Chapter 9: Traumatic bereavements

Back to Reflections on Chapter 8

Trauma in bereavement

In the following, the phrase “trauma reactions” refers to the psychological reactions that a bereaved person may experience where the death has been sudden, gruesome, violent and/or for which responsibility or incompetence is identified in oneself or others, or where external intervention has been crass.

There is a continuum from the “shock or realization” felt when a dying person actually dies; through the shock felt when someone dies noisily, messily in your presence of an unexpected heart attack, and through the various experiences mentioned below such as suicide, death in childbirth, murder, to the shock of finding a well loved body disfigured in some way, to disasters where danger, multiple horrors and an element of chaos can render the experience overwhelming.  This last category will not be addressed in this book because help in such circumstances is best provided by professionally experienced people.

Trauma and cognitive dislocation

Nearly everyone recovers from a shock.  It may leave them shaken and in need of recovery time, but things usually return to normal soon enough.  But sometimes people find themselves stuck with the experience. 

It may not be obvious that someone has been traumatised.  It is always necessary to start by listening, showing concern and interest and trying to piece together their story.  If there has been trauma, then it is very likely to disturb a person’s reasoning and judgement resulting in some confusion, failure of concentration, loss of competence, while possibly generating emotions such as fear, horror, hatred and anger. You may begin to notice responses that seem to you to be unexpected or inappropriate: such things as failures to concentrate, irritation, illogicalities, too much, or too little or inappropriate emotion.

This may happen for either or both of two reasons:

i) that the event was so sudden that it was accepted into the mind without being processed in terms of comparison with familiar events, opinions, values etc., e.g. at a crash, or when a bomb explodes;

ii) that the event was so disconcerting, so unjust or outrageous or against expectations that the mind cannot process it.

As a result the traumatised person may suffer distress that falls into one or both of these categories:

-- physical or behavioural symptoms,

-- changed assumptions about oneself.

Possible changes in physical working, in behaviour, cognition and emotions

Typical general symptoms following a traumatic event

These symptoms can occur long after the event but can be evident during or  immediately after it.  They can be resolved, but, if not, may result in illness and breakdown, both personally and in relationships generally, at home or at work.

Denial of feelings or of the need for help can also be very strong and this may prevent people from seeking help.

            a) Feelings

  • Sense of pointlessness.  Why bother?  Why go on?
  • Increased anxiety and sense of vulnerability.
  • Depression.
  • Intrusive thoughts and images.
  • Shame, anger, guilt and bitterness.
  • Survivor guilt --  Why me?                                                                
  • Sense of isolation.
  • Strong sense of group identity with other victims.
  • Fear of closed {open} spaces.
  • Fear of being in the same position again.
  • Fear of crowds or groups of people.

            b) Behaviour

  • Inability to make even simple decisions.
  • Impulsive actions {such as excessive spending, moving home, changing lifestyle or job}.
  • Irritability and lack of concentration.
  • Anger and even violence.
  • Sleep disturbance -- dreams and nightmares.
  • Retreat into isolation.

            c) Physical effects

  • Illness -- headaches, stomach-aches, pains, tightness in the chest.
  • Listlessness and fatigue or being generally unwell.
  • Excitement and hyperactivity.
  • Increased sensitivity to noise and other people.
  • Increased smoking or drinking; the use of drugs.

Of these, the symptoms which indicate a level of trauma that may need professional help are the following: {See Chapter 10}

1. Re-experiencing

The event can be re-experienced days and even years afterwards e.g. someone involved in an accident can feel that the event is happening again and the sensations and emotions induced at the time can be relived.  Such feelings can be triggered by sights {TV, video, pictures, media reports}, sounds, smells and feelings associated with the event.  But there may be no identifiable trigger and simply a return of the experience quite suddenly at work, home or anywhere and these can be overwhelming and even disabling.  For example, a man after attempting to rescue someone from a fire, might, days later, wake up from sleep imagining himself again surrounded by flames. The feelings of being out of control and his suppressed fear had returned to the surface of his awareness.

2 Avoidance

People can seek to avoid anything or anyone that reminds then of the event e.g. fear of getting into a ship, aeroplane, or a car.  Denial of feelings and reactions can also be common.  Avoidance can be associated with a sense of isolation and loneliness.

3. Arousal

There can be an increased sensitivity to noises and the slightest sound can seem like an explosion and can cause people to “jump”.  An increased awareness and arousal can mean an incapacity to accept or to cope with normal events such as the behaviour of children, spouses or friends.  This can lead to outbursts of anger or even violence, or a retreat from people into isolation.  For example, a married soldier after the Falklands would lock himself in a room for up to three days, yet, at times, would treat his wife like dirt and be quite abusive and violent.

There can be changes in values and readjustments in relationships.  What’s the point of a marriage, wife, family, job or of living when you have lost family, friends or someone you were with {or when you have lost personal affects and belongings}.  Things or people that were important can seem trivial or unnecessary, or there can be a clinging and a sense of dependency.   NB  many of the symptoms are similar to those associated with loss and grief.

Possible changes in assumptions about oneself

As well the above symptoms there may be very distressing change in one’s basic assumptions about oneself. Here is an attempt to explain.

Even if we have had a sound upbringing and fortunate life, a traumatic event can make us feel that we are, in some ways, alone in a world which has no obvious purpose or meaning.  People have filled our life with security, love and meaning.  We come to make assumptions about ourselves and the world that sustain us in coping with everyday living, for example:


1. The world is basically benevolent.  There will be help and support for me. Bad things happen to other people.  I can allow myself to be a bit  careless occasionally. {Or the opposite.}

2. The world makes sense, it can be explained with my pet theory, is predictable, controllable and just.  {Or the opposite}

3. Other people are sources of affection and support.  {Or the opposite}

4.  I am reasonably worthy, competent, loveable, upright, honest and brave.  {Or the opposite}

The effect of a traumatic event on these assumptions

We build up the above assumptions, forget them and fill our life with the usual activities.   But disasters may well undermine these assumptions -- “I have turned out to be neither brave, honest or loveable, people are not supporting me.” “ I cannot think why she, of all people had to die, or why I should be suffering like this; I’ve done nothing wrong.”  With such thoughts the bereaved  person may lose confidence, be unable to relate to others, become hopeless even suicidal.

Interventions

Interventions from other people may thus have two purposes:

- to enable the traumatically bereaved person to re-discover their understanding of what had happened, so regaining their coping mechanisms within the new circumstances.

The style of  therapeutic narrative formation set out below may help this.

- to enable the traumatically bereaved person to regain their confidence, and reassess their situation in the world.              

A return to the support mode as described in Chapter 3 would enable these issues to be explored.

Disorientation and failure to cope, can bring great distress and upset.  The strange thing is that an appropriate early intervention such as is suggested below, followed by one or two of the usual “support” sessions can bring about a transformation.  But any return of confusion or fearfulness, or especially of the  signs of post traumatic stress, may indicate the need for a medical/psychiatric specialist. {As these specialists are often not immediately available, be prepared to stand by.}

Supporting the client who has experienced trauma

Where there has been an element of trauma in the bereavement, there may be a reluctance to speak about it.  The companion needs therefore to exercise several qualities, for example the ability:

            -- to encourage the client to speak about the facts -- perhaps in great detail, without seeming either to interrupt or to prescribe the course of the “counselling” process;

            -- to move between these facts and the usual emotions of a grieving person without difficulty;

            -- to recognise when there is a need to dwell on these matters and to adjust to the appropriate degree of focus on them;

            -- to take control of the process  where there is such a degree of trauma that the client is not autonomous,

            -- to recognise where this process has not been effective {it will be seen quite soon and quite clearly}, so that it would be necessary to ask for professional help.

This process, in its formal mode, is sometimes known as “critical incident debriefing”.  For bereavement work, the degree of formality and rigour must be regulated to be only as far as need be.

It is important to realize that after about a month, a traumatised individual is likely to need specialist treatment using medication and that to continue to try to help otherwise is likely to waste his and the volunteer's time.

The idea would be that we would see the client, listen, establish an effective relationship, in the usual way.  Then, if the story including the behaviour of the client indicated a traumatic experience, we might suggest that the mode of working  be changed, just for one session, to a rather more formal and deliberate examination of the chain of events.

The fact-linking narrative to be encouraged might then take the following shape:--

            Explain the new emphasis that you are suggesting, confidentiality etc.

            Ask:

  • What were you doing before this happened?  Tell me in detail.
  • So what did actually happen? What led up to it?  How were you involved?
  • Where were your friends, colleagues, boss? How were they involved? 
  • What did you experience, sights, sounds, smells, etc.?  What was disturbing?
  • What were your emotions then?  How did you manage?
  • What are your emotions now?
  • What changes have you felt in yourself since then?

            Offer a list of symptoms, i.e. normal or expected reactions such as the one above either verbally or as a written list for reference.

            State that further support {described} is available.  Please keep in touch.

Be very careful for yourself

Remember that post traumatic stress is very contagious.  For example in any traumatic event, though the survivors may be in the greatest danger, the rescuers, observers, relatives and helpers are also at risk.  Be prepared to keep closely in touch with your supervisor and other support for your self.  Watch yourself for irritability, changes in values, overwork, new uncertainties, new unhappinesses at home, an inability to “let go” of the events, and all the usual signs of stress.

Continue to Reflections on Chapter 9