had in dealing with the criminal justice system. As this mother expressed it, “There is one closed door after another… you can’t show any emotion in the courtroom, can’t get a trial date set, can’t get a first degree murder charge” (p. 40). Court proceedings can result in a drain on survivors’ personal and economic resources as they make such decisions as how much time they should take off from work or whether they should hire a private investigator. If the state obtains a conviction and the murderer is incarcerated, many survivors feel compelled to monitor the situation. They are concerned that the sentence will be whittled away by appeals, early release, or other forms of legal maneuvering. These processes can affect survivors’ worldview, particularly their beliefs in justice and in fairness.

Many survivors do not have enough emotional energy to deal with both the criminal proceedings and the mourning processes simultaneously (Rando, 1993). For this reason, they often intentionally inhibit full mourning until the trial has ended. It often takes several years for legal proceedings to be resolved. This means that complicated mourning becomes a way of life for these survivors until they can turn their attention to their delayed mourning. Unfortunately, problematic adaptations may have developed in the interim. In addition, other family members and close friends may be ahead in their own mourning (because of not having to suppress it) and may have difficulty understanding the survivor’s emotions and symptoms. They may thus respond in unsupportive ways that can unintentionally shame or isolate the survivor.

Armour (2006) has pointed out that in a significant minority of cases, a murder is not solved and the assailant is never apprehended. This places stress on survivors who, in some instances, may live in fear that the murderer will return to harm them or their family members. When the assailant is not captured, they may constantly wonder, as they encounter friend and stranger alike, whether this is the person responsible for their significant other’s death.

In many cases, homicide survivors will also be required to deal with the media. In their efforts to procure a story, reporters are often persistent and at times intrusive. Survivors’ privacy is often stripped away, as details of their lives and that of the deceased become public. The news stories may include graphic details that are profoundly disturbing to survivors. TV and news stories are likely to appear not only at the time of the murder, but also at various points during the legal proceedings. Images can appear unexpectedly for a long time afterward. In a single instant, a news article, feature, or media clip can bring back all the anguish associated with the murder.

Like suicide survivors, homicide survivors are likely to have difficulty maintaining social support. These problems stem largely from the violence and horror associated with murder. It may be particularly difficult for survivors of homicide to initiate, or even to attend, social events. They often feel that their presence will make others uncomfortable. They may also feel that because of the murder, their friends and neighbors regard them negatively, viewing them as singled out for one of the worst imaginable outcomes. As one wife expressed it, “I feel like I have a big M on my forehead for murder” (Armour, 2006, p. 71). Of course, the behavior of potential support providers can also bring about difficulties. Most people experience trepidation at the prospect of interacting with someone whose loved one was murdered. In addition, supporters may be motivated to protect themselves from the belief that such an event might happen to them. In order to maintain their own feelings of security, they are often inclined to view the death as preventable. In so doing, they may attribute blame to the deceased and/or the survivors. Although this process may provide some peace of mind for potential support providers, it occurs at the expense of survivors. In many cases, they experience stigmatization and alienation, which can reduce their feelings of connection and intimacy with others.

Rando (1993) has suggested that working with homicide survivors places more demands on therapists than does working with those who have lost loved ones through other modes of death. She indicates that this is true in part because of the intense affect associated with this type of loss, and in part because therapists find such deaths so threatening: “The horror of the act and the awareness on some level that the victim could just as easily have been the caregiver’s own loved one fuel discomfort, as do the intensity and duration of the reactions with which these mourners present” (p. 552). According to Rando, homicide survivors often report that members of the mental health field have treated them insensitively, reflecting how fear or other strong feelings can overpower even the best intentions to provide good care.


Many practitioners believe that deaths caused by suicide pose greater problems for survivors than deaths that come about in other ways (see, e.g., Worden, 2009). Earlier in this chapter, we examined two studies that found relatively few differences between survivors of suicide and those of other modes of traumatic death, thus calling these beliefs into question (Dyregrov et al., 2003; Murphy, Johnson, Wu, et al., 2003). More recently, Sveen and Walby (2008) examined 41 studies that compared suicide survivors with those who were bereaved in other ways. No significant differences emerged in symptoms of mental health, such as depression, anxiety, or anger. They did find significant differences on some variables believed to differentiate between survivors of suicide and of other kinds of loss: rejection, shame, stigma, concealing the cause of death, and blaming others. Their results were inconsistent for other variables commonly believed to be more prevalent following suicide, such as guilt, relief, impaired functioning, and social support.

In an excellent discussion of these issues, Jordan and McIntosh (2010) have pointed out that all of the studies included in Sveen and Walby’s (2008) analysis utilized quantitative measures and comparison groups. They felt that the validity of the conclusions would be enhanced if qualitative studies, as well as their own clinical experience, were considered. Jordan and McIntosh maintain that there is clear evidence for differences between survivors of suicide and those of other kinds of loss in regard to rejection, shame, stigma, need to conceal the body, and tendency to blame others. They found some support for differences associated with such variables as

Event-Related Factors

anger, guilt, search for an explanation or desire to understand why, relief, shock/disbelief, social support issues, and family system effects. (See Jordan & McIntosh, 2011, for a more detailed discussion; see also Jordan, 2001.) Jordan and McIntosh assert that these variables reflect prominent themes in the subjective experience of survivors, and argue that an understanding of these factors is critical for treatment providers. Below, we consider these themes in more detail.

In many cases, suicide survivors regard suicide as intentional rejection; in a sense, the deceased person has chosen death over life with the mourner. A bereaved survivor may also feel betrayed by her loved one’s decision to end his life. The mourner may feel that she meant nothing to the deceased. In addition, the survivor often feels that the suicide invalidates everything positive that had transpired in the relationship. In such a case, the survivor’s inability to realistically remember her loved one or the relationship may compromise her mourning. Feelings of shame, humiliation, inadequacy, shattered self-worth, and rage related to these feelings often accompany beliefs that the survivor was not important to the deceased.

Given the feelings of humiliation and guilt that so often accompany suicide, it is not surprising that survivors may attempt to disguise the cause of death. For example, a family may present a loved one’s cause of death as a drug overdose, a motor vehicle crash, or an undiagnosed illness. In a review of the literature on suicide, Jordan (2001) concluded that such behavior is surprisingly common, occurring in over 40% of cases. Rando (1993) has pointed out that the survivors often defend this behavior as protecting surviving family members, particularly children. However, such a secret is likely to interfere markedly with sharing feelings of grief, both within the family and with others in the social network (Armour, 2006; Rando, 1993); hence it will probably have a negative impact on the mourning process. In addition, it is likely to reinforce the experience of shame.

As noted above, survivors of suicide are more likely to blame others than those who lose loved ones in other ways. In some cases, they may blame therapists, physicians, or other health care providers for what has happened. Family members may direct blame toward close friends or the life partner of the deceased for not preventing the suicide. It is also common for family members to blame one another in the aftermath of suicide. For example, a woman whose son killed himself may blame her husband because of the harsh discipline he employed.

The tendency of survivors to blame others is closely tied to feelings of guilt. It is common for them to ask themselves, “Why didn’t I know? What did I miss? If only…” Many survivors are consumed with guilt because they had no idea that their significant other was capable of this act. They struggle to understand how their loved one could have ended her life in this way. They may look back and see clues that make sense in retrospect, but that were impossible to recognize prior to the death. Sometimes a survivor may believe that he caused a suicide directly; for example, a father may believe that he precipitated his daughter’s suicide by taking away her privileges. In other cases, a suicide may occur following an altercation between a survivor and her loved one. Those who believe that they somehow brought about the suicide carry a heavy load. In other cases, survivors blame themselves for not anticipating the suicide, or not doing more to prevent it. For example, a parent may regret not making a stronger effort to get his son into psychiatric treatment.

It is common for suicide survivors to hold questions that they ache to ask their loved ones. The inability to do this and receive answers can result in unfinished business that they need to address. Many of the survivor’s unanswered questions concern the choice to commit suicide. Such questions might include “How could you do this to yourself? How could you do this to those who love you? Didn’t you know, or didn’t you care, about what this would do to us? How could you be so selfish? Why didn’t you give us a chance to help? Didn’t you know I loved you? How could you sentence me/us to all this pain and all these problems, while you’re now at peace?”

A suicide note may answer some of these questions. Such a note can be a blessing or a curse.

It can be beneficial if it does one or more of the following:

  • Absolves the survivor of responsibility.
  • Makes it explicit that the person was determined to end his life, that it was considered rather than impulsive, and that there was nothing the survivor could have done to prevent it.
  • Recognizes that the death will be difficult for the survivor, tells the survivor why he felt that suicide was the only choice, and asks the survivor to understand even if she doesn’t agree.
  • Conveys his love for the survivor and expresses regret that things ended this way.
  • Acknowledges that the survivor was a good parent, spouse, partner, sibling, child, friend, or other loved one.
  • Asks for the survivor’s forgiveness.
  • Helps the survivor understand what happened.

Although some suicides occur for no apparent reason or with no apparent precursors, most do not. In some cases, the deceased may have threatened suicide in the past, or perhaps even made previous attempts. Under these conditions, survivors’ guilt may be intensified. In other cases, the suicide may represent the culmination of a long history of problems in many domains of the deceased’s life. The deceased may have struggled with depression, anxiety, or addictions, and may have tried unsuccessfully to deal with these problems. In such a case, mourners’ emotional reactions may be complex and multifaceted: gratitude that the loved one is no longer suffering, profound sadness that nothing helped, relief at being free of the burdens and demands of an emotionally disturbed and self- destructive person, and guilt for feeling relieved (Jordan, 2001). As Cleiren (1993) has pointed out, it is important to recognize the enormous differences in the ways survivors view a suicide death: “For some bereaved, the suicide came undeniably as a solution to an unbearable situation, and created new opportunities and freedom of movement. For others, it meant personal failure or made no sense at all” (p. 250). (See Sands, Jordan, & Neimeyer, 2011, for more information about individual differences in reactions to the suicide of a loved one.)

There is some evidence that family problems are more common among those whose loved ones have completed suicide (see, e.g., Armour, 2006; Jordan, 2001; Jordan & McIntosh, 2011). It is important to recognize that in the case of a suicide, family dynamics are often highly problematic before the death occurs. Prior to the suicide, family members are often (although not always) locked into destructive patterns of behavior and communication. Problematic family dynamics may have contributed to the distress of the person who subsequently kills himself, or may even precipitate the suicide. Similarly, continual displays of disruptive and self- defeating behavior by that person may have had a negative impact on the mental health and functioning of other family members. Even in those cases where the family is functioning well prior to the suicide, the death is likely to have a detrimental effect on family interactions. There is typically an increase in hostility, recrimination, blame, and guilt induction (Jordan, 2001).

event-related Factors

As we discuss in Chapter 10, it is common for survivors of traumatic death to have difficulty maintaining effective support. There is some evidence to suggest that survivors of suicide have more pronounced difficulties. These support problems stem in large part from the negative attitudes others hold toward them. In a review of this literature, Jordan (1991) reported that others typically view those who have lost loved ones to suicide as less likeable, more psychologically disturbed, more in need of professional help, more blameworthy, and more ashamed than those whose loved ones died in other ways.

Clinical integration

Dr. Jack Brown had been meeting with Suzanne for about 10 weeks now. He was using the integrated treatment approach for traumatic bereavement with her. Although he was familiar with the approach after having used it with other clients, he decided to seek out ongoing peer consultation from a colleague for this particular therapy. He was anxious to speak with his colleague, Caitlin, today as he noticed a growing sense of dread in anticipation of his next session with Suzanne.

“So,” said Caitlin when they sat down in her office for their semimonthly consultation, “what do you know about this dread you’ve been feeling?”

“Well, I often feel a heaviness before I meet with Suzanne – like an inner awareness that the session is going to be really hard work, as well as some anticipation or worry that all our work will be futile. Suzanne is still so overwhelmed with both grief and traumatic stress symptoms; I worry that anything I do is not only too little, but will actually make things worse.”

“And if I remember correctly, you’re now focusing on some exposure work. Is that right?”

Jack nodded.

“I wonder if the anticipation of things getting worse might be a reflection of being in touch with Suzanne’s pain – the very pain she’s been avoiding.”

Jack took a breath. “Yeah. I know we need to go there, and I’m wondering if I’m up to it.”

“You doubt your ability to be helpful. Feeling overwhelmed?” “Really overwhelmed,” Jack agreed.

“Maybe you’re feeling a lot of what Suzanne herself is feeling?” Jack agreed again.

“Let’s say we assume for now that your thoughts and feelings are a window into Suzanne’s experience. If so, what does your experience tell you about where your client is in all of this?” Caitlin’s tone was compassionate yet confident, and seemed to indicate her faith in Jack.

“There’s just so much – so many feelings, thoughts, symptoms. I guess I understand the avoidance. If she avoids, then she won’t have to face all of the pain. If I avoid with her, then I won’t have to discover it’s too big to handle…” Jack paused for a long moment. “… or discover that I’ve made her go through that pain for nothing.”

“You’ll make her go through the pain.” Caitlin repeated his words deliberately. “It sounds as if you’re feeling responsible for her pain.”

“Yeah, I guess I am. And I can see how this could be a reflection of Suzanne’s feeling responsible for her daughter’s pain and death. This is one of the realizations she’s been avoiding, I think. Even though her guilt lives with her, under the surface, she hasn’t spoken this out loud – not fully, anyway.”

“And what do you know about that?” urged Caitlin.

“Well, I know that before her daughter’s death, Suzanne prided herself on being a great mother. She is a religious person – Catholic – and felt as though she was put on this earth to be a mother, to raise kind, compassionate, strong children, and to take care of other children as well. She reports that she and Sarah had a warm, close relationship. So I think that, in addition to other needs, her sense of identity has been violently assaulted by what happened. ‘How can someone who was put on this earth to mother fail to protect her own daughter?’ And then she experiences tremendous guilt for failing her daughter, which is how she sees it.”

“So Suzanne is dealing with the question ‘If I’m responsible for my daughter’s death, then who am I, and how do I live with myself?’ ” Caitlin was again reflecting on Jack’s own words.


“And you mentioned ‘among other needs.’ What are the others?”

“Well, self-trust. Her daughter’s suicide was a shock to her; she didn’t see it coming, and now she doesn’t trust her judgment or intuition at all. And, of course, her esteem. She believes she’s a bad person, and that she is no longer worthy of being supported by the God she believes in, which is a significant secondary loss for Suzanne in all of this.”

After a pause, Caitlin said, “It sounds as though you’re in touch with much of what Suzanne is experiencing. I want to encourage you to use that as a window into Suzanne’s experience as we did here today. And I want to remind you that you’ve done a thorough assessment and have expressed your belief that your client has the resources to get through this. I believe you have the clinical skill to help her through.” Caitlin smiled at Jack. With that, he felt himself begin to relax as the sense of being overwhelmed slightly diminished.

Concluding remarks

In this chapter, we have described the phenomenology of traumatic bereavement as it relates to factors surrounding the death. Recognizing many of the risk factors involved with traumatic bereavement, and understanding how these factors may affect the processes of mourning and trauma adaptation, will assist us in our work of helping survivors. First, this breadth of knowledge fosters empathic attunement with our clients. Second, it allows us to assess the unique challenges and stressors that an individual client may be confronting. Third, it helps us listen for specific themes that mark a client’s subjective experience of her traumatic loss.

The example of Suzanne’s horrific experience incorporates several of the risk factors named in this chapter. Suzanne experienced a suicide; she experienced the untimely death of her child; and she discovered her daughter’s body. Suzanne perceived the death as preventable and blamed herself for not having seen the warning signs. Unfortunately, it is not uncommon for bereaved survivors to experience multiple risk factors related to the death, as was the case for Suzanne.



Chapter 6. Person-Related Factors

Karen lost her teenage son, William, when a drunk driver who ran a red light struck his car broadside. In a similar situation, a drunk driver killed Juan, Sonia’s teenage son, as he was riding his bicycle home from school. Now, 3 years later, both women still experience intrusive thoughts about how the accidents unfolded and whether their sons suffered. Both struggle with guilt that they were unable to protect their sons. Both continue to mourn for their sons on a daily basis. In other ways, however, their reactions are very different.

Karen feels unable to go to the cemetery. When she tried to do so on William’s birthday, she experienced waves of nausea and had to return home. The fact that the perpetrator still has not been brought to justice fills Karen with rage. She has devoted a substantial amount of time to following the criminal case against the driver and becomes distraught when there is a setback, such as a continuance. Karen also has difficulty leaving the house. She dislikes it when others ask how she is doing. She has never driven by the scene of the accident, even though it is less than a mile from her home; in fact, she goes out of her way to avoid it. She also becomes distressed when she learns about someone else dying because of a drunk driving crash. Consequently, she minimizes her exposure to local newscasts and newspapers.

Sonia visits the cemetery on a regular basis, as doing so helps her to feel close to her son. Unlike Karen, Sonia’s feelings of sadness, rather than those of anger, are predominant. Although she is highly self- conscious when doing so, she is usually able to engage with others in social situations. Sonia frequently finds herself ruminating about Juan’s death. When she hears a news story about a drunk driving crash, she feels a deep sadness, knowing that others are struggling with the same painful issues that she is. She also feels compelled to do whatever she can to decrease the likelihood of alcohol- related motor vehicle crashes. Recently she has become involved with a group attempting to get Breathalyzers installed in the cars of repeat drunk driving offenders. However, she reports having little energy to put into it.

How can we account for the striking individual differences in response to traumatic death? Even when survivors have experienced losses that appear to be similar, as was the case with Karen and Sonia, their reactions and responses may be very different. As we have explained in Chapter 2, CSDT describes psychological trauma as arising from an interaction between aspects of the event and aspects of the person. In this chapter, we elaborate on some aspects of the person that can contribute to traumatic bereavement. We focus on those factors that seem most significant, according to both extant research and our clinical experience. In some cases, the research we present focused on survivors of traumatic death. In others, the investigators studied a heterogeneous group of respondents whose loved ones died in different ways. We have included studies in the latter group that we believe will generalize to survivors of traumatic death. The focus is on recognizing the variables that can help us to understand the different responses of survivors to similar events.


Men appear to have greater difficulty than do women in coping with the death of a spouse. A large number of studies have found that widowed men are more likely to become depressed and to experience greater mortality than are widowed women (see Miller & Wortman, 2002, and Stroebe, Stroebe, & Schut, 2001, for reviews). One possible explanation for these gender differences is that men may benefit more from marriage than do women, and thus the death of their spouses may affect them more adversely. Consistent with this view, several studies have shown that men rely primarily on their wives for social support, whereas women typically have many close friends besides their husbands (see Wortman & Boerner, 2011, for a review). Cleiren (1993) has reported that widowers are at relatively high risk for poor outcomes following the death of a spouse because their social activities decrease over time. His study also showed that widowers had great difficulty in maintaining and building social relationships following their wives’ deaths. It will be interesting to see whether these differences become less pronounced as more marital relationships are characterized by gender equality.

Umberson (1987, 1992) has identified another mechanism that may account for gender differences in the reaction to the loss of a spouse. She found that women typically take more responsibility for their partners’ health care, diet, nutrition, and exercise than men do. For example, married women are typically the ones who schedule medical appointments and monitor whether their spouse is taking prescribed medications. When men lose their wives, they experience these types of secondary losses at a time when they may need more support with basic health care regimens. Taken together, this research demonstrates the importance of talking with widowers about their support networks, and about how they handle matters pertaining to their physical health.

Studies of child loss have consistently found that, although fathers evidence considerable distress following the death of a child, mothers report significantly more distress than do fathers. This appears to be the case following perinatal deaths, deaths in infancy or childhood, and the deaths of older children. As described in Chapter 5, Dyregrov and colleagues (2003) conducted a study of the predictors of grief among parents who had lost children through suicide, accidents, or SIDS. Across all three samples, mothers evidenced higher levels of posttraumatic reactions and complicated mourning than fathers. Mothers also reported more intrusive thoughts, bodily symptoms, depression, anxiety, and grief than did fathers (Dyregrov & Matthiesen, 1987). Gender differences between parents also emerged in the previously discussed studies conducted by Murphy and her associates (Murphy et al., 1999; Murphy, Johnson, Wu, et al., 2003), which focused on parents who had lost a child as a result of accidents, suicide, or homicide. Regardless of gender, parents were devastated by the loss. Two years after their child’s death, mothers’ mental distress scores were up to five times higher than those of “typical” women in the United States. Fathers’ scores were up to four times higher than “typical” men in the United States. However, mothers scored higher than fathers on many other indices of mental distress, including depression, anxiety, somatic complaints, and cognitive functioning. Five years after the deaths, three times as many mothers (27.7%) met criteria for PTSD and twice as many fathers (12.5%) met criteria for PTSD compared with a normative sample (Murphy, Johnson, Chung, & Beaton, 2003). Women continued to show greater overall distress than men did as the study continued, and gender was one of the best predictors of changes in distress over time. The mental distress of fathers showed a greater decline over time than that of mothers (Murphy et al., 1999). Cleiren (1993) obtained similar results in his study of how people reacted to the death of a spouse, child, parent, or sibling as a result of motor vehicle crashes, suicide, or illness. He found that mothers were at far more risk for developing severe problems than were fathers, and that mothers scored higher on depression and health problems.

Available research has also found gender differences in the coping strategies that are most helpful in dealing with loss. In a treatment study conducted by Schut, Stroebe, van den Bout, and de Keijser (1997), for example, widows showed a greater decline in distress than widowers did after counseling that focused on day-to-day problems. In contrast, widowers showed a greater decline after counseling that facilitated emotional expression. According to Archer (1999), such findings reflect a sociocultural pattern of gender differences involving the inhibition of emotional expression by boys and men. Similar findings emerged from studies focusing on the death of a child. Mothers typically cope with such losses by seeking support or by communicating with other family members. Fathers attempt to conceal their feelings, which they claim is to support their wives. However, wives often complain that their husbands are not willing to share their feelings. Archer has stated that these findings “can be seen as part of a widespread pattern of male inexpressiveness” (1999, p. 245).

Murphy and colleagues (1999) reported an interesting shift in the symptom patterns for fathers and mothers starting in the second year of their study. At that point, mothers’ symptoms declined. Fathers, who started out with lower distress than their wives did, reported slight increases in 5 of the 10 symptoms that were assessed. This suggests that men may “hold in” their grief initially in an effort to be strong for their families (Martin & Doka, 2000). Cleiren (1993) also reported that for a number of the fathers in his research, bereavement symptoms increased over time. Cleiren has similarly suggested that this pattern occurs because fathers initially take the role of principal comforters and supporters of their wives. He maintains that in many cases, this constitutes an additional burden for fathers.

A program of research by Doka and Martin (2010; Martin & Doka, 2011) has considerable relevance for understanding gender differences in reaction to loss. These investigators have found that there are two primary patterns of grieving. Intuitive grieving involves intense expression of emotions, often at the cost of role functioning. Intuitive grievers often experience their grief as “waves of affect.” Because it is important to them to express their grief, they make an effort to find outlets to do so. Instrumental grievers direct energy away from the expression of feelings. In most cases, their affect is more muted than that of intuitive grievers. They tend to express their emotions in concrete ways, such as setting up a scholarship fund to honor the memory of a deceased child.

According to Martin and Doka, intuitive and instrumental patterns of grief should be regarded as the two ends of a continuum. They emphasize that there are no pure intuitive or instrumental patterns of grief. In fact, many people have a blended style of grieving, sometimes expressing their feelings and sometimes channeling them into constructive activities.

These investigators have noted that the intuitive style is widely viewed as “feminine,” while the instrumental pattern is regarded as a masculine grieving style. In our culture, it is common to pathologize the masculine style and to portray men as ineffectual mourners. As Martin and Doka (2011) have emphasized, such a characterization is inappropriate. They note that while containing one’s emotions is more prevalent among men, it also occurs among women (see Doka & Martin, 2010, for a more detailed discussion). Interestingly, they note that women who are instrumental grievers are more likely than men with the same style to be criticized for not expressing their feelings following a loved one’s death. Because women are expected to express their feelings, they may be judged harshly when they do not.

religion and spiritual Beliefs

Over the past decade, there has been increasing interest in studying the role that religion may play in coping with the death of a loved one. As Park and Halifax (2011) have emphasized, “religion and spirituality continue to thrive throughout the world and there is little evidence of its abatement” (p. 356). According to public opinion polls, nearly 90% of people in the United States describe themselves as religious or spiritual. Over 90% say that they believe in God; approximately 70% state that they are members of a church or synagogue; and 90% report that they pray regularly (see Becker et al., 2007; Kelley & Chan, 2012).

Evidence suggests that religious beliefs and practices are widely used by bereaved individuals, and that the majority of the bereaved regard them as helpful. For example, in their study of coping with the violent death of a child, Murphy, Johnson, and Lohan (2003b) found that 70% of the sample identified prayer as an important coping resource. The assumption that religious beliefs are beneficial is also widely held among treatment providers (Wortmann & Park, 2008).

Most studies report a positive relationship between religious beliefs or practices and some indicators of adjustment to the loss (for reviews, see Becker et al., 2007; Hays & Hendrix, 2008; Wortmann & Park, 2008). However, there is a consensus that the results of these studies should be interpreted with caution. This research has been plagued by methodological problems, such as reliance on weak experimental designs and lack of consensus regarding how religion should be conceptualized and measured. Wortmann and Park (2008) have indicated that the measures of religion used in most studies are too broad and “do not adequately capture the complex nature of religion in people’s lives” (p. 705). When the specific facets of religious beliefs are examined, we find several intriguing lines of research that have clear relevance for clinical practice.

As Park and Halifax (2011) have emphasized, religious and spiritual traditions “offer a panoply of coping resources for dealing with death” (p. 359). One such resource is prayer. Available evidence suggests that an increase in one’s frequency of prayer is helpful in coping with the death of a loved one (Wortmann & Park, 2008). A second is religious social support, which includes support from clergy and members of a congregation. Religious social support can impart a sense of belonging to a broader community of individuals with similar religious views. In addition, religious social support can help the bereaved find solace and comfort, which can assist them in coming to terms with their loss (Wortmann & Park, 2009). A number of studies have shown that religious social support during bereavement has a positive impact on psychological well-being (see Hays & Hendrix, 2008, for a review). For example, Thompson and Vardaman (1997) found that religious social support was beneficial to families who had lost loved ones to homicide.

Person-related Factors

A third way in which religious beliefs might influence adjustment to the death of a loved one is by affecting how survivors cope with the loss. In a study focusing on respondents whose partners had died of AIDS, those with religious beliefs were more likely to use positive appraisal and effective problem- solving techniques (Richards, Acree, & Folkman, 1999; Richards & Folkman, 1997). There is also evidence to suggest that religious beliefs can facilitate finding meaning in a loss (Park & Halifax, 2011; Wortmann & Park, 2009). Drawing from many studies in this area, Wortmann and Park (2009) concluded that meaning making is the major pathway through which religious beliefs influence the mourning process. In one study of parents who lost an infant to SIDS, the more important religious beliefs were in the parents’ lives, the more they were able to find meaning in their children’s deaths (McIntosh, Silver, & Wortman, 1993). Murphy, Johnson, and Lohan (2003b) found that the use of religious coping strategies such as seeking God’s help was associated with finding meaning in the loss of a child from suicide, homicide, or an accident 5 years after the death occurred. Finding meaning, in turn, was associated with less mental distress and higher marital satisfaction. As described in Chapters 3 and 10, however, many survivors of traumatic loss are unable to sustain their faith or find meaning in the loss.

Coping strategies such as maintaining a rewarding connection through prayer, utilizing proffered support of the faith community, and drawing on religious beliefs to find meaning in the loss are referred to as positive religious coping (Cowchock, Lasker, Toedter, Skumanich, & Koenig, 2010). Several investigators have maintained that it is equally important to assess negative religious coping, which is sometimes called religious struggle. Feelings of anger toward God, feelings of abandonment or betrayal, or feelings that one is being punished for sins are all believed to reflect negative coping or religious struggle. Some researchers have found that those who expect to be comforted by their religious beliefs, but ultimately are not, are at heightened risk for negative coping or religious struggle.

Labeling beliefs such as anger toward God as negative coping is not helpful to mourners. It is clear that those who have experienced sudden, traumatic losses are more likely to struggle with their religious beliefs than those whose loved ones died of natural causes (Chapple, Swift, & Ziebland, 2011). As we have discussed in Chapter 3, it is extremely common for survivors of such losses to experience a crisis of faith, and to believe that now that their loved one has died, life holds no meaning. Religious struggle has been identified as a powerful predictor of poor outcome following the death of a loved one (Cowchock et al., 2010). Thus individuals engaged in religious struggle are likely to benefit from therapeutic support in dealing with these issues. This work can be facilitated by doing an assessment of each client’s spiritual beliefs. For example, clients might be asked to articulate their views on the afterlife, or to discuss why they think bad things happen to good people.

According to Tedeschi and Calhoun (2006, 2008), there are some cases in which people emerge from their religious struggle with spiritual lives that are more meaningful and satisfying than before the loss. Tedeschi and Calhoun use the term posttraumatic growth to refer to positive changes that may occur through a struggle with life events like the death of a loved one. The posttraumatic growth construct may offer clinicians some useful hypotheses to explore, despite problems with its measurement (Wortman, 2004).

Tedeschi and Calhoun (2006, 2008) have emphasized that the loss event itself is not what promotes growth. Rather, the survivor’s struggle with the painful ramifications of the loss is the catalyst for growth. They use the metaphor of an earthquake to describe this process, noting that a traumatic event, like an earthquake, can severely shake, threaten, or reduce to rubble many of the schematic structures that have guided a person’s life. They state that life events are most likely to promote growth if they challenge an individual’s assumptions about the world.

Tedeschi and Calhoun (2006, 2008) maintain that five different types of experiences indicate personal growth (see Tedeschi & Calhoun, 2008, for a more detailed discussion). The first is the emergence of new possibilities. For example, some women who lost their husbands stated that they were able to learn new skills, such as how to handle finances; they felt proud that they were able to do so. Second, a death sometimes brought about a positive change in relationships. For example, many parents who had lost children reported greater compassion and connection to other human beings, especially those who had experienced a similar loss. Survivors of traumatic loss may also report that they no longer take their loved ones for granted. As one bereaved parent expressed it, “I always tell the people I love that I love them.” Third, many survivors reported an increased sense of personal strength. As one bereaved person explained, “I’ve been through the absolute worst that I know. And no matter what happens, I’ll be able to deal with it” (quoted in Tedeschi & Calhoun, 2008, pp. 33 – 34). A fourth type of change is a greater appreciation for life. This is often accomplished by a shift in priorities, as when a parent decides to come home from work earlier so that she can be more involved in her children’s activities. Finally, Tedeschi and Calhoun have emphasized that people often report changes in their religious and spiritual orientation. For example, an encounter with the death of a loved one may lead a person to a more meaningful or satisfying religious or spiritual life. As one survivor expressed it, “the understanding that God is going to get you through anything that happens to you… gives you a different outlook on life… that takes away a lot of fear and trepidation that most of us walk through life with” (Tedeschi & Calhoun, 2008, pp. 33 – 34).

Currier, Mallot, Martinez, Sandy, and Neimeyer (2012) have maintained that the violent deaths of loved ones will challenge survivors’ assumptive worlds more than deaths that come about through natural causes. They have suggested that as a result, violent deaths are more likely to precipitate positive life changes. These investigators found that survivors who lost loved ones to violent deaths reported more psychological distress, but also scored higher on indices of posttraumatic growth, than either those who experienced nonviolent deaths or those who did not experience the death of a loved one.

It appears that the concept of posttraumatic growth has been embraced by researchers and clinicians working in the field of bereavement, as well as in other fields involving human adversity. An important question is whether the available data can and should be taken as valid. One criticism that has been raised about this work concerns the validity of respondents’ statements about the growth they have shown. If a study participant states that the death of his child has made him stronger, should this be taken at face value? A respondent may wish to convince others, and perhaps himself as well, that something positive has come out of all of the anguish his family has experienced. In fact, research suggests that people in a survivor’s life – family, friends, and professionals – may “pull” for expressions of positive change, in part by reacting negatively to expressions of distress (see, e.g., Silver, Wortman, & Crofton, 1990).

Results from a study focusing on the long-term impact of losing a spouse or child in a motor vehicle crash (Lehman et al., 1987), described in Chapter 1, casts some doubt about whether respondents’ self- reports about personal growth are valid. In this study, people were asked whether anything positive had come out of their spouse’s or child’s death; 74% of respondents reported at least one positive change, with the majority reporting only one. The most common ones were increased self- confidence and focusing more on enjoying the present. In their review

Person-Related Factors

of the literature regarding posttraumatic growth, Tedeschi and Calhoun (2006, 2008) cited this study as indicative that people indeed experience posttraumatic growth following the traumatic death of a loved one.

When we look at the study data as a whole, however, two issues emerge. First, at least in this study, the one or two positive comments made by the respondents were dwarfed by the negative changes that they reported. If a person says that she is focusing more on enjoying the present – but sees the world as a more dangerous place, is struggling with symptoms of depression and PTSD, is going through a divorce, cannot concentrate at work, and is experiencing impaired quality of life – is that growth?

Second, the results reflect clear inconsistencies between respondents’ statements about personal growth and other measures included in the study. Tedeschi and Calhoun (2006, 2008) have emphasized that warmer, more intimate relationships with others is one of the most important elements in posttraumatic growth. Only 20% of Lehman and colleagues’ (1987) respondents indicated that they emphasized family more as a result of the accident. In comparison to controls, those who lost a spouse reported feeling more tense, upset, unhappy, and emotionally worn out when reflecting on their current experiences as a parent. These same findings emerged when respondents who lost a child were asked to reflect on their experiences as a parent to surviving children. Moreover, those who lost a child tended to feel more bothered, tense, and neglected than controls when thinking about their daily life with their spouse. As noted earlier, they were also more likely to seek and obtain a divorce.

In the Lehman and colleagues (1987) study, the traumatic death of a spouse or child also had an adverse impact on relationships with friends and relatives. Those who lost a spouse reported spending less time with their friends, having more arguments with them, and feeling more hurt and offended by them than controls. Those who lost a child indicated that they were less likely to talk with their relatives about their feelings or problems. They reported that in many cases, they felt angry or disappointed in their relatives and expressed agreement with the statement that they were “more likely to want to do the opposite of what their relatives wanted in order to make them angry.” In this study, therefore, warmth and intimacy did not increase and, in fact, the impact on respondents’ relationships with family and friends was decidedly negative (see Wortman, 2004, for a more detailed discussion).

In many cases, people try to comfort the bereaved by mentioning positive things that have come about as a result of the death. As Mehren (1997) has indicated, bereaved parents are hurt and offended by such remarks, as they imply that whatever good things emerge from the situation, such as increased compassion, are worth losing the child. As Mehren has indicated,

It annoys many of us when people tell us we’ll be better people because of all the sorrows we’re going through. While we must grasp for any small blessings we can salvage, we’d rather be our rotten old selves and have our babies back. Besides, it’s not like we were ax murderers to begin with! (p. 93)

As a result of challenges to their ideas, Tedeschi and Calhoun (2008) have stated that it is not a foregone conclusion that those who struggle with the ramifications of their loss will ultimately experience personal growth. Taken together, the research cited above emphasizes the importance of remaining open to alternative possibilities when our clients talk about personal growth. Our society clearly champions people who are strong in the face of adversity. As health care providers, will we be disappointed if a particular client does not manifest growth? Will survivors of traumatic loss experience feelings of inadequacy and shame if they are not able to find something good in what has happened?

It is critically important that clinicians not bring an expectation of growth to their clients, thus creating an environment in which they can fail. This body of work suggests that clinicians should create a space where clients can fully express and discuss issues surrounding these and other religious and spiritual beliefs. In Chapter 10, we offer specific suggestions regarding how to assist clients in this endeavor.

Personality and Coping strategies

Personality refers to dispositional tendencies toward such states as optimism, self- esteem, anxiety, and emotionality. There is clear evidence that these and other aspects of personality predict adjustment to the death of a significant other (see Robinson & Marwit, 2006, for a review). For example, Riley, LaMontagne, Hepworth, and Murphy (2007) found that mothers who were more optimistic by nature reported less intense grief reactions. Similarly, in a study of mourners whose loved ones died of cancer or AIDS, Nolen- Hoeksema (2001) found that those who scored high on dispositional optimism (i.e., a tendency to be optimistic in most circumstances) showed a greater decline in grief symptoms following the loss of their significant other and were more likely to find meaning in the loss. It is clear that personality traits can exert their influence by affecting the coping strategies a survivor employs. For example, those who are generally optimistic may be more able to elicit support from their family and friends.

Evidence also suggests that self- esteem is associated with adjustment following loss. For example, Murphy and colleagues (1999) and Murphy, Chung, and Johnson (2002) found that for both mothers and fathers, self- esteem measures taken 4 months after their child’s violent death were strong predictors of reduced mental distress throughout the five years of the study. Perhaps those with higher self- esteem were better able to restore their trust in themselves and others and to maintain their connection with others, allowing them greater access to social support. Similarly, Boelen, van den Hout, and van den Bout (2006) reported that negative beliefs about the self were strongly related to levels of complicated grief. Murphy and colleagues (1999) have suggested that clinicians should attempt to assist bereaved clients in gaining and/or maintaining feelings of self- esteem. Some therapists may not recognize the importance of this for traumatically bereaved clients. Another personality variable that contributes to a poor outcome following the loss of a loved one is neuroticism (Wijngaards- de Meij et al., 2005). People who score high on neuroticism are more likely to develop negative cognitions, which increase the likelihood that they will get stuck in the mourning process.

Sudden, traumatic death usually has an adverse effect on affect management (a self-capacity that involves staying grounded in the face of strong feelings, described further in Chapter 10). Prigerson, Shear, Frank, and Beery (1997) found that difficulties in regulating one’s emotions enhanced vulnerability to complicated grief. An individual who has never developed this self-capacity (usually because of childhood family dysfunction or attachment challenges) may struggle more following a traumatic death than one who has.

Traumatic bereavement can also impair ego resources described within CSDT, such as initiative, judgment, ability to manage boundaries, ability to foresee consequences, and decision making. Again, the individuals at greatest risk for longer- term problems in these realms are those who may not have had the opportunity to develop these resources in childhood.



Kinship relationship to the deceased

Several studies have shown that the death of a child leads to more intense and prolonged grief and depression than the death of a spouse, sibling, or parent does (Cleiren, 1991, 1993; Cleiren, Diekstra, Kerkhof, & van der Wal, 1994; Leahy, 1992; Nolen- Hoeksema & Larson, 1999). In an important study, Cleiren (1993) examined mourners who had lost either a child, spouse, sibling, or parent. These losses resulted from suicide, traffic accidents, or long-term illness. He found that the kinship relationship to the deceased was by far the most important factor studied, determining mourners’ adaptation to a substantial degree. His results showed that the group at greatest risk for a poor outcome was mothers, followed by husbands, fathers, and sisters of the deceased. As Cleiren (1993) expressed it, “Regardless of the age of their child or their own age, the loss [of a child] seems to create a permanent vacuum in their [mothers’] lives” (p. 253).

Li, Laursen, Precht, Olsen, and Mortensen (2005) studied a large cohort of people in Denmark. They conducted follow- up interviews with respondents who had lost a child, and a control group who had not suffered such a loss. Bereaved parents had a significantly higher risk of admission to a psychiatric hospital. This was particularly the case for mothers, who continued to show an elevated risk of psychiatric hospitalization for 5 years or more after the death. Li, Precht, Mortensen, and Olsen (2003) have also found an increased risk of mortality among parents after the loss of a child from unnatural causes.

A study by Rogers, Floyd, Seltzer, Greenberg, and Hong (2008) provides corroborating evidence regarding the long-term impact of child loss. They obtained information from a large number of parents who had lost a child and from a control group of individuals with similar backgrounds. Approximately 18 years following the child’s death, bereaved parents reported more depressive symptoms, poorer well-being, more marital conflict, and more health problems than members of the control group did. Cause of death did not significantly influence these results, suggesting that the death of a child is devastating under almost any circumstances. In this study, both mothers and fathers showed high levels of enduring distress.

To our knowledge, Cleiren (1993) is one of the few investigators to study the impact of losing a brother or sister. He found that women who lost a sibling were at risk for a poor outcome. He reported that in contrast, men showed a much more favorable adaptation to the death of a brother or sister. According to Cleiren, these gender differences may have occurred because women are more likely to feel a greater sense of connection to and responsibility for their siblings than are men.

Marshall and Davies (2011) maintain that in many cases, the loss of an adult sibling is a disenfranchised loss; this means that others do not recognize the loss, its severity, or its meaning to the bereaved person. They cite data indicating that the average adult “has contact with a sibling once or twice a month for 60 or 70 years after leaving home” (p. 111). Nonetheless, most people who lose a sibling find that friends, co- workers, and even family members fail to acknowledge the loss or offer support. Moreover, in addition to dealing with their own grief, many adults who lose a sibling must support their parents, who are dealing with the loss of a child (see Marshall & Davies, 2011, for a more detailed discussion).

In recent years, there has been increasing interest in understanding how the traumatic death of a child affects surviving siblings. Buckle and Fleming (2011) maintained that surviving siblings face “wide- ranging and enduring consequences following the death of a brother or sister” (p. 93). Like their parents, they may experience the demise of the feelings of security that their family provided. Siblings often feel that their parents are focusing more attention on the deceased child than on them. Moreover, parents’ comments about their child who died (e.g., “She was always such a good girl” or “He was so gifted”) may engender feelings of anger and resentment (Handsley, 2001). Such families often find themselves in a vicious cycle: Parents’ grief renders them less effective in dealing with surviving children, and the absence of attentive and consistent parenting contributes to the symptoms displayed by surviving siblings. This in turn adds to the parents’ distress, making it even more difficult for them to relate effectively to their surviving children.

Another death that is often disenfranchised is the loss of a child during pregnancy. It is common for parents, particularly mothers, to experience feelings of guilt and emptiness as well as grief (Adolfsson, Larsson, Wijma, & Berterö, 2004; Jaffe & Diamond, 2011). Outsiders often fail to understand what was lost or to appreciate the impact of the loss. Consequently, couples often feel alone in their grief. This is also true for couples experiencing stillbirth or neonatal death. Bereaved parents often receive comments from others that minimize their loss – for example, “It was only a baby you didn’t know.”

In fact, Buchi and colleagues (2007) found that 2 – 6 years after the death of a premature baby (24 – 26 weeks’ gestation), parents, especially mothers, were experiencing grief symptoms and significant emotional distress. According to these authors, clinicians should be aware that the death of a preterm infant can trigger a painful long-term process of mourning.

nature of the relationship with the deceased

Historically, clinical writings on loss have maintained that prolonged or chronic grief results from conflict with or feelings of ambivalence toward the deceased (see, e.g., Bowlby, 1980; Parkes & Weiss, 1983). This hypothesis derives from psychoanalytic theories of grief (e.g., Abraham, 1924/1927). Supposedly, survivors who have ambivalent or conflictual relationships with their deceased loved ones have to cope with powerful angry or contradictory feelings toward them. In theory, this makes it more difficult for the survivors to process and accommodate the loss. Although this view may be widely accepted among practicing clinicians, well- controlled studies fail to support it. Wheaton (1990), a sociologist, advanced a hypothesis about the relationship between marital quality and reaction to spousal loss that is in direct opposition to the psychodynamic approach. He argued that those who are involved in conflictual marriages should show an improvement in their mental health following the death, in comparison to those who are not involved in such marriages, because they are exiting a stressful role. He conducted a study that provided strong support for this view.

Carr and colleagues (Carr, 2008; Carr et al., 2000) assessed respondents prior to losing their spouses and again 6 and 18 months later. They found that adjustment to widowhood was most difficult for those whose relationships had the highest levels of warmth and closeness. Those who were involved in conflictual relationships prior to their spouse’s death showed low levels of yearning for their spouse throughout the study. Van Doorn, Kasl, Beery, Jacobs, and Prigerson (1998) and Prigerson, Maciejewski, and Rosenheck (2000) also found that people in close, supportive marriages were at elevated risk for complicated grief following the death of their spouse. Although these studies did not focus exclusively on respondents who experienced sudden, traumatic loss, the findings suggest that therapists should recognize that bereaved individuals who had warm and loving relationships might be at greater risk for traumatic bereavement.

Clinicians have also maintained that excessive dependency on one’s spouse is a risk factor for intense and prolonged grief (see, e.g., Lopata, 1979; Parkes & Weiss, 1983; Rando, 1993). Excessive dependency is characterized by overreliance on another person in order to feel secure and manage daily affairs (Rando, 1993). Rando (1993) has stated that such individuals feel completely devastated if the loved one dies. Empirical evidence indicates that individuals are indeed at risk for poor outcome if they are highly dependent on their spouse (Bonanno et al., 2002). In one study, widowhood was associated with elevated anxiety among those who were highly dependent on their spouses (Carr et al., 2000). Johnson and colleagues (2007) obtained similar findings. Those who were highly dependent on their spouses were more likely to develop symptoms of complicated grief (see also Johnson, Zhang, & Prigerson, 2008). Women who depended on their husbands for assistance with daily tasks were particularly likely to have difficulty coping with their husband’s death.

In an interesting line of research, Carr (2008) examined the connection between quality of a marital relationship and interest in remarriage following the death of a spouse. She found that interest in dating was determined in part by gender and in part by the nature of the mourner’s relationship with the deceased spouse. Greater marital conflict was associated with less interest in dating. Widowers were much more likely to express interest in a new relationship than were widows. Men who had been the most emotionally reliant on their spouse expressed the greatest interest in remarriage. The reverse was true for women: The more emotionally reliant they had been on their husbands, the less interested they were in pursuing subsequent relationships. These findings have implications for understanding why some clients may be more interested in dating than others.

Attachment style

In recent years, scholars have begun to examine the impact of attachment style on reactions to the death of a spouse. Drawing from the work of John Bowlby (1980), Mikulincer and Shaver (2008) indicated that attachment security is crucial for maintaining emotional stability and forming mutually rewarding and long- lasting close relationships. Bowlby (1973) hypothesized that if caregivers are consistently available and are responsive to a child’s needs, the child is likely to develop a secure attachment style.

Bartholemew and Horowitz (1991) developed a model of attachment styles that has been highly influential. This model is based on the idea that attachment styles reflect people’s beliefs about their partners and themselves. Specifically, attachment styles are determined by whether people judge their partners to be generally accessible and responsive to requests for support, and also whether they judge themselves to be the kind of person that others wish to support. People who judge their partners and themselves positively are characterized as secure. Secure individuals find it easy to become emotionally close to others, and don’t worry about whether others will like or accept them. People who rate themselves positively but their partners negatively are characterized as dismissive – avoidant. These individuals deny needing close relationships and avoid attachment to others. People who rate themselves negatively but rate their partners positively are characterized as anxious – preoccupied. People with this style seek high levels of intimacy but tend to become too dependent on their partners. People who rate themselves negatively and their partners negatively are characterized as fearful – avoidant. These individuals are uncomfortable getting close to others, and worry that they will be hurt if they allow themselves to get too close to others.

Mikulincer and Shaver (2008) have suggested that secure attachment increases the likelihood of adjustment to a loss. According to these authors, securely attached people are able to experience and express feelings of grief and distress without becoming overwhelmed. A secure attachment style also serves as an important resource for tolerating separation, for making effective use of social support (Field & Wogrin, 2011), for regulating physiological and behavioral states, and for exploring the world (Shear & Shair, 2005). An individual who does not have a secure attachment style typically experiences the loss of a partner as a devastating event that triggers intense and pervasive stress. The situation is even more stressful when the deceased was the primary attachment figure – the one to whom the mourner would have turned for support in times of duress (Shear & Shair, 2005). According to Mikulincer and Shaver, individuals without a secure attachment style have great difficulty with the mourning process. They experience intense anxiety, depression, and anger. Those with anxious – ambivalent styles may be especially likely to show greater clinging and loneliness (Parkes, 2009). Their overwhelming negative affect presents an obstacle to mourning.

Although few studies have tested these ideas, available research supports Mikulincer and Shaver’s (2008) hypothesis that there is a relationship between a person’s attachment style and her reaction to the loss of a loved one. For example, Waskowic and Chartier (2003) found that following the death of their spouse, securely attached people were less angry, were less socially isolated, felt less guilty, had less death anxiety, and ruminated less than insecurely attached people.

Lobb and colleagues (2010) have maintained that poor outcome following the death of a loved one stems from insults to a child’s sense of security that can result from weak parental bonding. Childhood separation anxiety, as well as high levels of strict parental control, have been shown to impede adjustment to subsequent loss (Johnson, Zhang, Greer, & Prigerson, 2007; Vanderwerker, Jacobs, Parkes, & Prigerson, 2006). Silverman, Johnson, and Prigerson (2001) showed that childhood abuse or serious neglect – experiences likely to interfere with the development of secure attachments and self-capacities – put people at risk for poor outcomes following the death of a loved one. Other studies have also provided evidence that those who have insecure or anxious attachments to their partners show the most intense and prolonged grief (for more detailed discussions, see Shaver & Tancredy, 2001; M. S. Stroebe et al., 2005; Zhang, El- Jawahri, & Prigerson, 2006).

Bowlby (1973, 1980) noted that in some cases, parents discourage displays of what they perceive as negative emotions (e.g., crying), and encourage premature or unreasonable independence. According to Bowlby, such children are likely to develop an avoidant attachment style. People with this style try to suppress and deny attachment needs. Following the death of their partner, such individuals are typically unwilling or unable to express thoughts, feelings, or memories related to the deceased loved one. They also tend to downplay the importance of their loss. This impedes the commencement of the mourning process. In fact, Zech and Arnold (2011) have argued that avoidant individuals are less likely to enter therapy, given their tendency to minimize their distress.

Mancini, Robinaugh, Shear, and Bonanno (2009) have discussed the potential role of both generalized attachment style and the specific nature of the attachment to the deceased in shaping bereavement responses. In examining data from bereaved spouses, they found that attachment avoidance, attachment anxiety, and marital quality predicted complicated grief symptoms at both 4 and 18 months after the death. Interestingly, those individuals with a dismissive – avoidant style and high self- reported marital quality reported significant reductions in complicated grief symptoms over time. This finding is consistent with Fraley and Bonanno’s (2004) work, which found among 59 bereaved adults that persons with a dismissive – avoidant style showed a similar symptom picture to those with a secure attachment style. This group contrasted with the fearful – avoidant group, whose members had a difficult time adapting to their losses. Thus it seems important to consider the mourner’s generalized attachment style, as well as the attachment needs that characterized the mourner’s relationship with the deceased.

Zech and Arnold (2011) have provided a thoughtful discussion of the therapeutic implications of these various attachment styles. They maintain that anxiously attached clients are likely to be emotionally hyper aroused much of the time, whereas avoidantly attached clients may be hypo aroused (i.e., numb and shut down). Zech and Arnold argue that if therapists try to engage either type in exploring deep feelings surrounding the loss, this “can potentially result in both types of clients being outside their ‘window of tolerance’ ” (p. 29). They suggest that the ramifications of this process are unfortunate. Anxiously attached clients can easily be destabilized in therapy. They are likely to ruminate about their loved ones, which will result in an increase in their distress. Avoidantly attached clients may feel that as a result of the treatment, they are being flooded with unwelcome, distressing emotions. They may take any opportunity to distract themselves from their distress, or may drop out of treatment. Zech and Arnold offer guidance regarding how clinicians can address these challenges.

Individuals who have experienced abuse or neglect in childhood may develop complex developmental trauma (Courtois & Ford, 2009), also referred to as complex PTSD. Its hallmark symptoms are somatization, revictimization, affect dysregulation, relationship difficulties, disruptions of identity, and dissociation (Pelcovitz et al., 1997). Disorganized attachment, also referred to as a fearful – avoidant/dissociative style (Lyons-Ruth, Dutra, Schuder, & Bianchi, 2006), is characteristic of persons with complex developmental trauma. Although it seems that individuals who evidence complex developmental trauma adaptations may be more likely to experience traumatic bereavement following a sudden death, research has not yet adequately examined this hypothesis.

Taken together, these findings underscore the importance of assessing such childhood adversities as strict parental control and harsh parenting, childhood neglect and abuse, and other challenging childhood experiences. Our treatment approach utilizes the framework of CSDT, which, based on attachment theory, offers a map for the assessment of aspects of the self-affected by inadequate attachment experiences earlier in life. It also provides guidance for resource- building activities before proceeding to trauma processing, which may be particularly important for those with insecure attachment styles.

Additional Person related variables

The limited available research supports the view that a history of prior traumatic events or a family history of psychopathology enhances vulnerability to complicated grief (see Auster, Moutier, & Lanouette, 2008, for a review). There is also research to suggest that the presence of other major stressors can interferes with the resolution of grief. These might include serious health problems, caregiving responsibilities for an elderly parent or other loved one, behavioral problems of a child, or financial difficulties (see, e.g., Ott, 2003; van der Houwen et al., 2010; Zisook & Shuchter, 1993). Clients who are dealing with such stressors may have difficulty becoming engaged in the treatment.

Clients who are dealing with other major stressors during the mourning process may find it more difficult to participate in a treatment that demands time and energy. Such stressors might include serious health problems, caregiving responsibilities for an elderly parent or other loved one, behavioral problems of a child, or financial problems.

Among parents who have lost a child, Li and colleagues (2005) found that parents who lost their only child had the greatest risk of admission to a psychiatric hospital. Consistent with these findings, Dyregrov and colleagues (2003) found that not having surviving children was a significant predictor of distress in all three of the samples they studied (loss of children via suicide, accident, or SIDS). Drawing from interview data, these investigators reported that among parents who had surviving children, parents of their children’s friends helped to provide social support, inviting them into a social network following the death. In a study of parents who lost a child to natural causes, accidents, suicide, or homicide, Wijngaards- de Meij and colleagues (2005) found that the more children there were in a family after a death occurred, the fewer grief symptoms the parents reported. In addition, families in which the mothers became pregnant following the deaths showed a greater decrease in depression than families in which the mothers did not become pregnant. Rogers and colleagues (2008) obtained similar findings. They found that parents who had other children at the time of the loss were less likely to experience marital disruption. These authors suggested that the presence of other children “can be a way of finding meaning through important life tasks” (p. 210).

From these studies of child loss, two additional demographic variables have emerged as significant: work and educational attainment. Wijngaards- de Meij and colleagues (2005) found that the more bereaved parents worked outside the home, the fewer grief symptoms they reported. Respondents with more years of education also reported less grief than those with less education. Dyregrov and colleagues (2003) obtained similar results: Not working outside the home and fewer years of education were predictors of distress among those who lost a child via accidents, suicide, and SIDS.

Clinical integration

Evan’s thoughts were swirling as he waited for Sonia to arrive for her session. Fifteen minutes earlier, Karen had walked out of his office after her therapy session; her clinical file still lay open on his desk. “Karen is doing well in therapy,” he thought to himself, “but she is in such a different place from Sonia.”

Evan found it difficult not to compare the two women. He saw them in back-to-back appointments every Wednesday afternoon. Both women had lost sons in car accidents. Both had been mourning for about 3 years. Both experienced trauma symptoms. And Karen was so angry – in a way that Sonia wasn’t. Karen seemed to adapt to the loss of her son by avoiding reminders of his death as much as she could. The exception to this was her intense focus on the ongoing criminal trial of the man accused of killing her son. If avoidance seemed so necessary to Karen, how was she able to throw herself into the trial – itself a reminder of William’s death? And just as Evan conjured up this thought, a light bulb went on:

“I get it! Karen is pretty comfortable with anger; it’s the hurt and despair she’s warding off. I was framing Karen’s avoidance in terms of the actual death rather than in terms of her feelings. It makes sense that she would avoid some feelings and not others. It’s as though her anger and the trial itself protect her from these other feelings, allowing her to be engaged with William’s death without feeling so much pain. The anger is easier. The problem, of course, is she’s feeling that pain anyway, and…”

Such were Evan’s thoughts when Sonia tapped on his door. “Are you ready for me?”

Startled, Evan replied, “Yes, of course, come on in.” Evan quickly adjusted, flipping Karen’s file closed and turning his attention to Sonia, though Karen was still in the background. He had a new hypothesis. Whereas Karen was avoiding feelings of profound grief and despair, maybe Sonia was avoiding anger.

After checking in about the independent activities Evan had asked Sonia to complete a week ago, he turned their attention to a new topic. “Sonia, I remember that when I asked you about your upbringing in our first session, you described your father as an angry person – as emotionally volatile and scary to you and your sisters. I wonder if you can tell me a bit about how you responded to your dad’s anger.”

“Well, I remember a few things. I remember really hoping something would happen that would distract him, like hoping he would turn on the TV. I also remember being glad his anger wasn’t directed toward me, and usually it wasn’t. I tried to stay quiet and out of the way. If I was involved, it was to try to calm or appease my dad before he got angry and out of control. When he wasn’t so angry, I loved being with him. He was just so unpredictable, and so I often felt like I was walking on eggshells.

And I didn’t have a lot of my own feelings; I was too busy monitoring his.” “It sounds like anger was a pretty scary feeling for you?”

“Yeah, it was.”

“And maybe it still is?” asked Evan.

“Yeah, I guess it is.”

“And it sounds as though feelings – your own feelings, that is – are pretty unfamiliar to you? You said you didn’t have a lot of your own feelings?”

“I think that’s true. I respond to others’ feelings, but I tend to have a difficult time feeling much of anything other than depression myself, especially these days. Do you think my father has something to do with my grief for Juan?” asked Sonia.

“I do,” responded Evan. “I think that you may have learned some things about relationships and feelings from your father. And my guess is that anger is difficult for you to experience and express.” Evan paused before continuing. “I wonder if you have allowed yourself to experience the full force of your anger about Juan being gone.”

This question opened up a new area of exploration for Evan and Sonia. Evan worked with Sonia to address possible obstacles to her capacity to experience her full range of feelings, anger included. After this session with Sonia, his therapy with Karen also opened into a new direction. He again thought about their similarities and differences, and specifically about their respective attachment styles. Whereas Evan believed both women were more or less securely attached, he conceptualized Sonia’s style as tending toward anxious- preoccupied and Karen’s as tending toward fearful- avoidant, although Karen certainly experienced a bond with her son. When that bond was severed to the extent that it was by his death, Karen turned away from a range of painful emotions and toward anger, which helped her to feel more powerful. Both women were finding ways to adapt that worked for them. Evan’s job was to understand how these adaptations served them, as well as how they posed obstacles to moving through their traumatic bereavement in a more complete way.

Concluding remarks

We have provided a comprehensive discussion of person- related risk factors in this chapter, in an effort to offer our fellow clinicians information about their clients that will make their interventions more effective. The issues discussed in this chapter – for example, personality and attachment style – help provide a framework for the thematic content we might listen for in our ongoing work with clients. If we can hold an awareness of those factors that have been shown both to facilitate and to challenge the mourning process and that of trauma accommodation, then we are in a better position to assess our clients’ unique needs and to intervene accordingly. Assessing what is true and relevant for a particular individual demonstrates respect and allows for the creation and strengthening of a therapeutic alliance.

The example of Evan’s work with two different clients who had lost sons in similar circumstances illustrates this process. Evan was able to assess and explore each woman’s general style of relating, conceptualize how this influenced their challenges in mourning the loss of their sons, and use this information to “fill in” the content of the particular interventions and processes that we discuss in Part III. Like Evan, we will all benefit from having a framework from which to assess those variables and risk factors that may affect a particular client’s experience, thereby deepening empathy and facilitating recovery.



Chapter 7. Treatment research

Two days before the Thanksgiving holiday, Harriet witnessed her partner die of a massive heart attack. She and Gwen were home alone, and Gwen was carrying extra chairs into their dining room from a spare bedroom upstairs. Harriet heard a crash and ran into the dining room to see Gwen clutching her chest. She was lying on the floor, gasping for breath, as Harriet picked up the phone to call 911. The next thing Harriet remembered was being down on the floor with Gwen, calling out her name over and over after she became nonresponsive. When the paramedics arrived, they began chest compressions, used the defibrillator, and quickly transported her to the hospital – but Gwen was already gone.

For the next year, Harriet felt as though she were in a daze. She seemed to be thinking about Gwen all the time, yet avoided talking about her to others, including their adult children. Harriet was haunted by images of what happened that day and memories of her own feelings of helplessness. In an effort to keep these images at bay, she tried to stay busy. She hated turning in at night because of the intense emptiness that she felt lying in bed alone. She also steered clear of their dining room because it evoked painful memories of the terrible scene of Gwen’s final moments. She decided to sell the house shortly after the first anniversary of Gwen’s death. Harriet came to recognize that staying in the home where they raised their children together would be impossible for her. She had come to realize that she could not continue living there without Gwen.

In developing this treatment approach, our goal has been to integrate work on the treatment of grief with work on the treatment of trauma. In so doing, we have identified a number of treatment elements that we believe are important for treating the traumatically bereaved, such as building self-capacities and prolonged exposure. Is there an empirical basis for these and other components that form the foundation of our treatment approach? In this chapter, we review the scientific evidence regarding efficacious treatments for survivors of sudden, traumatic loss. We begin by considering research and treatments pertaining to grief. We then examine several treatments that have been developed for PTSD. Although many practitioners regard grief counseling as effective, there is far more research evidence in support of trauma treatments. We discuss the implications of research in both areas for treating traumatic bereavement.

Treatment for grief and mourning

To learn more about grief research and treatments that might inform our approach, we draw from three topics. First, we trace the development of the most important and influential ideas about grief and its resolution. In so doing, we illustrate how beliefs about grief therapy have changed over the years. Theoretical orientations that were once central to our understanding of grief, such as Freud’s (1917/1957) notion of grief work and the various stage models of grief resolution, are far less influential today. To a considerable extent, these early views have been superseded by theoretical orientations that, in our judgment, have more to offer practitioners working in this field. These include the models of the mourning process developed by Worden (2009) and Rando (1993, 2014); the stress and coping model (Lazarus & Folkman, 1984); the continuing- bonds approach (Klass et al., 1996); the role of positive emotions in the grief process; the dual- process model of bereavement (Stroebe & Schut, 1999; M. S. Stroebe et al., 2005); and the role of meaning in the mourning process (Neimeyer, 2001; Neimeyer & Sands, 2011).

Second, we take a look at research designed to assess grief counseling as it is practiced in the United States today. These studies have compared clients receiving grief counseling with those in a control condition, such as being placed on a wait list. Taken as a whole, this research provides little support for the effectiveness of grief therapy.

Finally, we discuss scholarly research on complicated grief. As Shear, Simon, and colleagues (2011) have described it, complicated grief is a painful condition in which the normal grieving process becomes derailed. The bereaved person experiences prolonged acute grief symptoms, has difficulty meeting role obligations, and struggles unsuccessfully to build a rewarding life without the deceased person. The goal of this body of work is to identify those individuals who are most in need of grief treatment and most likely to benefit from it. To the extent that those with traumatic bereavement experience complicated grief, this work illustrates the devastating physical and mental health consequences that face traumatically bereaved clients.

Classic grief Theories: overview and description

Freud’s grief Work Perspective

One of the most influential approaches to loss has been the classic psychoanalytic model of bereavement, which is based on Freud’s (1917/1957) seminal paper “Mourning and Melancholia.” According to Freud, the primary task of mourning is the gradual surrender of one’s psychological attachment to the deceased. Freud believed that relinquishing the love object involves a painful internal struggle. The individual experiences intense yearning for the lost loved one, yet is faced with the reality of that person’s absence. As mourners review thoughts and memories, ties to the loved one are gradually withdrawn. Freud referred to this process, which requires considerable time and energy, as “grief work” or “the work of mourning.” At the conclusion of the mourning period, the bereaved individual is said to have “worked through” the loss and to have freed herself from an intense attachment to an unavailable person. Freud maintained that when the process has been completed, the bereaved person regains sufficient emotional energy to invest in new relationships and pursuits.

The understandings that emerged from Freud’s ideas have had a profound effect on grief treatment and have only recently been called into question (Bonanno & Kaltman, 1999; Stroebe, 1992 – 1993; Wortman & Boerner, 2011). For years, it was common for therapists to organize their entire treatment approach around the notion of loosening or breaking down bonds between the mourner and the deceased. Continued attachment to the deceased was referred to as unresolved grief (Klass et al., 1996). Rando (1993) has pointed out that a therapist who focuses on the importance of breaking the bond may see behaviors reflecting a continuing connection with the deceased, such as asking his advice on current life decisions, as maladaptive. Along similar lines, Valentine (2006) has emphasized that although “sensing the presence of the deceased” is very common (see our discussion in Chapter 12), treatment providers have often regarded it as a sign of continued attachment to the deceased and thus as indicative of pathology.

In a review of the literature on breaking down attachments to the loved one, Malkinson (2010) states that studies have not found support for the theory of relinquishing bonds. She argues that in many cases, studies have shown that inner relationships with the deceased often continue throughout one’s life, and that such ties are often beneficial. In fact, as we describe below, available evidence suggests that treatments centered around breaking down bonds between the bereaved person and the deceased may actually be harmful (Klass et al., 1996).

emphasis on negative emotions

In examining the mourning process as described by Freud, we are struck by the singular focus on negative emotions. Freud’s model emphasized the importance of working through the emotional pain associated with the loss. Amid the despair and anguish that often accompany grief, positive emotions may seem unwarranted or even inappropriate (Fredrickson, Tugade, Waugh, & Larkin, 2003). When they are mentioned at all, positive emotions are typically viewed as indicating denial and as impediments to the mourning process (Deutsch, 1937; Sanders, 1993; see Keltner & Bonanno, 1997, for a review). With notable exceptions (e.g., Folkman, 1997b, 2008; Folkman & Moskowitz, 2000; Fredrickson, 2001; Lazarus, Kanner, & Folkman, 1980), theories focusing on the grieving process have failed to consider the role that positive emotions may play. Subsequent work, discussed below, has demonstrated unequivocally that positive emotions can facilitate the healing process.

Stage models of grief

One of the most widely held assumptions about the mourning process is that people proceed through a series of stages as they attempt to come to terms with loss. One of the most influential stage models was proposed by John Bowlby (1980). In his seminal work on grief, Bowlby integrated ideas from psychodynamic thought, the developmental literature on young children’s reactions to separation, and work on the mourning behavior of primates. Bowlby maintained that during the course of normal development, individuals form instinctive affectional bonds or attachments. These are initially created between child and parent and later between adults. Bowlby was also the first to maintain that there is a relationship between a person’s attachment history and how he will react to the loss of a loved one.

According to Bowlby (1980), these attachments are formed because of a need for safety and security. He suggested that threats to affectional bonds activate powerful attachment behaviors, such as intense anxiety, crying, and angry protest. Unlike Freud, Bowlby believed that the biological function of these behaviors is not withdrawal from the loved one, but rather reunion. However, in the case of a permanent loss, the biological function of ensuring proximity with attachment figures becomes dysfunctional. Consequently, the bereaved person struggles between the opposing forces of activated attachment behavior and the reality of the loved one’s absence.

Bowlby maintained that in order to deal with these opposing forces, the mourner goes through four stages of grieving: initial numbness, disbelief, or shock; yearning or searching for the deceased, accompanied by anger and protest; despair and disorganization as the bereaved gives up the search, accompanied by feelings of depression and hopelessness; and reorganization or recovery as he accepts the loss, with a gradual return to former interests. By emphasizing the survival value of attachment behavior, Bowlby was the first to give a plausible explanation for responses such as anger or searching for the deceased during the mourning process. Drawing from this work, several theorists have proposed that people go through stages or phases in coming to terms with loss (see, e.g., Bowlby & Parkes, 1970; Engel, 1961; Parkes, 1972; Ramsay & Happee, 1977; Sanders, 1989).

Perhaps the best known stage model, preceding Bowlby’s model by a decade, is the one Kübler-Ross (1969) proposed in her highly influential book On Death and Dying. This model was developed to explain how dying persons react to their own impending deaths. It posits that people go through denial, anger, bargaining, depression, and ultimately acceptance. This model generated considerable interest among professionals providing late-stage and end-of-life care.

Within a few years, practitioners working in the field of bereavement began to apply Kübler-Ross’s stages of dying to individuals who were mourning the loss of a loved one. This approach captured the imagination of many grief practitioners. The book On Grief and Grieving: Finding the Meaning of Grief through the Five Stages of Loss (Kübler-Ross & Kessler, 2005), published shortly after Kübler-Ross’s own death, facilitated the application of Kübler-Ross’s ideas to the grief process.

Since that time, professionals with an interest in grief and loss have embraced Kübler-Ross’s stages of grief. Her stages have been integrated into the curriculum of thousands of academic and professional institutions across the country. The five stages proposed by Kübler-Ross have become a mainstay not only in counseling, but in social work, hospitals, medical schools, nursing programs, and seminaries. We see these stages in popular media (e.g., the TV shows Grey’s Anatomy and The Simpsons) as well as in self-help literature for the bereaved, appearing in magazines and books, and on influential websites.

Is there scientific evidence in support of stage models? With few exceptions (Maciejewski, Zhang, Block, & Prigerson, 2007), there are virtually no studies corroborating these models of the mourning process. Instead, well- designed studies have produced findings that do not support stage models (Barrett & Schneweis, 1981; Holland & Neimeyer, 2010). Robert Neimeyer (2001) has indicated that research has failed to identify a universal or normative pattern of mourning. As we have described in Chapters 5 and 6, there is considerable variability in the kinds of emotions people experience after a loss, and the order in which they are experienced. Nor do stage models help us understand why some people are devastated by a loss, while others emerge unscathed or even strengthened. Another criticism of stage models is that they place mourners in a passive role (Neimeyer, 1998). As we have described in Chapter 2, mourning is a process that requires the active involvement of the survivor. In addition, stage models focus almost exclusively on the survivor’s emotional responses to the loss. There is consensus that cognitions and behaviors are equally important targets of interventions. Finally, stage models do not acknowledge the role of situational factors – aspects of the death and its surrounding circumstances – which influence the effects on survivors.

Treatment Research

Stage models can have a negative effect on bereaved individuals, on those in their social networks, and on professionals who treat them. Each of these groups may use a stage model as a yardstick to assess how well a bereaved person is coping. Bereaved people may worry if they don’t experience a particular stage, erroneously inferring that they cannot move forward until they do. As one woman explained, “I haven’t felt much anger since my husband died. I asked my family to do things that would make me mad, so that I can go through the anger stage.” Or health care providers may lead mourners to feel that they are not coping correctly if they do not experience a certain stage. A woman who lost her daughter in a drunk driving crash told her therapist that she did not feel angry. The therapist replied, “Why aren’t you angry? You should be angry.”

Stage models can also lead others to dismiss mourners’ legitimate emotional reactions as “just a stage.” One woman attended a family gathering shortly after her husband’s death. Her sister asked repeatedly about how much insurance money she would receive. She finally rebuked her sister sharply, stating that she did not want to discuss the matter. Later she overheard her sister say to another family member, “Don’t worry about Jill. She’s just going through the anger stage.” In fact, one of the most problematic aspects of stage models is that they have great potential to confuse, inhibit, misdirect, or pathologize mourners.

Ironically, some of the harshest criticisms of the stage model were made by Kübler-Ross herself. To her credit, she noted in her final book (Kübler-Ross & Kessler, 2005) that the stages should be applied flexibly because all people don’t mourn in the same way. Unfortunately, many of her followers have paid little attention to these qualifications, and have tended to view her stages as a fixed sequence of responses. Shortly before her death in 2004, she stated that despite her best intentions, the stages she proposed have contributed to misunderstandings about the mourning process.

Why do treatment providers and laypersons alike cling to these models despite the absence of empirical support? Neimeyer (2001) has pointed out that stage models offer an apparent roadmap through turbulent terrains. It may be less frightening for people to go through the mourning process, or help others through it, if they know what is supposed to happen next. Such roadmap, however imperfect, may provide considerably more comfort than flying blind.

Classic Grief Theories: Impact on Clinical Practice

As Breen (2010 – 2011) indicates, “there is very little research describing grief counselors’ understandings of grief and how they incorporate these understandings into their practices” (p. 286). However, there are reasons to believe that the classic grief models are continuing to hold sway over some practitioners. As Jordan and Neimeyer (2003) emphasize, “It is a truism that grief is unique to each individual, yet this wisdom is rarely reflected in the design and delivery of services to the bereaved” (p. 782). Breen and O’Connor (2007) state that “although the assumptions within the dominant grief discourse have been subject to robust empirical and theoretical challenges in recent years, they remain uncritically accepted by many service providers” (p. 205). On the basis of their review of studies of current practices of health care providers, they conclude that the prevailing construction of grief “remains a stage-based reaction, where recovery occurs within a relatively short time frame… and continued attachment to the deceased is pathologized” (p. 202). Similarly, Rando (1993) has maintained that while practitioners pay lip service to the idea that grief is an individual process, many are still likely to believe that having a continued relationship with the deceased indicates complicated or pathological mourning, and that they need to “help” the bereaved to detach from the deceased and move on. Bennett and Bennett (2000 – 2001) note that the concept of a progression from desolation through detachment to “recovery” persists in much of the literature written by and for grief counselors.

Our observation is that clinicians practicing today are becoming increasingly skeptical about the value of any stage approach. However, there is evidence to suggest that other health care providers, such as physicians, nurses, and social workers, are likely to endorse views that are consistent with a stage approach. In a systematic study of 23 highly rated and best- selling psychiatric nursing texts, Holman, Perisho, Edwards, and Mlakar (2010) reported that 87% of the texts stated that there are set stages or a predictable course of coping. Moreover, 65% of the texts mentioned a timeline specific enough to indicate a given number of weeks or months for the mourning process to be completed. There was no significant correlation between the age of a textbook and the presence of such statements, suggesting that these problems in how grief is conceptualized in these terms are not being resolved over time. Holman and colleagues find these results surprising, in light of the fact that the nursing profession has adopted an evidence- based approach to practice. They express concern that these beliefs may undermine nurses’ ability to provide appropriate, supportive care that meets the unique needs of each patient.

The mourning Process: more recent Theoretical developments

Largely in reaction to the classic grief models described above, subsequent bereavement experts have proposed views of the mourning process that are less dogmatic, more flexible, and more consistent with research evidence. Six distinct approaches to the mourning process have informed our treatment approach. First, both Worden (2009) and Rando (1993) have rejected the idea that grief should be regarded as a fixed series of stages. Both maintain that much can be gained by regarding mourning as a set of overlapping tasks (Worden, 2009) or processes (Rando, 1993, 2014). The second approach, the stress and coping model (Lazarus & Folkman, 1984), addresses why some people show intense and prolonged distress following the death of a loved one while others do not. The model also helps to clarify how risk factors, such as the circumstances surrounding the loss, can help account for the variability in individual responses to the death of a loved one. Third, the continuing bonds approach has focused on the connection between the mourner and the deceased. This model has posed a challenge to the idea that the bond between the mourner and the deceased must be severed. Studies indicate that in many cases, a continuing connection with the deceased can be beneficial (Klass et al., 1996). Fourth, we discuss research on positive emotions (Folkman, 1997a, 2001) – a topic rarely considered by those interested in grief and loss. Such emotions are surprisingly prevalent during the mourning process. Moreover, it is clear that positive emotions can facilitate the process in many ways. Fifth, Stroebe and her associates (Stroebe & Schut, 1999; M. S. Stroebe et al., 2005) have developed a theoretical approach to grief known as the dual- process model. They have emphasized that loss- oriented responses, such as experiencing intrusive images of the loved one’s death, represent only part of the story of processing the loss. This model indicates that restorative activities, such as engaging in new pursuits or meeting new people, can play a vital role in the mourning process. Finally, as a way of emphasizing the uniqueness of each individual’s grief, Neimeyer and his associates (Holland et al., 2006; Holland & Neimeyer, 2010; Neimeyer, 2001; Neimeyer & Sands, 2011; Shear, Boelen, & Neimeyer, 2011) maintain that the process of mourning is in many cases a search for meaning. This perspective is valuable because it helps therapists engage with clients whose ways of finding meaning in life have been disrupted, if not destroyed, by the loved one’s death and its related losses. Each of these approaches to understanding and treating bereaved people is discussed below.

moving beyond Stages: Worden’s Tasks and rando’s “r” Processes

One shortcoming of the stage models is that they lack flexibility because each prescribes a specific sequence of responses to loss. Stage models also provide little guidance about how to help clients move forward with their mourning process. Two models have been designed to overcome these problems: Worden’s task model (Worden, 2009; Worden & Winokuer, 2011) and Rando’s (1993, 2014) “R” processes. Both of these approaches have been developed specifically to aid practitioners in intervening in the mourning process. Both are widely used in clinical settings, and practitioners generally regard them as helpful (see, e.g., Stroebe, Stroebe, Schut, & van den Bout, 1998).

Worden (2009) regards the grieving process as a series of specific tasks that should be addressed during treatment: to accept the reality of the loss; to process the pain of grief; to adjust to a world without the deceased; and to find an enduring connection with the deceased in the midst of embarking on a new life. According to Worden, a task approach is flexible because tasks can be addressed in different orders, depending on each client’s needs. In addition, he emphasizes that tasks can be revisited and reworked over time. He also states that unlike stages, which must be passed through, the tasks convey to the mourner that there are things she can do to adapt to the loss. This may help the mourner to maintain hope that she will be able to cope with the loss and move forward with her life. As Worden puts it, “This can be a powerful antidote to the feelings of helplessness that most mourners experience” (p. 38).

Rando (1993, 2014) conceptualizes mourning in terms of processes rather than tasks. As we have described in Chapter 2, she identifies six specific processes: Recognize the loss; React to the separation; Recollect and re-experience the deceased and the relationship; Relinquish the old attachments to the deceased and the old assumptive world; Readjust to move adaptively into the new world without forgetting the old; and Reinvest. Although there is some overlap between these two approaches, Rando’s “Rs” offer practitioners a more detailed and fine- grained analysis of the mourning process. Like Worden (2009), Rando maintains that the sequence of the “Rs” is not fixed. According to Rando, mourners may move back and forth among processes; such movement illustrates the nonlinear and fluctuating course of mourning.

Rando (1993) believes that keeping the focus on processes rather than tasks helps a therapist to focus on what a mourner is doing at present, thus providing more immediate feedback on where the mourner is in the process and how to intervene. These “R” processes form an important component of our treatment approach, and are discussed further in Chapter 12.

understanding variability in response to Loss: The Stress and coping approach

Over the past two decades, a theoretical orientation referred to as the stress and coping approach (Lazarus & Folkman, 1984) has become highly influential in the field of bereavement. The basic assumption underlying this model is that exposure to stressful life events, such as the death of a loved one, can precipitate the onset of physical or mental health problems. Investigators using this approach were particularly interested in understanding why some people show great vulnerability to stressful life experiences while others do not (Wortman & Boerner, 2011).

The stress and coping approach highlights the role of cognitive appraisal in understanding how people react to loss. A person’s appraisal, or subjective assessment, of what has happened is hypothesized to play a major role in determining her reaction to the stressor. The stress and coping model also calls attention to the critical role played by the survivor’s coping resources. Individuals appraise events as stressful when they believe their coping resources are insufficient to deal with what has happened. Building clients’ coping resources is a major focus of this treatment approach. Augmenting their resources enables clients to do the hard work of processing and mourning the loss.

To account further for why a given loss has more impact on one person than on another, stress and coping researchers have focused on the identification of potential risk factors, or factors that enhance vulnerability to the stressful event. Over the past decade, countless studies have demonstrated that risk or vulnerability factors dramatically affect reactions to the death of a loved one. As we have discussed in Chapter 5, some risk factors focus on circumstances surrounding the loss, such as whether the death was violent. Others are person- related factors like attachment history and gender, as described in Chapter 6. Knowledge of risk factors helps practitioners to tailor the treatment to the unique vulnerabilities of each client.

Breaking Down attachments

According to the traditional view of the mourning process, it is necessary to disengage from the deceased in order to get on with life (Freud, 1917/1957; Volkan, 1971). As described above, these writers believed that for grief work to be completed, the bereaved person must withdraw energy from the deceased and thus free himself from that attachment. Until recently, relinquishing the tie to the deceased has been a major goal of grief therapy (see, e.g., Humphrey & Zimpfer, 1996; Sanders, 1989).

During the past decade, this view has been called into question (for reviews, see Stroebe & Schut, 2005; Wortman & Boerner, 2011). Indeed, it appears that an increasing number of researchers and practitioners now believe that it is normal to maintain a continuing connection to the deceased, and that such a connection may actually promote good adjustment following the loss (Attig, 1996; Klass et al., 1996; Neimeyer, 1998; Shmotkin, 1999). In their ground- breaking book Continuing Bonds, Klass and colleagues (1996) have also emphasized the potential value of maintaining a healthy connection with the deceased loved one. These investigators note that their training led them to expect grief resolution to be accompanied by breaking down attachments to the deceased. However, this was not what they found in their research or in their clinical work. For example, in their work with bereaved parents, they found that the process through which parents resolved their grief involved sustaining an intense connection with the child who died. They report that in almost all cases, parents were able to move forward only by maintaining the child as a significant presence in their lives.

In their study of how the death of a child as a result of accident, suicide, or homicide affected parents, Murphy and colleagues (1999) obtained similar findings. When asked what challenge they were facing at the present time, 76% of the respondents at 4 months, and 52% at 12 months, stressed the importance of maintaining ties with their deceased child.

In recent years, practitioners working within a continuing- bonds framework have come to recognize that encouraging such bonds is not always beneficial to a client. As we discuss in more detail in Chapter 12, it is important to identify what can be continued and what needs to be relinquished, given the reality of the death (Field, 2008; Rando, 1993, 2014). In an excellent discussion of this matter, Field and Wogrin (2011) emphasize the importance of transforming the bond from a physical one to one that is mental or symbolic. They suggest that a symbolic bond can serve as a “safe haven” for a bereaved client, which can facilitate the ability to move forward.

The role of Positive emotions

Until recently, grief therapy has been based on the implicit assumption that negative feelings must be “worked through.” As noted above, it was also widely assumed that mourners rarely experience positive emotions. When they do emerge, such feelings are thought to reflect a failure to accept the loss and its ramifications.

In the 1980s, Wortman and her associates became interested in whether positive emotions were experienced by people who had encountered major losses, and if so, whether they might sustain hope and facilitate adjustment. Therefore, they decided to measure positive as well as negative emotions in a study focusing on loss of a child as a result of SIDS (see Wortman & Boerner, 2011, for a more detailed discussion).

This study provided clear evidence that positive emotions are prevalent following major loss. At 3 weeks following the death of their infant to SIDS, parents reported experiencing positive emotions such as happiness as frequently as they experienced negative feelings. By the second interview, conducted 3 months after the infant’s death, positive affect was more prevalent than negative affect; this continued to be the case at the third interview, conducted at 18 months after the loss. Respondents were asked to describe the intensity as well as the frequency of their feelings. These measures were included so that the investigators could determine whether negative feelings, while no more prevalent than positive ones, were more intense. However, this did not turn out to be the case. At all three interviews, feelings of happiness were found to be just as intense as feelings of sadness. In fact, at the second and third interviews, respondents reported that their feelings of happiness were significantly more intense than their feelings of sadness.

Subsequent studies have corroborated that positive emotions are surprisingly prevalent during bereavement (Folkman, 1997a, 2001; Folkman & Moskowitz, 2000; Stein, Folkman, Trabasso, & Richards, 1997). Research has also demonstrated that the ability to display positive emotions is associated with the resolution of grief. Bonanno and Keltner (1997) conducted a study with people who lost a spouse. At 6 months after the loss, they asked respondents to talk about their relationships with their deceased spouse. Participants were videotaped during the interviews, and the videotapes were then coded for the presence of genuine laughs or smiles, which involve movements in the muscles around the eyes. The majority of participants exhibited positive emotion. Moreover, the presence of positive affect was associated with reduced grief at 14 and 25 months after the losses. Those who exhibited laughs or smiles also evoked more favorable responses in observers (Keltner & Bonanno, 1997). In addition to rating them more positively overall, observers rated those who engaged in laughs and smiles as healthier, better adjusted, less frustrating, and more amusing. These findings suggest that one way positive emotions may facilitate coping with loss is by eliciting positive responses from those in the social environment. On the basis of these results, Bonanno (2001) maintains that recovery is most likely when negative grief- related emotions are regulated or minimized and when positive emotions are instigated or enhanced.

Folkman (1997b, 2001, 2008) has also conducted important work on the role of positive emotions in coping with bereavement. Folkman proposes that when people are distressed as a result of a loss event, they can generate positive emotions by infusing ordinary events with positive meaning. This observation came about in an interesting way. In a study of caregiving partners of men with AIDS, Folkman (1997b) had initially focused exclusively on stressful aspects of the caregiving situation. Respondents were questioned about these aspects every 2 months. Shortly after the study began, several participants “reported that we were missing an important part of their experience by asking only about stressful events; they said we needed to ask about positive events as well if we were to understand how they coped with the stress of caregiving” (p. 1215). Consequently, Folkman added a question in which respondents were asked to describe “something you did, or something that happened to you, that made you feel good and that was meaningful to you and helped you get through the day” (p. 1215). Such events were reported by 99.5% of the respondents. Events focused on many different aspects of daily life, such as enjoying a good meal, receiving appreciation for something done for one’s partner, or going to the movies with friends. Folkman has hypothesized that events of this sort generate positive emotion by helping people feel connected and cared about, by providing a sense of achievement and self- esteem, and by providing a respite or distraction from the stress of caregiving. She has suggested that engaging in activities that generate positive emotions, and positive emotions themselves, can help sustain coping efforts in dealing with a stressful situation. More recent empirical evidence is consistent with this prediction (Bonanno, Moskowitz, Pappa, & Folkman, 2005; Moskowitz, Folkman, & Acree, 2003).

The Dual-Process model

As described above, the concept of grief work, or working through the loss, is central to grief treatment as it is practiced today. Grief work typically refers to such processes as confronting the reality of the death and its many ramifications.

Stroebe and Schut (2010) have argued that despite its dominance in the field of grief counseling, the grief work hypothesis has a number of serious limitations. First, drawing on bereavement practices in non- Western cultures, they maintain that confronting one’s grief is not always necessary for adaptation to occur. Second, consistent with other bereavement researchers and practitioners, they indicate that the grief work approach “seems somewhat passive (as though the person is being put through, rather than dealing with… the effortful struggle that is so much part of grieving)” (p. 275). Finally, they state that those working within a grief work perspective fail to acknowledge the need for “dosage” of grief, given how arduous and exhausting the mourning process can be.

In order to address these shortcomings, Stroebe and Schut (1999, 2010) have developed the dual- process model of grief. They suggest that responses to the death of a loved one can be classified into two broad categories: loss- oriented and restoration- oriented. Loss- oriented coping refers to processing some aspect of the lost relationship. Examples of loss- oriented responses include experiencing the pain associated with the loss, reminiscing about life as it had been, or ruminating about the circumstances surrounding the death. Most past models of mourning have focused exclusively on loss- oriented coping.

Stroebe and Schut’s (1999, 2010) focus on the benefits of restoration- oriented coping is highly compatible with the material on positive emotions discussed above. Such coping might involve doing new things, mastering new skills, taking on new roles or identities, or entering new relationships. Like positive emotions, restoration- oriented coping provides a respite from the intense pain associated with loss- oriented coping. Stroebe and Schut (2001a, 2010) have proposed that a bereaved person typically alternates between loss- and restoration-oriented coping. They indicated that oscillation between these types of responses is necessary for accommodating the loss. Restorative activities not only give the mourner a break from the difficult work of facing the loss, but also help replenish psychological resources such as energy and hope (Folkman, 2001). Over time, there is usually a shift away from loss- oriented coping and toward restoration- oriented coping, such as developing new relationships.

The dual- process model has generated a great deal of interest among researchers and practitioners. Some clinicians who have developed interventions for the bereaved have used this model as an organizing framework (Richardson, 2010; Shear, Frank, Houck, & Reynolds, 2005; Shear, Gorscak, & Simon, 2006). One of the most significant aspects of this model is that it advocates exposing clients to the painful aspects of their grief in small amounts. As Rando (1993) has expressed it, “Respites and diversions permit distance and allow for replenishment, reconnection with other parts of life, and a renewed sense of control” (p. 47). Similarly, Shear (2010) has stated that “Coming to terms with the death is a process that works best if it is grappled with, set aside, and revisited” (p. 364). Approaching grief in manageable pieces is essential in treating traumatic bereavement, and is central to our treatment approach.

The importance of meaning

A major development in the treatment of grief is Neimeyer’s work on meaning reconstruction following the death of a loved one (Holland et al., 2006; Holland & Neimeyer, 2010; Neimeyer, 2001; Neimeyer & Sands, 2011; Shear, Boelen, & Neimeyer, 2011). Unlike many accounts of the mourning process, Neimeyer has emphasized that grief is an idiosyncratic process in which people strive to make sense out of what has happened. Neimeyer and Sands (2011) have pointed out that this quest can occur at many levels, “from the practical (How did my loved one die?) through the relational (Who am I, now that I am no longer a spouse?) to the spiritual or existential (Why did God allow this to happen?)” (p. 11; emphasis in original). There is accumulating evidence that the effort to find meaning can play a constructive role in the mourning process (Holland & Neimeyer, 2010).

Much of our description of the impact of traumatic death has focused on how it robs our lives of meaning. We have drawn from Neimeyer’s rich and thoughtful body of work to address how the traumatically bereaved are affected by their losses, as well as how issues surrounding meaning can be addressed with sensitivity and compassion.

grief Treatment effects

During the 1990s, there was a proliferation of opportunities for therapy for those mourning the loss of a loved one. This was reflected in the wide variety of workshops, professional conferences, and individual and group treatments offered in most communities (Neimeyer, 2000b). During this period, a new field called grief counseling was born. Generally speaking, grief counseling is based on the assumption that individuals must “work through” and accommodate their loss (see, e.g., Rando, 1993; Worden, 2009). Some practitioners have differentiated between grief counseling and grief therapy. For example, Worden (2009) has indicated that the goal in grief counseling is to facilitate the tasks of mourning, such as accepting the reality of the loss and processing the pain of grief. In contrast, he notes that grief therapy should be used when the survivor is experiencing feelings of grief that are more intense than usual, more prolonged, or both. Grief counseling or therapy typically includes such elements as helping a survivor to grasp the reality of what has happened; assisting her in identifying and expressing feelings; normalizing feelings that emerge; helping her to formulate a realistic appraisal of her relationship to her loved one; assisting her in learning to live without the deceased; and helping her to form a new identity and reengage with life (see Worden, 2009, for a more detailed discussion).

As Neimeyer (2000b) has indicated, it is widely assumed that grief counseling is “a firmly established, demonstrably effective service, which seems to have found a secure niche in the health care field” (p. 542). Has research in fact shown that this type of treatment is effective? In recent years, several reviews of grief treatment studies have appeared in the literature (e.g., Allumbough & Hoyt, 1999; Fortner & Neimeyer, summarized in Neimeyer, 2000b; Jordan & Neimeyer, 2003; Kato & Mann, 1999; Larson & Hoyt, 2007; Schut, Stroebe, van den Bout, & Terheggen, 2001; M. S. Stroebe et al., 2005). With one exception (Larson & Hoyt, 2007), these reviews have come to the same conclusion: that the scientific basis for the efficacy of counseling for grief and mourning is weak. The most comprehensive and methodologically rigorous review was conducted by Currier, Neimeyer, and Berman (2008). Overall, their analyses demonstrated that interventions had only a small effect when they assessed respondents at posttreatment and no significant effect at follow- up, which was on average about 36 weeks later.

Despite the absence of overall effects, Currier and colleagues (2008) noted that there was considerable variation in the impact of different treatments. They found that respondents’ levels of distress strongly influenced the benefits derived from treatment. If the respondents were experiencing high distress, the results showed a clear benefit at both posttreatment and follow- up. Currier and colleagues indicated that effect sizes (a measure of clinical relevance) for respondents showing high distress compared favorably with the positive outcomes shown for psychotherapy in general.

Neimeyer and his colleagues have identified some additional factors that help to contextualize the findings from grief treatment studies. One important factor is the timing of the treatment. Jordan and Neimeyer (2003) found that interventions that were delivered shortly after the death had significantly smaller effect sizes than those delivered later. Jordan and Neimeyer have suggested that there may be a “critical window of time” (p. 774) when it is best to offer interventions – perhaps 6 – 18 months after the loss, “before problematic patterns of adjustment have become entrenched” (p. 774). These investigators have also emphasized that the types of counseling needed shortly after a loss may differ markedly from what is needed a year after the loss, or 10 years later, noting that therapists should attempt to customize the type of intervention to the particular points their clients have reached in the mourning trajectory.

Complicated grief

One of the most influential and important lines of research on bereavement is that on complicated grief (abbreviated in this section as CG). Chief goals of this work involve identifying individuals who develop persistent and debilitating symptoms of grief, and examining the consequences of CG for subsequent physical and mental health. Researchers working in this area have been interested in developing effective treatments for those with CG. Finally, there has been increasing interest among researchers in getting CG classified as a mental disorder in the Diagnostic and Statistical Manual of Mental Disorders (DSM). (For a full discussion of CG and its implications for research and treatment of the bereaved, see Stroebe, Schut, & van den Bout, 2013.)

Since the 1960s, bereavement researchers have been interested in identifying individuals who maintain chronically high levels of grief symptoms that do not abate with time. However, there have been no standard guidelines to determine how therapists should diagnose and treat complications following bereavement. Researchers and clinicians have used a variety of terms to describe the mourning process of these individuals. Some of these terms include atypical, neurotic, pathological, unresolved, chronic, and prolonged grief (Prigerson, Frank, et al., 1995; Prigerson et al., 2009; Rando, 1993). As Rando has noted, different clinicians have used these terms in different ways, thus impeding communication not only among clinicians, but between clinicians and their clients.

There has been considerable interest in the development of a uniform set of criteria that could be used to diagnose CG (see, e.g., Horowitz et al., 1997), presumably in the interest of providing better treatment for mourners. Over the last 15 years, significant progress has been made in clarifying how CG should be conceptualized and measured. One way of conceptualizing CG has been proposed by Prigerson and her associates (e.g., Jacobs, Mazure, & Prigerson, 2000; Prigerson, Maciejewski, et al., 1995; Prigerson et al., 1999; for reviews, see Lichtenthal, Cruess, & Prigerson, 2004; Prigerson, Vanderwerker, & Maciejewski, 2008; Zhang et al., 2006). In a ground- breaking program of research, these investigators have focused on the development of diagnostic criteria to identify bereaved individuals who exhibit intense and prolonged distress and thus would be candidates for clinical intervention. Drawing from the opinions of experts as well as epidemiological and clinical research, Prigerson and colleagues have identified a unique pattern of symptoms that they call prolonged grief disorder (PGD).[4] They maintain that these symptoms are associated with enduring mental and physical health problems that are typically slow to resolve, and that can persist for years if left untreated.

Prigerson and colleagues (2009) have also developed a scale to measure PGD, and have devoted considerable effort to establishing its reliability and validity. To meet criteria for PGD, an individual must experience intense yearning or longing for the deceased, either daily or to a disabling degree. In addition, she must have five or more of the following symptoms, and these must be experienced daily, or to a disabling degree: feeling stunned, dazed, or shocked by the death; avoiding reminders of the reality of the loss; having trouble accepting the death; having difficulty trusting others; feeling bitterness or anger related to the loss; experiencing difficulty moving on with life; experiencing confusion about one’s role in life or a diminished sense of self; feeling that life is unfulfilling, empty, or meaningless since the loss; and feeling numb (absence of emotion) since the loss. These symptoms must cause clinically significant impairment or dysfunction in social, occupational, or other important roles, and a diagnosis should not be made until at least 6 months have elapsed since the death.

Several other criteria sets have been proposed for CG (see Shear, Simon, et al., 2011, for a review). Shear, Simon, and colleagues (2011) identified three symptoms not included in Prigerson’s criteria: suicidal thinking and behavior; rumination about the circumstances or consequences of the death; and physical and emotional activation when one is exposed to reminders.

Except for these symptoms, there is considerable overlap between the two sets of criteria.

Virtually all of the empirical work on CG has focused on these two sets of criteria. However, it must be noted that there are other ways of conceptualizing CG. For instance, CG can be manifested in a variety of symptoms or syndromes, or as a diagnosable mental or physical disorder (e.g., PTSD, irritable bowel syndrome; Rando, 1993, 2013). Recently, a panel of experts identified several types of grief- related syndromes that, in their judgment, reflect CG and warrant further research and consideration. These included, but were not limited to, delayed grief, inhibited grief, and other forms of chronic grief that can be differentiated from PGD (Rando et al., 2012).

For the remainder of this section, the reader should be aware that when we are talking about CG, we are focusing on research that has been conducted primarily using PGD (or the Shear model), mentioned above. To the extent that a therapist is working with different forms of CG, the research cited below may be less applicable.

Research indicates that CG symptoms form a unified cluster and that they are distinct from depression, anxiety, or PTSD. For example, feeling sad and blue is characteristic of depression but not of CG, and hyper arousal is characteristic of PTSD but not of CG (Bonanno et al., 2007). Treatments for depression or PTSD are not effective for intense and prolonged grief symptoms. In fact, available evidence indicates that antidepressant medication has little impact on the symptoms associated with CG (Zhang et al., 2006). Consequently, if persons with CG symptoms are diagnosed with depression or PTSD rather than CG, they may not receive the treatment that is most appropriate. Moreover, until CG or a comparable diagnostic category is given formal recognition as a mental disorder in the DSM, clients with CG symptoms who do not meet criteria for another diagnosis may not receive insurance reimbursement for their treatment.[5]

With its focus on specific criteria for identifying those with PGD, Prigerson’s program of research laid the groundwork for research on the physical and psychological ramifications of CG. Studies suggest that the prevalence of CG among individuals who have lost a loved one is between 10 and 20%. Symptoms of CG typically last for several years. They predict morbidity (e.g., suicidal thoughts and behaviors, incidence of cardiac events, high blood pressure), adverse health behaviors (e.g., increased alcohol consumption and use of tobacco), and impairments in the quality of life (e.g., loss of energy) (for reviews, see Boelen & Prigerson, 2013; Prigerson et al., 2009; Zhang et al., 2006). As a result, it is critically important that those with CG be diagnosed and treated. Interestingly, bereaved people with CG are significantly less likely to seek professional services than bereaved persons without CG. People with CG may have difficulty mobilizing themselves to go into treatment. Alternatively, they may also avoid treatment because they believe it would be unbearably painful to focus on the loss. Even those who are interested in receiving treatment may have difficulty getting the help they need. Shear, Simon, and colleagues (2011) interviewed over 200 individuals seeking help for CG about their previous treatment experiences. According to these investigators, many patients had “been on treatment seeking odysseys for years” (p. 106). Shear, Simon, and colleagues reported that 85% of their respondents had previously sought treatment for grief, and that many had made multiple attempts to get help.

What is the relation between CG and traumatic bereavement? Both focus on individuals who are unable to move forward, to accept the reality of their loved ones’ deaths, or to reinvest in the future. Among the traumatically bereaved, circumstances surrounding the loss (e.g., whether it was sudden or untimely) are critically important. Such characteristics of the loss are not essential risk factors for CG. Instead, researchers posit that vulnerability to CG is rooted primarily in threats to secure attachment. As Zhang and colleagues (2006) have noted, CG “is fundamentally an attachment disturbance” (p. 1195). Most of the other risk factors for CG that are discussed in the literature include person- related factors, such as a family history of mood or anxiety disorders, childhood abuse and neglect, childhood separation anxiety, insecure attachment, and marital closeness (see Shear, Simon, et al., 2011, and Zhang et al., 2006, for reviews).

Despite this focus on person- related variables, researchers have noted increasingly that the circumstances surrounding the death indeed constitute an important risk factor for the development of CG. For example, Shear, Boelen, and Neimeyer (2011) emphasized that CG is more likely to occur among those who experience an “untimely, unexpected, violent or seemingly preventable death” (p. 140). Thus, at this time, it appears that some thinking about CG is placing greater emphasis on the circumstances under which the loss occurs. In fact, some investigators have maintained that CG has two components: separation distress, assessed by such factors as yearning and considered the core of CG; and traumatic distress, assessed by such factors as feeling shocked or stunned by what has happened (Holland & Neimeyer, 2011).

Yet the traumatically bereaved population faces issues that are not typically encountered by those with CG. Because of the traumatic circumstances under which the death occurred, most survivors of traumatic bereavement will be preoccupied with the issues raised in Chapter 3, such as difficulty accepting the loss, grappling with meaning, questioning their faith, struggling with issues of guilt and blame, and preoccupation with their loved ones’ possible suffering. It is critically important that these issues be thoroughly addressed during the course of the treatment. In many instances, this has not been the case in the research on CG or its treatment. Of course, some people with CG will struggle with these issues as well, but in our reading of the literature, they are not as predominant among those with CG as within the traumatic bereavement population. These clients have lost loved ones in deeply shocking ways. The traumatically bereaved population is, by definition, dealing with trauma in addition to grief. This is why our treatment places great emphasis on developing clients’ internal and external resources to support trauma processing and facilitate mourning.

Treatment for PTSD

In contrast to the research on treatments for grief, there is a substantial body of research demonstrating the efficacy of several treatments for PTSD. Given the prevalence of PTSD symptoms among survivors of sudden, traumatic death, this body of work has important implications for the treatment of traumatically bereaved persons. Of course, there are many other reactions to traumatic events besides PTSD symptoms. Elements of complex trauma, such as dissociation, somatization, and affect lability, are also very significant among survivors of traumatic death. Because a traumatic death is a sudden (Type I) rather than a chronic (Type II) stressor (see Terr, 1995, for more on this distinction), however, we focus on PTSD rather than complex trauma responses. We use PTSD at times, and trauma at other times, to refer to the traumatic stress element within traumatic bereavement.

Below, we first summarize the evidence for PTSD treatment effects among trauma survivors. We then focus our attention on three treatments for PTSD that are particularly relevant to the treatment of traumatic bereavement. Two of these treatments – one developed by Edna Foa and one developed by Patricia Resick – were originally designed to treat survivors of rape (for reviews, see Cahill, Rothbaum, Resick, & Follette, 2009; Riggs, Cahill, & Foa, 2006; Shipherd, Street, & Resick, 2006). The third treatment was developed by Marylene Cloitre for adult survivors of childhood sexual abuse (for a review, see Cloitre & Rosenberg, 2006).

PTSD Treatment effects

A large number of randomized studies have been conducted to evaluate various treatments for PTSD. Over time, these studies have become increasingly rigorous and methodologically sophisticated. Most of the treatments evaluated in these studies have involved some type of CBT. Several different types of CBT programs have been tested empirically. Prolonged exposure (PE; Foa & Rothbaum, 1998) involves imaginal exposure to the traumatic memory and behavioral exposure to reminders of the traumatic event. Cognitive processing therapy (CPT; Resick & Schnicke, 1993) involves challenging distorted beliefs and includes a form of PE. In some studies, elements of these treatments have been implemented individually; in others, they have been combined. For example, Cloitre and colleagues (2002) combined an initial phase of training in self- regulation with a second phase that involved exposure.

It should be noted that these studies have not focused specifically on survivors of traumatic death. Many of the treatments were developed for survivors of sexual assault or for war veterans. Some have focused on survivors of a broad array of traumatic experiences, including the deaths of loved ones (see Foa, Keane, Friedman, & Cohen, 2009, for a review). It is our belief that the results of these studies will generalize to those facing the sudden, traumatic death of a loved one. Consequently, we discuss them in some detail.

As treatment research on PTSD has continued to accumulate, a number of meta- analyses have appeared in the literature. Some have focused on the broad array of CBT treatments that are available. For example, Bradley, Greene, Russ, Dutra, and Westen (2005) conducted a meta- analysis of randomized treatment studies for PTSD. The authors reviewed 26 studies focusing on a wide array of traumatic stressors, including violent crime, combat, accidents, rape, and childhood sexual abuse. The vast majority of studies involved some form of CBT (including eye movement desensitization and reprocessing [EMDR]).[6] These treatments were compared with control conditions, some of which involved supportive counseling and some of which were waitlist controls. In examining pre- to posttreatment change among those who received some form of CBT, the authors found a large effect size for these treatments, and a far smaller effect size for supportive or wait-list controls. At the conclusion of the treatment, 67% of those who completed one of the CBT treatment programs no longer met the criteria for PTSD. Bradley and colleagues concluded that based on these results, the treatments produced “substantial improvement for patients with PTSD” (p. 223). Several other reviews have drawn similar conclusions about the efficacy of CBT for PTSD, including the expert consensus guidelines on the treatment of PTSD (Foa, Davidson, & Frances, 1999); the practice guidelines from the International Society for Traumatic Stress Studies (ISTSS; Foa et al., 2009), and a narrative review completed by Harvey, Bryant, and Tarrier (2003). Taken together, these reviews, and the studies on which they are based, provide overwhelming evidence for the efficacy of CBT for PTSD.

This body of work has a great deal to offer those who are treating survivors of traumatic death. We believe that three types of PTSD treatments are critically important: offering PE; challenging distorted beliefs about the traumatic event; and strengthening clients’ personal resources (e.g., helping them identify and regulate their feelings) prior to exposure. Below, we first review the evidence in support of these treatment types. Next, we describe how we have drawn from these treatments in developing our treatment approach for traumatic bereavement.

Types of Treatment for PTSD

Prolonged exposure

Foa and her associates (e.g., Foa, Dancu, et al., 1999; Foa, Zoellner, Feeny, Hembree, & Alvarez- Conrad, 2002) have been involved in a program of research to assess the efficacy of PE in the treatment of rape survivors. The term exposure therapy refers to “a treatment strategy for reducing anxiety that involves confronting situations, activities, thoughts, and memories that are feared and avoided even though they are not inherently harmful” (Riggs et al., 2006, p. 65). PE is a treatment involving four components: (1) psychoeducation about trauma and PTSD; (2) breathing retraining; (3) in vivo (meaning “in life”) exposure to the trauma- related situations that the client fears and avoids; and (4) imaginal exposure that involves repeatedly reviewing memories of the traumatic event. In many studies, each client is asked to make a tape recording of her account of the rape and to listen to it between sessions (for a more detailed description, see Foa & Rothbaum, 1998).

Studies conducted by Foa and her colleagues have provided consistent evidence that PE is a powerful treatment for survivors of rape (for a review, see Riggs et al., 2006). For example, Foa and colleagues (2002) compared PE alone to PE combined with cognitive restructuring and a wait-list control condition. Results showed that both treatment conditions were highly effective in reducing PTSD, as well as alleviating depression and anxiety, in comparison with the wait-list control. Since these studies have been conducted, PE, either alone or in combination with other CBT approaches, has been found to be effective for a wide variety of populations, including survivors of motor vehicle accidents (Blanchard et al., 2003), domestic violence (Aderka, Gillihan, McLean, & Foa, 2013; Kubany, Hill, & Owens, 2003), and physical assault (Foa, Dancu, et al., 1999; Foa et al., 2002).

Powers, Halpern, Ferenschak, Gillihan, and Foa (2010) conducted a meta- analytic review of studies using PE to treat PTSD. Their goal was to determine the effectiveness of PE in comparison to control conditions (wait-list or “psychological placebo”). Analyses showed a large effect of PE in comparison to controls at the conclusion of the study, and a medium to large effect at follow- up. The average PE-treated patient fared better than 86% of patients in control conditions. Powers and colleagues concluded that “PE is a highly effective treatment for PTSD that confers lasting benefits across a wide range of outcomes” (p. 639).

In a narrative review of studies using PE, Sharpless and Barber (2011) concluded that there is more evidence in favor of using PE to treat PTSD than using any other treatment. These investigators further note that PE is one of only two therapies selected by the Department of Veterans Affairs (VA) and the U.S. military for widespread dissemination. Sharpless and Barber point out that the effectiveness of this treatment has been replicated across gender and types of traumatic events.

cognitive Processing therapy

A second treatment that has implications for treating traumatically bereaved clients is CPT, developed by Resick and Schnicke (1992, 1993) for the treatment of rape survivors. The PE component of their treatment involves writing accounts of the rape, including thoughts, feelings, and sensory details, and reading the account daily and in session. However, Resick and Schnicke maintain that PE alone may be insufficient to deal with the powerful emotions that rape survivors sometimes experience. One emotion that is quite prevalent among these survivors is guilt. Resick and Schnicke (1993) believe that emotions like guilt and the related self-blame may benefit from a more direct and focused intervention targeting the distorted beliefs that maintain them. Hence CPT combines PE with cognitive therapy. Clients focus on distorted beliefs that underlie guilt and self-blame. They work with the therapist to complete several exercises, such as “faulty thinking pattern” sheets, in order to challenge these erroneous beliefs.

In developing CPT, Resick and Schnicke (1996) drew from the work of Pearlman and colleagues (McCann & Pearlman, 1990b; Pearlman & Saakvitne, 1995), mentioned in earlier chapters, in identifying disrupted beliefs or schemas (safety, trust, control, esteem, and intimacy) particularly sensitive to trauma. They conducted a randomized study in which they compared CPT with the best available empirically tested treatment, which was PE, and a minimal- attention wait-list condition. The target population in this study was female survivors of rape. The findings indicated that both treatments were highly effective and were superior to the control condition. Results of the two therapies were similar, except that CPT produced better scores on some of the scales measuring guilt. It should be noted, however, that far more research has been conducted on the efficacy of PE than on CPT. In their review, Sharpless and Barber (2011) state that the treatment has very strong empirical support. These investigators also note that CPT is the other psychological treatment chosen to be utilized by the military and the VA.

Further comments on Pe and CPT

The treatments described above, PE and CPT, both involve exposure to reminders of the traumatic event. There is consistent evidence that exposure plays a critical role in reducing symptoms among individuals with PTSD. More studies support the use of exposure than any other treatment.

To summarize, there is a striking difference between the scientific literature on treatment for grief and treatment for PTSD. As discussed above, there is weak evidence that grief therapy, as it is practiced today, is effective overall in reducing symptoms (although there is stronger evidence of its effectiveness for highly distressed persons). In contrast, there is overwhelming evidence for the effectiveness for such treatments as PE and CPT for the treatment of PTSD. Taken together, the studies on the efficacy of PE and CPT demonstrate that in most cases, respondents improve on a variety of measures. For example, Resick and colleagues (2008) found that female survivors of interpersonal violence with PTSD showed marked improvement following CPT not only in PTSD, but in depression, anxiety, anger, guilt, shame, and cognitive distortions. There is also clear evidence that in many cases, these treatments result in enduring changes. For example, Resick, Williams, Suvak, Monson, and Gradus (2012) conducted a longterm follow- up of rape victims with extensive histories of trauma, who were previously treated with CPT or PE. These respondents were assessed 5 – 10 years after the original study. They showed lasting changes in PTSD and related symptoms.

In the past few years, books have been written for clinicians who wish to integrate these evidence- based treatments for PTSD into their practice (see, e.g., Foa, Hembree, & Rothbaum, 2007; Foa et al., 2009). The latter book focuses specifically on the use of PE, and provides specific and detailed suggestions about how to implement it. Nevertheless, many investigators have commented that despite overwhelming evidence of its effectiveness, practicing clinicians rarely implement exposure- based treatments (see Cahill, Foa, Hembree, Marshall, & Nacash, 2006, for a more detailed discussion). Becker, Zayfert, and Anderson (2004) reported that only 17% of the sample of 207 psychologists they interviewed reported using exposure treatment for PTSD. These researchers note several possible reasons why clinicians may be reluctant to use exposure. Some may be concerned about patient dropout rates. In a study of the efficacy of PE in a clinical practice, the treatment completion rate was only 28% (Zayfert et al., 2005). This rate encompassed patients electing not to start the therapy, as well as those dropping out prematurely. Some therapists may fear the intensity of emotions that exposure can generate. Others may be concerned that such treatments may exacerbate symptoms and possibly retraumatize the clients. As one therapist indicated while treating a woman who had been brutally attacked and then raped, “I was overwhelmed by her feelings of profound anger and shame as she recounted what happened. My initial impulse was to steer her away from her painful feelings and disturbing memories. I thought that if she continued to describe the incident, it might make her feel worse, that she might have a flashback or something. And to be honest, I had a hard time staying with her as she continued her graphic description of what happened.”

Research by Foa and colleagues (2002) has demonstrated that only a small minority of respondents show an exacerbation of symptoms, and that these respondents are nonetheless likely to experience treatment gains. Moreover, many potential clients prefer exposure over medication. When asked to choose among treatments for PTSD or when asked to rank-order their preferences, clients rate exposure therapy as one of the most preferred treatment options (Jaeger, Echiverri, Zoellner, Post, & Feeny, 2010).

Strengthening Self-capacities

As described earlier, PE and CPT play a central role in our treatment for traumatic bereavement. Our approach is also designed to strengthen peoples’ self-capacities so that they will be able to tolerate exposure work. A third important program of research has provided clear evidence that strengthening self-capacities is critically important in treating trauma (Cloitre et al., 2002). This program, developed for survivors of childhood sexual abuse, has two phases. The initial phase focuses on skills training in affect and interpersonal regulation (STAIR). For example, the therapist teaches the client to identify and label his feelings, use positive self- statements, and identify and challenge maladaptive cognitions. The second phase of this treatment, the exposure phase, was adapted from Foa’s PE treatment for PTSD in rape survivors (Foa, Rothbaum, Riggs, & Murdock, 1991). Cloitre and her associates (2002) reasoned that the first phase, STAIR, would strengthen the development of the therapeutic relationship and facilitate clients’ ability to tolerate and benefit from PE.

Cloitre and colleagues (2002) conducted a study that provided clear support for their ideas. The study focused on women who were sexually abused as children. Compared to wait-list controls, women who completed the treatment program showed a dramatic drop in PTSD symptoms. At the end of the treatment, 75% of the respondents no longer met criteria for PTSD. Clients in the treatment condition showed improvements in many different areas, including affect regulation skills and interpersonal problems. Similarly impressive results were obtained in a more recent study (Cloitre et al., 2010). These investigators compared STAIR followed by PE to two control conditions: supportive counseling followed by PE, and skills training followed by PE. They found that the STAIR/PE group was more likely to achieve sustained and complete PTSD remission relative to the other conditions. In this study, dropout rate was lowest among respondents who were in the treatment that combined skills training and PE. Respondents in the two control groups were more likely to drop out of the study. This study provides compelling evidence that including STAIR as part of the treatment enables survivors to derive maximum benefit from exposure work. This work has additional relevance to those in the traumatically bereaved population who demonstrate difficulties with affect regulation.

integrating grief and Trauma Treatment research

It is evident that a treatment is needed for traumatic bereavement that integrates elements from both grief and trauma therapies. What are the implications of the research reviewed above for that treatment? Although the overall findings from the literature on treatment following the death of a loved one are disappointing, there is a clear indication that grief treatments focused on people who are highly distressed are likely to be helpful. Unfortunately, prior research on treatment for grief provides little guidance regarding the elements of treatment that should be included or how these should be implemented. In contrast, the treatment research on PTSD has identified many specific treatment components that are effective in alleviating PTSD symptoms. Until recently, however, these treatments have not been evaluated among respondents coping with sudden, traumatic death.

The fields of trauma and grief, for the most part, have developed independently of one another (see, e.g., Brom & Kleber, 2000; Figley, 1998; Figley, Bride, & Mazza, 1997; Malkinson, Rubin, & Witztum, 2000). People from both fields have commented on the separation of these two disciplines. According to Brom and Kleber (2000), for example, trauma and grief research have much to offer one another, but this cross- fertilization has not occurred. They indicated that neither field has benefited from the existing body of empirical research in the other.

A few authors in each field have recognized the importance of drawing from work on both trauma and loss in treating survivors of sudden, traumatic death. Pioneers in the integration of these two fields include Eth and Pynoos (1985, 1994), Green and colleagues (2000), Nader (1997), and Lindy (1986) in traumatology; and Raphael (1986), Redmond (1989), Rynearson (2001), Rynearson and McCreery (1993), and Shear and colleagues (2005) in grief. Green and colleagues (2000) was one of the first people to emphasize that the mode of death is a critically important issue in determining the psychological ramifications of the loss. Rynearson (2001; Rynearson & McCreery, 1993) has focused on the recurrent images of the unfolding horror that typically accompany deaths by homicide, and has argued that these may be misinterpreted as pathological grief. Raphael (1983; Raphael & Martinek, 1997) has described how the circumstances surrounding the death influence the nature of the bereavement response and dictate the type of treatment approach that may be most effective. In addition, she has discussed the disturbing images that often accompany a traumatic death, and has stressed the importance of integrating these images within grief therapy.

Despite these and other contributions, little headway has been made in the development of theoretical or clinical approaches that integrate research on trauma and grief. As Stroebe, Schut, and Finkenauer (2001) concluded over a decade ago, “Much work still needs to be done to pinpoint the exact differences and similarities between trauma, bereavement, and traumatic bereavement” (p. 198). According to Neria and Litz (2004), the phenomenology, clinical symptoms, clinical needs, and risk factors associated with traumatic death have yet to be studied systematically. As Brom and Kleber (2000) have observed, “In clinical practice, we still encounter therapists who consider themselves fit to treat only one of the fields of extreme distress (i.e., bereavement or trauma) and not others” (p. 60). These investigators also emphasize that even therapists who draw from both treatment approaches often assume that grief processing and trauma processing are separate, and thus implement them sequentially rather than integrating them.

The research on complicated grief, reviewed earlier in this chapter, emphasizes the importance of developing interventions for mourners who are at high risk for a poor outcome. In a landmark study, Shear and her associates (Shear & Frank, 2006; Shear et al., 2005) did just that. They drew from research on trauma, as well as from their expertise on grief, to develop a multifaceted treatment for people with complicated grief. They compared this intervention, which they call complicated grief therapy (CGT), to a more standard treatment for depression (interpersonal therapy). Shear and colleagues’ treatment starts with a phase designed to strengthen the therapeutic alliance and explore current and past relationships, including the relationship with the deceased. The client also tells the story of the death in this phase. In addition, this phase focuses on helping the client to understand the mourning process. Drawing from the dual- process model of loss described earlier in this chapter (see, e.g., Stroebe & Schut, 1999), the therapist explains that grief typically oscillates between two distinct processes: thinking about the death and its ramifications; and avoiding or distracting oneself from grief and focusing on thoughts or activities that are restorative. The therapist explains that the restorative process involves work on future goals. The clients are asked to identify things they would like to be doing if they were no longer grieving, and to meet one or more of these goals each week.

Next, there is a middle phase, which includes imaginal exposure and cognitive processing. In this phase, the therapist gives the client exercises to help in confronting avoided situations. The client is also asked to tell her story into a tape recorder and play it back during the week, and to participate in an imaginal conversation with the deceased. Work on the client’s goals continues during this period.

In the third and final phase of treatment, the therapist and client discuss plans for reinforcing treatment gains and continuing progress. The therapist assists the client in developing concrete plans for reaching her goals. The client is also encouraged to reengage in meaningful relationships. Therapist and client also discuss the client’s feelings about ending the treatment.

The average length of the treatment is 19 weeks.

Risk FactoRs and Related evidence

Shear and colleagues’ study revealed that although both the CGT and interpersonal therapy groups showed improvement in symptoms, there was a higher response rate and a faster time to response for those in the CGT group. This study suggests that integrating treatment elements developed to target symptoms of grief with those designed to address PTSD is highly effective in treating complicated grief. (For a more detailed discussion of treatments for complicated grief, including an updated version of Shear and colleagues’ CGT, see Shear, Boelen, & Neimeyer, 2011.)

Similar findings have been obtained by a number of investigators who drew from the PTSD treatment literature to develop a treatment for complicated grief (see, e.g., Boelen, 2006; Boelen, de Keijser, van den Hout, & van den Bout, 2007; Boelen et al., 2006; for a review, see Boelen, van den Hout, & van den Bout, 2013; Wagner, Knaevelsrud, & Maercker, 2006). In each of these studies, the authors developed a treatment that used exposure and cognitive processing. In fact, in a recent meta- analysis of 14 randomized controlled studies of treatment for complicated grief, the treatments were found to be effective. The authors maintain that during the follow- up period, the positive effect of the interventions actually increased (Wittouck, Autreve, Jaegere, Portzky, & van Heeringen, 2011).

In an innovative approach to combining grief treatment with exposure- based and cognitive processing elements, Wagner and colleagues (2006) developed a treatment for complicated grief that was designed to be offered on the Internet. Bereaved individuals were randomly assigned to a treatment group or to a wait-list control condition. The intervention had three components. The first component involved deliberate exposure to bereavement cues. Respondents were asked to write about the circumstances of the death, and to express their thoughts about the event in as much detail as possible. The second component focused on cognitive restructuring. Participants were given exercises to help them develop new perspectives on the death and how it came about. They were taught how to question biased automatic thinking, such as guilt or self-blame. In the third phase, each participant was asked to write a letter to the deceased, and also to describe plans for coping with the loss at the present time and in the future. Participants in the treatment group showed significantly greater improvement on symptoms of intrusion, avoidance, maladaptive behavior, and general psychopathology. These improvements were maintained at follow- up, 3 months after loss. Kersting, Kroker, Schlicht, Baust, and Wagner (2011) obtained similar results in a study of parents who had lost a child during pregnancy. (For a review of Internet- based interventions for traumatic stress – related mental health problems, see Amstadter, Broman-Fulks, Zinzow, Ruggiero, & Cercone, 2009; Wagner, 2013.) As these interventions become more widely available, they may constitute a good alternative for mourners who cannot afford, or for other reasons do not have access to, psychotherapy.

Taken together, these studies provide strong evidence that two elements from the PTSD literature, PE and CPT, can play a central role in the treatment of complicated grief. We certainly believe that they will be effective with traumatic bereavement clients. As noted above, however, the treatment would be more effective for these clients if two additional elements were included. The first entails augmenting the clients’ personal resources. The second involves including content that has direct relevance for survivors of sudden, traumatic loss, but not necessarily for clients with complicated grief. This would include discussion of the themes that are prevalent among these survivors, such as struggling with guilt or self-blame, or feeling betrayed by God, difficulty accepting the loss, grappling with meaning, and preoccupation with the deceased’s suffering (see Chapter 3).

Clinical integration

Because Harriet was putting so much energy into avoiding painful reminders of Gwen, she was unable to live in the present. This precluded opportunities to process her grief, engage with life, and move forward in ways that might ultimately prove fulfilling. Her children sensed how much she missed their other mom; their hearts broke for her, adding to their own grief. Partly in order to relieve her own heartbreak over losing two parents – which was how it felt to her – the oldest daughter, Amy, begged her mother to see a psychologist. After several requests, Harriet agreed. Amy accompanied her to the first session and was surprised when the psychologist invited both of them in. He asked who wanted to start, and Amy jumped in.

“My mom’s been through a lot after witnessing Gwen’s death, which was really traumatic for her. Now, over a year later, she seems frozen by her own grief – by the grief she’s keeping in and not sharing with anyone,” said Amy to the psychologist. “Can you help her?”

“What do you think of this, Harriet?” asked Dr. Joyce Lake.

“I think Amy’s always had a way with words. Frozen is right. And traumatic is right also. My daughter can explain how I feel better than I can,” Harriet sighed.

“Can you tell me a bit about Gwen?” Joyce addressed this question to Harriet.

“She was my light.” Harriet, seemingly surprised and clearly moved, was happy to answer. “I mean that almost literally. My world had been dark before I met her. I was isolated and withdrawn. I had a difficult upbringing – an abusive father – and Gwen showed me I could enjoy life. She was really funny. And very social: always meeting people and happy to strike up a conversation. I’m having a hard time surviving without her.”

“Well, you’re doing well in here.” Joyce smiled at both women, noting their resemblance to one another. Harriet sighed again, but this time she was experiencing the first whisper of relief she had felt in months.

In the next session, which Amy again attended with her mom, Joyce noted, “We’ve just begun talking, and already you have touched on some important themes. It seems possible that you may be suffering from traumatic bereavement. This is a term that describes the aftermath of losing a person you love in a traumatic way. A traumatic death is usually untimely and unexpected, as Gwen’s was, and such deaths are often marked by other traumatic elements. In your case, these included feeling powerless while you waited for help to arrive, watching the paramedics swoop in to work on your partner in your own home, hearing Gwen gasping for breath – as you described to me when we first spoke by phone. When you’re dealing with grief plus traumatic stress, your resources are likely to be used up. Without resources, it’s hard to process the trauma, and the inability to process trauma gets in the way of mourning. The result is often a feeling of being really stuck – or frozen, as Amy so aptly described in our last session.”

“I recently put our house on the market,” said Harriet slowly. “I’m hoping that might help me to unfreeze, but I don’t know. It’s hard to have any hope that anything will work.”

Joyce heard Harriet’s hesitancy within this comment, as well as a possible question underneath the hesitancy: “Can you help me?” Joyce decided to address this. “Selling the house may help. It may not. If you decide to work with me, one of the things I’ll talk a lot about is adaptation.” Joyce stressed this word. “As human beings, we are constantly adapting to our circumstances in a way that allows us to meet our needs. For example, maybe Amy doesn’t like to work, but she might love to spend money.” (As Joyce said this, Amy and Harriet smiled for the first time since they had come in.) “She therefore decides to work part-time so she can spend some money. It’s a compromise. Maybe the compromise works well; maybe it doesn’t. One of the things we would do together is to explore how you’re adapting to Gwen’s death and ask how well these adaptations are working. If they’re not working well, we’ll see if we can add some more choices. We could look at whether selling the house would be a useful adaptation. Can I give you another example?” Harriet nodded yes.

“My guess is that withdrawing from friends isn’t helping very much. It seems as though it’s difficult to be social without Gwen by your side, but I think some part of you does want the satisfaction that comes from being with friends. Gwen gave this to you: an opening up of your social life. Remember, she turned the light on? She was the light. One way of honoring both her and you would be to learn to do this for yourself. You depended on Gwen for this, and research shows us that depending on a spouse in such a way makes it more difficult when she’s gone. It makes sense, right? I think you might be able to adapt and do this for yourself.”

Amy looked at her mom, who looked back at her. Each saw the reflection of a tear in the other’s eye. Joyce understood something that Harriet did not have words for, and with that, an alliance was beginning to form.

Concluding remarks

Joyce knew that helping Harriet to adapt to her partner’s death would require an integration of interventions. She knew she would need to complete some exposure work with Harriet, and in preparing to do so, she hoped to discover any beliefs Harriet held that might prove to be maladaptive. Harriet’s belief that she couldn’t be social without Gwen – a belief that Joyce questioned – appeared in their first session together. Throughout their work, they would discover and address others; they would move through the sometimes difficult process of exposure; and they would concretely explore the “R” processes of mourning – all in an attempt to assist Harriet to accommodate Gwen’s death so that she could reinvest in life.

Throughout this chapter, we have pointed to research supporting specific interventions and approaches to treating both grief and traumatic stress. From our review of this research, and from our own theoretical knowledge and clinical experience, we have concluded that integrating treatment elements targeting grief (facilitating mourning) with those targeting traumatic stress (processing trauma), while shoring up a person’s coping strategies and support (building resources), is the most effective means of helping those suffering from traumatic bereavement.

We now turn our attention to designing and implementing such a treatment approach.



Part IV. Guidelines for implementing the treatment approach






Chapter 8. client assessment

Barbara entered the therapist’s waiting room nervously. She walked with a limp – a continuous reminder of the car accident that had injured her 4 years ago and killed her daughter, Janie. Their car had been hit from behind by a sleep- deprived truck driver. As Barbara took a seat, she noticed that her hands were shaking, her heart pounding, and her thoughts racing. This anxious state was not new to Barbara; neither was seeking help. With the support of Alcoholics Anonymous (AA), Barbara had been sober for 7 years prior to Janie’s death. After the accident, she stepped up her program of recovery, attending meetings at least three times per week. Still, not a single day passed when Barbara didn’t struggle against the urge to drink. She had relapsed twice in the time since the accident.

Barbara had sought out other support as well. She attended a support group for bereaved parents for about 3 months. She met with a therapist for another few months. She also spent time online in a chat room for people who had lost children. Although she received some help from each of these sources of support, the accident that stole her daughter still haunted and debilitated her, and left her wishing that she rather than Janie had died. Barbara spoke this wish aloud once she was seated across from Donald, her new therapist: “Why couldn’t it have been me who died that day? How can I go on living knowing that Janie is gone forever?” She added in a whisper, “Janie would have turned 16 next month.”

There are many reasons to conduct a thorough assessment of every client entering psychotherapy. Assessment is of even greater importance with a population as vulnerable as those who may be experiencing traumatic bereavement. Careful evaluation will allow you as the therapist to ensure that this is the right treatment approach for a particular client at this time, facilitate the formulation of a treatment plan, and yield the diagnosis or diagnoses required for insurance payment. Given the possibility (as for all mourners) of past trauma, past loss, mental health issues, or a troubled or very dependent relationship with the deceased, those experiencing traumatic bereavement may present with a complicated combination of problems. Beyond these issues, sudden, traumatic death produces a host of challenging symptoms and responses even in individuals who have no history of trauma, loss, or excessive dependence on their loved ones. It is imperative to understand both the client’s resources and the client’s needs in order to apply the treatment effectively. The more care that goes into the assessment and planning phase, the more the client will feel hopeful, safe, and understood, and the greater the likelihood of a successful treatment will be. In addition, a careful assessment will equip you to adapt as new information or problems arise, crises erupt, the client develops new skills, and so forth.

There is an ethical imperative to understand the client’s needs before proceeding with this treatment. Without adequate information about who this client is, how he manages memories and feelings, and what resources he possesses for dealing with distress, there is a genuine risk of endangering the client. Without such a foundation, the treatment may retraumatize the client; solidify the client’s avoidance; shame or humiliate him; or use his valuable therapy time, money, and motivation to no avail. It can be difficult for people to go to psychotherapy for the first time, and if their first experience is a failed therapy, they may never return. In addition, it is essential that clients have adequate resources to support the challenging work of this treatment approach. Assessment is vital to these concerns.

This chapter provides an overview of areas for assessment with traumatically bereaved clients. We do not address in depth general assessment issues that any therapist would consider, such as the client’s safety and the fit between the client and therapist. We encourage you to spend time on assessment with each client, addressing the issues identified below in whatever style best suits your client’s clinical needs and your own expertise. Throughout the assessment process, your clinical judgment is your best tool for gathering, interpreting, and using the information you collect.

An additional important role of assessment is in measuring progress. Such assessment can provide feedback to both you and the client about whether and how the client is progressing. This can help shape subsequent treatment and provide hope to the client. In addition, if the client should leave the treatment before it is complete, midcourse assessments may provide some clues about the reasons.

Appropriateness of This Treatment Approach for A Particular Client

This integrated approach is designed for people who have experienced the sudden, traumatic death of a loved one. By this, we mean a death that occurs suddenly and is characterized by one or more of the risk factors described in Chapter 5 (e.g., it was untimely, it is viewed as preventable). The death must overwhelm the person’s capacity to manage her thoughts, feelings, and behavioral responses to the death and related losses. The treatment can help a person with one or more of the following indicators: • The person needs to process both trauma and grief.

  • Trauma, as evidenced by symptoms of PTSD (such as intrusive thoughts, avoidance of reminders of the event, cognitive and mood alterations, and physiological hyper arousal) or other trauma responses (such as dissociation, loss of meaning, affect dysregulation, somatization, impaired concentration, and disrupted relationships – complex trauma adaptations that have been described by Pelcovitz et al., 1997, and Courtois & Ford, 2009).
  • Grief, as evidenced by such symptoms as shock, sadness, yearning for the deceased, difficulty accepting the loss, avoidance of reminders of the loss, anger, feeling numb or empty inside, and suicidal thoughts (for further information about grief symptoms, see Prigerson et al., 2009; Rando, 1993; Shear, Simon, et al., 2011; Worden, 2009).
  • The person feels stalled or stuck and is having difficulty fulfilling role obligations (e.g., as parent, as worker) or moving forward with life (e.g., making friends, pursuing new interests; see Prigerson et al., 2009).
  • The person is experiencing relentless, debilitating automatic thoughts or disrupted cognitive schemas, which can be assessed with the Trauma and Attachment Belief Scale (Pearlman, 2003), for example.

readiness for This Treatment Approach

This treatment approach requires clients to participate actively in the processes of mourning a traumatic death. It requires that clients engage with trauma material, identify and challenge problematic cognitions that interfere with mourning, and connect with internal experiences that can include a host of very challenging feelings.

As is the case in all therapies, decisions regarding appropriateness and fit of a particular approach are both clinical and ethical in nature. You must consider whether a particular client has the ability both to participate in and to benefit from the treatment. One of the advantages of this treatment approach is that even if you decide that the treatment approach as a whole is inappropriate for a given client, you can utilize certain aspects of it effectively. For example, Dr. Hogarth decided to use only the resource- building interventions and activities, with an emphasis on self-capacities work, with his client, Ms. Lestor, who reported dissociation (e.g., persistent inability to recall activities performed within a given day, difficulty paying attention to time, lack of connection between thoughts and feelings) during the intake process. The treatment approach requires engagement with trauma material, and effective engagement requires an ability to stay grounded in one’s internal experience (i.e., the opposite of dissociation). Dr. Hogarth concluded that Ms. Lestor would not be able to participate in the treatment at this time, that she would not be likely to benefit from it, and that it might actually lead to increased dissociation. However, he felt that a focus on building self-capacities could greatly help this client, and that with such help, she might become an appropriate candidate for other aspects of the treatment in time.

As a second example, Dr. Hogarth was contacted by Mr. Waters, whose best friend had been murdered within the past few weeks. At the end of their initial session, Dr. Hogarth concluded that Mr. Waters was not a candidate for this treatment. Recall that the treatment is designed for survivors who are stuck in the process of mourning – in other words, unable to engage actively in one or more of the essential tasks of mourning. This young man was still experiencing some shock over this sudden death. Mr. Waters was grieving, but had not yet moved into a process of actively attempting to accommodate this loss (i.e., mourning). Furthermore, he was not yet aware of the various secondary losses he would experience, including how this death would violate his assumptive world. Launching into this treatment approach with Mr. Waters at this time would have been premature. However, he did benefit from a supportive therapeutic relationship and from psychoeducation about grief, mourning, and trauma – both important elements of this treatment approach. Four months after his friend’s death, Mr. Waters’s initial grief subsided, although he had unsuccessfully attempted to accommodate the loss. He found himself haunted by the traumatic circumstances of the death, stuck in self-blame, and overwhelmed with rage. At this time, Dr. Hogarth determined that the treatment approach as a whole might benefit him.

As a third example, Ms. Arnold, an employed mother with three children, lost her wife, Jennifer, in an automobile accident. About 6 months later, she went to see a therapist, Ms.

Rodriguez, who thought that she seemed to be an appropriate candidate for this treatment approach. In the assessment process, Ms. Arnold demonstrated an ability to tolerate strong affect (she stated that she cried often, but was usually able to calm herself and minimally continue to fulfill her responsibilities as worker and mother). She reported being unable to remember Jennifer without being consumed by memories of the accident; and spoke of experiencing overwhelming self-blame. In other words, she demonstrated the sort of distress targeted by the treatment, and at least the minimum capacities needed to engage with the treatment interventions. However, she canceled the first therapy session and arrived 15 minutes late for the next one. As she and her therapist talked, it became clear that Ms. Arnold had very little support in taking care of her three young children, and thus that child care issues were already interfering with the treatment in the opening sessions. Ms. Rodriguez decided to modify the treatment approach and to address the need for increased social support as a prerequisite for moving into any exposure work. As it turned out, Ms. Arnold was harboring some problematic beliefs about asking for help, which prevented her from seeking the support she would need to move forward in mourning Jennifer’s death. A focus on augmenting social support, and using cognitive processing to address obstacles to this, were effective adaptations of the treatment approach for this particular client.

During this same time period, Ms. Rodriguez was deciding whether to use this treatment approach with Mr. Hyun, a 42-year-old man whose wife had died in a fire at her office building a year earlier. Mr. Hyun was having great difficulty parenting his teenage son and daughter, due to symptoms of severe depression. Since his wife’s death, he was also experiencing insomnia, symptoms of PTSD, and constant exhaustion that interfered with even simple daily tasks. During his initial session with Ms. Rodriguez, Mr. Hyun reported feeling guilty about his inability to be more present for his son and daughter, and his tone and language suggested severe self- criticism about the state he was in. Ms. Rodriguez had two specific concerns in her assessment of Mr. Hyun: (1) Did he have the physical energy needed to attend appointments, engage with independent activities, and participate within sessions? (2) If Mr. Hyun were to feel worse before he felt better within the therapy, would he be able to continue so as to experience the lifting of symptoms that Ms. Rodriguez believed was possible for him? She concluded that this treatment approach offered the potential for Mr. Hyun to feel better; she thought carefully about how to maximize the likelihood of his success in therapy; and she sketched out a treatment plan that heavily emphasized resource building, both initially and throughout the treatment. She believed that her supportive connection with Mr. Hyun would help to contain his anxiety as he confronted painful memories of his wife’s death through exposure work, which would in turn help to alleviate the PTSD symptoms. She also knew that she would target his self- criticism with cognitive restructuring techniques, believing that this would diminish his depression. Finally, Ms. Rodriguez referred Mr. Hyun for a medication consultation, in order to establish whether an antidepressant and/or a temporary sleep aid might be appropriate.

As this last example illustrates, it is not necessarily the severity of symptoms that rules out a person as a candidate for this treatment. Rather, the guiding question is whether the supports available within the treatment will enable the client to engage in the tasks of mourning and exposure while remaining grounded in his experience.

The rationale for each of the treatment elements provided in Chapters 10, 11, and 12, along with the material presented in the remainder of this chapter, will help you think through the questions of whether a survivor can participate actively in this treatment and whether it can address her distress effectively. With regard to the former, one of the main concerns involves the client’s ability to tolerate exposure work. Clients who are currently living in a dangerous situation (such as a violent relationship), abusing substances, or experiencing extreme dissociation need to work with you or with other clinicians or agencies to address those concerns before pursuing the exposure activities outlined in this treatment. Clients who are mildly dissociative or emotionally numb may benefit from a stronger emphasis on the strategies for coping with emotion and other resource- building strategies described in Chapter 10. A foundational assumption of this treatment approach is that a client will only be able to address and process painful thoughts, feelings, and memories if she has the internal and interpersonal capacities, stability, and coping strategies to do so fully and consciously. The approach is designed to assess, build, and utilize the resources required to engage in processing work. Clinical judgment and the art of psychotherapy come into play as you assess your clients’ needs for resource development.

When an individual’s current status, behaviors, or needs seem to be in conflict with the treatment (e.g., the client is actively overusing alcohol, in the midst of a work- related crisis, or unable to use the written handout materials because of limited English literacy or for other reasons), you should use your judgment about whether to adapt the treatment and proceed, or to abandon it and try a different approach. It is crucial to provide the client with a thorough description of what the therapy entails, including both the opportunity to learn and practice new coping strategies and the rationale and process of exposure. This therapy is a collaborative process, and the client’s thoughts and feelings about his readiness to engage in all the aspects of this work are the most important sources of information to consider in designing your therapy approach. Clients often respond to the description of aspects of the therapy (from examining thoughts about the loss to engaging in imaginal exposure) with a mixture of anxiety and an intuitive understanding that avoiding thoughts and feelings associated with the loss does not alleviate them. The natural reluctance to confront those thoughts and feelings highlights the role of psychoeducation about avoidance. You can base the decision about how to proceed on your assessment of the client’s resources (including typical coping behaviors and use of social support) and a thorough evaluation of current risk potential (including history of suicidal or other potentially dangerous behavior).

Progression Through The six “r” Processes

Because the treatment will foster movement through Rando’s (1993) six “R” processes, you will also need to understand where each client is in that journey at the outset of treatment. We refer you to Rando’s (1993) volume Treatment of Complicated Mourning – particularly the appendix containing the Grief and Mourning Status Interview and Inventory (GAMSII), and Chapter 6 of that book, which provides guidance in using the GAMSII. Part III of the GAMSII is a structured interview designed specifically to assess the client’s mourning processes to date and to identify areas that need to be addressed in treatment. Some of the issues addressed in this comprehensive inventory include the following:

  • Circumstances surrounding the death
  • Nature and meaning of what has been lost
  • The mourner’s reactions to the death
  • Changes in the mourner’s life since the death
  • The mourner’s relationship to the deceased
  • The mourner’s self- assessment of how well she is coping with the loss
  • The mourner’s comprehension of the mourning processes and her expectations regarding the mourning process

In addition to assessing the client’s mourning processes, the GAMSII can assess relevant demographic information (Part I) and provide a comprehensive evaluation of the client’s history, mental status, and selected premorbid personality characteristics (Part II). Rando (1993) has granted permission for therapists to reproduce the GAMSII for clinical use.


Both a sudden, traumatic death and this treatment approach, particularly the exposure component, are likely to elicit strong affect. For this reason, supportive resources (self-capacities or feelings skills; social support; coping skills; the ability to manage bereavement- specific issues; values and goals; and meaning and spirituality) constitute the foundation for the treatment. In this and all trauma treatment, it is important to balance support with challenge, helping the client to stay in the so- called “therapeutic window” (Briere, 1996a; Briere & Scott, 2006) – that place where more challenge would be too much, and less would not be enough. Thus a very early task is to assess these resources, which must precede and accompany any exposure work.

To assess how the client has coped with stress and distress until now, you can use questionnaires such as the Inner Experience Questionnaire (Brock, Pearlman, & Varra, 2006) or the Inventory of Altered Self- Capacities (Briere & Runtz, 2002) as well as conversations with the client. For example, you can ask (as well as generally listen for) what the client does when he is very upset or how he brings himself out of a state of numbness. Praising positive strategies and exploring potentially destructive ones are ongoing processes that may continue throughout the treatment.

Certain coping strategies may be problematic for anyone. These include immersion in potentially addictive behaviors, such as excessive physical exercise, drinking, shopping, gambling, sexual activity, eating, and Internet use; they also include engagement in destructive activities, such as aggression against oneself or others or risk- taking behaviors. In the context of treatment for traumatic bereavement, additional potentially problematic coping activities include those that promote unhealthy or immoderate avoidance of memories or feelings about the deceased, and withdrawal from people or constructive activities. Some of the behaviors mentioned above, such as alcohol use, may lead to emotional numbing – a form of avoidance.

Individuals may use other activities that are not inherently destructive to avoid feelings. These may include using work or exercise to distract themselves from memories or feelings. Avoidance is not problematic when individuals use it consciously, in a balanced way, to take a needed break from confronting memories or feelings; in such cases, it might better be termed distraction than avoidance. It can be useful to discuss the difference between distraction, a healthy coping strategy in which a client exercises conscious choice to manage or dose pain, and avoidance, which is often automatic and does not include returning to challenging thoughts or feelings. It is important to explore and understand both the activity and the ways the individual uses it. The aim is to help the client find a balance between support and exposure – in other words, to keep moving back to the therapeutic window, where there is enough challenge for growth but not so much that the client’s anxiety precludes that growth. Table 8.1 provides guidelines for assessing a client’s resources.

Trauma and loss history and processing

It can be useful to acknowledge that the treatment will focus on one particular traumatic death, but can accommodate other losses in a client’s history. It is important to assess a client’s entire trauma history because processing one loss may trigger thoughts and emotions related to another. The therapy can address the primary loss and then other losses the client identifies as less traumatic, using the same techniques. Note, however, that asking a new client to list all of the painful, traumatic things he has ever experienced can overload his self-capacities. As Najavits (2002) has indicated, eliciting a full trauma history can be like conducting an exposure therapy session without any preparation or safeguards. Clinical skill is needed to obtain this history in a way that is sensitive to the client’s ability and willingness to share this material. Such skill will also help to manage the affect that may emerge in the telling or its aftermath (Pearlman & McCann, 1994). This task is sometimes easier in the context of asking the client to name major life events or experiences, traumatic and otherwise. For example, you might ask the client whether there is anything he would like you to know at this time about past traumatic experiences (Najavits, 2002).

It is important to determine whether any traumatic event from the past stands out as more problematic now than the sudden death. If another loss is more significant than the target loss, the client will have difficulty focusing and working effectively on the target loss. If prior losses are continuing to exert a powerful impact on the client, you and the client can create a plan to address those losses after the target loss has begun to feel less overwhelming. Working on automatic thoughts and issues related to one loss may generalize to other losses, and it may make processing of another loss less painful. Understanding the client’s trauma history enables you to address issues related to all the traumatic events in the client’s life, and it may help the work on the sudden, traumatic death generalize to other losses even before they are addressed directly. It is also important to assess how the client has processed other traumatic events, as this may alert you both to potential resources and to possible obstacles.

With all of this in mind, you can consider the following questions. If the client has experienced prior traumatic events, you can obtain valuable information by following up with the question “What helped you cope at that time?”

  1. Are there any other traumatic experiences the client would like to let you know about (other than the target death)?
  2. What has been going on in the client’s life since the death? (probing for subsequent losses or traumatic experiences not directly related to the target death, e.g., job loss)
  3. Does some other traumatic event stand out as more powerful than the current (target) death?
  4. (If the client reports other traumatic experiences) Has she received treatment related to these experiences? Has she told anyone about the violence, victimization, abuse, or traumatic loss or had the opportunity to think, write, or express or process feelings about it?



TABLE 8.1. Guide to Assessing a Client’s Resources

  1. Self-capacities
  2. Signs of difficulties in self-capacities: depression, anxiety, avoidance of affect, easily becoming overwhelmed, problematic behaviors (self-injury, substance overuse, dissociation, etc.). Most people coming for treatment will demonstrate or report trouble with self-capacities, which the treatment can enhance.
  3. Questions to explore:
    1. How does the client respond to his own strong affect?
    2. Will he be able to maintain or regain his position within the therapeutic window in the face of strong affect? If so, how?
    3. Can he maintain or regain connection with his inner experience (feelings, thoughts, and needs) in the face of strong affect? If so, how?
    4. Can he manage the necessary tasks of his daily life? What strategies does he use when this is difficult?
  4. The Inner Experience Questionnaire (Brock et al., 2006) and the Inventory of Altered SelfCapacities (Briere & Runtz, 2002) can provide systematic evaluations of self-capacities.
  5. Social support
    1. Signs of social support difficulties: discomfort in the presence of others, a persistent feeling that others’ remarks or behaviors are insensitive; increased conflict with one or more members of the social network; social withdrawal or isolation. B. Questions to explore:
      1. What type of support does the client need?
      2. Are there needs for social support that are not being met?
      3. Who is in the network? How available are they? Are they helpful? If so, in what specific ways?
      4. Who is not helpful?
      5. Who is damaging or hurtful and in what ways?
      6. Can the client identify any potential additional support providers?
  • Coping skills
    1. Signs of coping difficulties: use of destructive coping strategies such as substance abuse, compulsive or addictive behaviors; inability to self-regulate affect and/or bodily states. B. Questions to explore:
      1. What coping strategies is the client currently using?
      2. How are these coping strategies useful?
      3. How are these coping strategies problematic?
      4. What has been helpful in the past?
      5. What obstacles can the client identify to using previously helpful coping strategies?
    2. Bereavement-specific issues (these are events and experiences related to the loss, dealing with the deceased person’s belongings, anniversaries, and holidays, that can trigger trauma or grief reactions). A. Which bereavement-specific issues does the client identify as problematic?
    3. How has the client managed these issues to date?
    4. Meaning and spirituality
      1. Is the client struggling to make sense of or find meaning in what happened?
      2. Does the client feel that life has no meaning without the deceased?
      3. (For a client who believes in God) In dealing with the loss, does the client feel supported, abandoned, or betrayed by God?
      4. (For a client who attended religious services prior to the death) Has the loss affected the client’s participation in his faith community?
    5. Values and goals
      1. If you ask the client what matters most to him at this point, is he able to articulate any values that guide her behavior?
      2. If you ask the client whether he has any goals at the present time, is he able to articulate future goals?


Of course, it is important to keep in mind that events are defined as traumatic by those who experience them, and that people react in myriad ways to events, so you should not assume that any particular event requires processing.

In Table 8.2, we list many other considerations for deciding whether to use this treatment with a given client. Note that the treatment can help with some of these issues, so they are not necessarily exclusionary criteria. Rather, they are important considerations in deciding whether the client can engage in the treatment, and if so, whether and how the treatment ought to be tailored to fit this particular client’s needs. You can think of these not as red flags that should stop you in your tracks, but rather yellow ones that call attention to an issue so as to encourage further thought about treatment fit and design. Once you have addressed these issues, you can turn your attention to planning and conducting the treatment.