Managing Grief after Disaster
A National Center for PTSD Fact Sheet
By Katherine Shear, Ph.D.
The recent terrorist disasters left many people suddenly bereaved of
spouses, children, parents, close friends, and coworkers. In the immediate
aftermath, some have been numb or unable to accept the loss. Many have felt
shocked, lost, anxious, depressed, and physically unwell as a result of this
loss. For many, the pain has been intense and unrelenting. In the acute
aftermath of the violent death of a loved one, a sense of disbelief or intense,
uncontrollable emotionality is very frequent. Distressing physical symptoms are
also common (Lindeman, 1944; Stroebe & Stroebe, 1993). These emotional and
bodily reactions may be very strong and can themselves be traumatizing,
especially if they are unfamiliar and unexpected. Such a secondary reaction can
further amplify the pain caused by the loss and can be mitigated by information
about grief and stress reactions. It is important to realize that intense and
unfamiliar emotionality is entirely normal and does not necessarily have
implications for long-term emotional stability or health. The fact that a
popular Internet book site lists 2,776 titles on the topic attests to the fact
that grief is both common and difficult. In ordinary, peaceful times millions
of people die every year, each leaving friends and family bereaved. Many
experience numbness or intense pain in the immediate aftermath. For most, this
initial reaction subsides with time, and the bereaved person finds a way to
again engage fully in life. However, studies show bereaved individuals, in
general, are at risk for longer term mental and physical health problems. It is
a good idea to provide ongoing support, monitor the outcome of grief, and know
that professional intervention can be helpful.
Given the universality of bereavement, there has been relatively little
research to characterize its course, develop a nosology for bereavement
problems, identify risk factors, or guide treatment. The information provided
below draws upon what has been done and upon ongoing work.
The course of bereavement
The course of bereavement has become increasingly better understood since
the mid ‘80s, with the development of several measures that have proven
consistent across some populations. These include the Texas Revised Inventory
of Grief (Faschinbauer, Zisook & DeVaul, 1987), Core Bereavement Items
(Burnett, Middleton, Raphael & Martinek, 1997), Criteria for Complicated
Grief Disorder (Horowitz, Siegel, Holen, et al., 1997), and the Inventory of
Complicated Grief (Prigerson et al., 1995). Few studies have targeted a full
range of ages and circumstances of death and the bereaved. Most of the
information available refers to older people or widows, although selected
studies have targeted parents of deceased children, surviving friends and
partners of HIV sufferers, parents of children who have died violently, and
combat veterans. However, younger individuals, especially men, may be at
highest risk for complications, relative to a comparison group of same age and
sex (Ball, 1977; Stroebe & Stroebe, 1983).
Research by Stroebe and colleagues (1993) provides a model of the type of
study needed. These researchers compared widows and widowers under retirement
age to a control group consisting of married couples, interviewing participants
4 to 7 months following their loss and again at 14 months and at two years. The
researchers found that widows who participated were more depressed than widows
who did not while the reverse was true for widowers. It is important to keep in
mind that most studies of bereavement have succeeded in recruiting only about
one-third of eligible individuals, so all data need to be viewed in light of
the characteristics of the individuals who choose to participate. Given this
caveat, studies consistently find bereaved individuals to have higher levels of
depressive symptoms than matched controls in the 6-12 months after the death.
Most of those with milder levels of depression improve by year 2, while those
who are clinically depressed (about 20%) remain depressed. Somatic symptoms are
reported by widows and widowers at a rate nearly 10 times the rate reported by
members of the control group in the initial 6 months, and these symptoms are
still reported 4 times as much at two years.
Less is known about the course of bereavement following violent death, but
available studies have consistently found that symptoms and impairment are more
prolonged and a sense of resolution less likely (e.g., Murphy, 2000). A recent
study of women college students (Green, 2001) found those who experienced a
violent loss had symptoms and impairments similar to those who experienced
assault. A dissertation study by Pivar documented grief symptoms in 70% of
veterans and found that these could be differentiated from symptoms of PTSD and
depression. Taken together, this work suggests that sudden violent bereavement
is a very intense stressor. While many people will find a way to cope without
intervention, skilled professional assistance may be important in decreasing
the morbidity and even mortality of those bereaved as a result of disaster. In
order to provide such assistance, professionals need to be informed about grief
and about treatment strategies that have been developed and tested.
The experience of grief
Grief is the process by which we adjust to the loss of a close
relationship. Therefore, grief is an
inevitable companion to love and attachment. The lives of those we love are
interwoven with our own in thousands of small and large ways. One’s immediate
family, in particular, contributes to a sense of comfort, security, and
happiness and reinforces behavior. Endocrine function can become entrained by
cues from another person. When this happens, losing that person requires a
period of physiological adjustment. In all cases, loss of a loved one engenders
feelings of loneliness, sadness, and vulnerability. The death of someone close
also makes one’s own death imaginable, thus evoking fear of dying. When a
person experiences the death of someone close, that person is confronted by
mortality and undergoes a certain degree of acute separation distress. Sometimes, there is also guilt about being
alive when the other person has died, or there is guilt about not being able to
save the person or make his or her life or dying easier.
While grief is not the same for every person, there are certain
commonalities. During the initial phase, the bereaved person is preoccupied
with the deceased, preoccupied with feelings of yearning and longing, and with
searching for him or her. While grieving, most people withdraw from the world
and turn inward, often reviewing the course of the relationship, including
positive and negative thoughts and feelings. People often also review the
meaning the relationship had in their lives. Grief entails a host of painful
emotions that can sometimes be very strong and persistent. Strong feelings of
sadness and loneliness almost always occur following the death of a close
friend or family member. Fear and anxiety are also common. Difficult feelings of resentment, anger, and
guilt can occur. Experiencing any or all of these emotions following the loss
of a friend or family member is perfectly normal.
As the transition to life without a friend or family member progresses, the
intensity of grief subsides. The bereaved person accepts the death and begins
to take some comfort in positive memories, establishing a permanent sense of
connection to the person who died. It becomes possible to reengage in
activities and relationships while still having memories of and maintaining a
sense of closeness to the deceased. The period over which this adjustment
occurs is variable, depending on the circumstances of the death, the characteristics
of the bereaved, and the nature of the relationship. In some circumstances,
intense grief persists for many months or even years. Intrusive images and
disturbing ideas inhibit the healing process, and there is a sense that the
death is unacceptable and unfair. For some who have difficulty coping with the
death, grief sometimes seems to be all that is left of the relationship. Also,
a decrease in the intensity of the grief may feel like a betrayal of the person
who died. Some people also have persistent feelings of guilt. When a death is
sudden, violent, and untimely, the bereaved will most likely also face other
difficulties. The condition in which unmanageably intense and/or persistent
grief symptoms occur is called Traumatic Grief. Symptoms of Traumatic Grief are
listed in Table 1. Work is underway to establish diagnostic criteria and to
develop treatments for this condition. Traumatic Grief may predispose to other
psychiatric, medical, and behavioral problems that can complicate bereavement.
These are generally treatable conditions and need to be recognized by
professionals and by the bereaved individuals themselves.
Complications of bereavement
Bereavement is a risk factor for a range of mental and physical health
problems. Among these are the following:
·
Prolonged grief or Traumatic Grief
·
Onset or recurrence of Major Depressive Disorder
·
Onset or recurrence of Panic Disorder or other anxiety
disorders
·
Possible increased vulnerability to PTSD
·
Alcohol and other substance abuse
·
Smoking, poor nutrition, low levels of exercise
·
Suicidal ideation
·
Onset or worsening of health problems, especially
cardiovascular and immunologic dysfunction
Traumatic Grief
Grief will inevitably disrupt mental functioning following the death of a
loved one. While it should be emphasized that grief itself is a normal process
of adapting emotionally and cognitively to the loss or absence of a loved one,
sometimes the intensity of a person’s grief may be overwhelming or last longer
than is healthy. This may occur for a variety of reasons. The relationship
between the deceased and the bereaved might have been very close or
complicated; the circumstances of the death may be sudden or traumatic, as in
accident, disaster, or illness; or the grieving person may not have good coping
skills or the social support that would help the grieving process. In
situations like these, it may be helpful to seek professional help or
counseling in order to resolve the grief.
When grief goes on longer than is healthy or when it is overwhelming, a diagnosis
of Traumatic Grief might be appropriate. It may be helpful to draw an analogy
to a physical illness. An illness is not a characteristic of a person; it is a
state a person is in at a given time. Many illnesses are very treatable.
Another analogy is to an acute injury. People are more or less vulnerable to
disability from an injury, but some types of injury are so severe that they
always cause impairment. Using such an analogy, it is possible to see that
following an accident or disaster or the sudden death of a very close person,
it is entirely normal to experience Traumatic Grief, just as it is quite normal
to develop tuberculosis upon exposure to a virulent organism, and it is normal
to be unable to walk on a broken leg. It is also clear that it is a good idea
to diagnose and treat these conditions. No one would tell a person with
pneumonia "pull yourself together" or "get on with it" or
expect a person with a deep cut or a broken bone to heal him- or herself.
Although labels can be hurtful if misused, they can also be helpful. An ill
person needs to have a "sick role" and to receive treatment. An ill
person benefits from support and assistance from family and friends, as well as
from treatment by a trained professional.
Table 1: Symptoms of Traumatic Grief (Prigerson, 1995)
·
Preoccupation with the deceased
·
Pain in the same area as the deceased
·
Memories are upsetting
·
Avoid reminders of the death
·
Death is unacceptable
·
Feeling life is empty
·
Longing for the person
·
Hear the voice of the person who died
·
Drawn to places and things associated with the deceased
·
See the person who died
·
Anger about the death
·
Feel it is unfair to live when this person died
·
Disbelief about the death
·
Bitter about the death
·
Feeling stunned or dazed
·
Envious of others
·
Difficulty trusting others
·
Lonely most of the time
·
Difficulty caring about others
Risk factors for complications of bereavement
Risk factors are those aspects of a situation that tend to increase
vulnerability to complications and that may slow recovery. Existing studies
suggest that risk factors relate to the characteristics of an individual, the
nature of the relationship to the deceased, the circumstances of the death, and
the social context within which recovery takes place. Some risk factors relate
to the larger situation in which the bereaved finds him- or herself, and some
risk factors relate to the bereaved individual’s specific history and makeup.
While both kinds of risk factors raise the distress level of the bereaved
person, it is useful for clinicians to be particularly aware of the bereaved’s
individual situation.
The following risk factors have been identified:
·
Demographic factors: Socioeconomic status: Lower
socioeconomic status is related to a poorer health status in general.
Bereavement appears to affect people similarly, regardless of socioeconomic
status. Age: Bereavement appears to be somewhat more stressful for younger
individuals than it is for older individuals, with the exception of elderly
people. The disparity between how older
individuals are affected and how elderly people are affected may be because the
stress experienced by elderly people is related to preexisting health problems.
Gender: There is some evidence that men, especially widowers, have more
bereavement-related health problems than women, especially when dealing
specifically with the loss of a spouse.
Although both men and women are deeply affected by the loss of close
family members and friends, the death of a child may be more difficult for
mothers than for fathers. Women may also recognize the effects of bereavement
more readily than men, and men and women may cope differently.
·
Individual characteristics: Overall, individuals
who are defined as "neurotic" have been shown to have more health
problems. Low internal locus of control is generally associated with more
depression. This is not specific for bereavement. On the other hand, high
internal locus of control does not act as a buffer for bereavement-related
distress. Anecdotal evidence suggests that a belief in life after death may be
protective. However, when this was examined in a study, a protective effect was
not found (Stroebe & Stroebe, 1987). Guilt or self-blame about the death
may contribute to traumatic grief.
·
Relationship quality: Relationship quality may
affect men and women differently when it comes to difficulty with
bereavement. A good marriage may be
associated with more bereavement-related problems in women, while the opposite
may be true for men. In general, data does not support clinical lore that
implies that bereavement problems occur because of ambivalence or problems in a
relationship. It is very clear that in some instances an especially positive
relationship may be associated with very difficult bereavement reactions.
·
Circumstances of the death: Not surprisingly,
sudden death is associated with more symptoms of bereavement difficulty in the
first 6 months after the loss. In some studies this difference was not present
in later interviews, while in other studies it was. A low score on a measure of
internal locus of control signified a greater likelihood for difficulty for
younger bereaved spouses. In some studies, there is evidence of continuing
distress from the loss for many years following a sudden, violent loss.
Experiencing multiple losses or witnessing the death (especially a factor for
children who witness a death) has been found to correlate with levels of grief
intensity. Feelings of helplessness and powerlessness, survivor guilt, threat
to one’s own life, confrontation with the massive and shocking deaths and
mutilations of others, and a violation of one’s assumptive world of safety and
meaning are traumatic factors that may impact a person’s ability to resolve
grief. It is clear that many of those bereaved by the WTC disaster may
experience treatable psychiatric difficulties for a long period of time. It is
important for professionals to be vigilant about this possibility.
·
Social context: Both perceived and received
social support are related to lower symptoms of depression in the general
population, but there does not appear to be a specific relationship between
social support and bereavement outcome. However, it is important to note that
bereaved individuals often perceive that others lack empathy and that others
are hostile about the bereaved’s continued symptoms. This perception is likely
related to a poorer outcome but has not been specifically studied. In general,
however, social support and positive family functioning, along with the
opportunity to express grief, may help to mitigate the negative effects of
bereavement.
Treatment of bereaved individuals
Grief support groups and grief counseling are widespread and undoubtedly
highly variable. Little information is available related to support group and
counseling outcome. There is specific controversy regarding the importance of
confronting the death (also called "grief work") in the early phase
of grief. In one study (Stroebe), investigators developed a measure to assess
the extent to which individuals confronted or avoided their loss and used scores
on this instrument to predict outcomes at later times. They found that low
scores for widows did not influence outcome, but low scores for widowers
predicted poorer outcome. There is some evidence that the occurrence of
symptoms of major depression in the first month following the death predicts a
worse course later, especially for suicidally bereaved individuals (e.g.,
Jordan, 2001).
It goes without saying that the loss of a close relationship permanently
affects the bereaved person. It is not reasonable to think that one can recover
from such a loss or resolve the loss. Such a loss is permanent and has
permanent effects on the bereaved. Still, it is possible and important that the
bereaved person will eventually have comforting memories of the deceased and
feel interested in and able to engage in life. Weiss (1993) provides a list of
reasonable expectations we can have for the bereaved. A person who has lost someone should eventually have (1) the
ability to give energy to everyday life, (2) psychological comfort, or freedom
from pain and distress, (3) the ability to experience satisfaction and
gratification in life, (4) hopefulness for the future, and (5) the ability to
function adequately in a range of social roles. How can a professional assist the
bereaved in achieving these goals?
The role of a professional in the early phase of disaster bereavement
There is little data on the effectiveness of early intervention for grief.
However, it is clear that early intervention is a good idea following a disaster,
provided a skilled, empathic clinician administers the intervention. Although data suggest that even after
sudden, violent death, most people eventually grieve successfully, the initial
process can take a long time. Many people consider grief to be a personal
experience and so do not turn to mental-health professionals for help with
grief. However, when a loss is sudden and violent, the intensity of emotions
can be frightening and the need for support and outside intervention greater.
In response, the professional needs to engage in a skilled, supportive
intervention. Useful components of such an intervention include:
·
Providing information about grief and its symptoms,
course, and complications
·
Evaluating the nature of the individual’s distress
·
Helping to identify and solve practical problems
·
Providing strategies for management of intense feelings
·
Helping the person think about the death in a way that
leads to emotional resolution
Affect-evoking interventions must be used with care and expert skill and be
balanced with containing and soothing strategies. During the early phase of
bereavement, it may be very useful to provide information and strategies for
thinking about the death. It is best if the professional provides some
follow-up and remains available for consultation and support, should this be
needed.
Prigerson and Jacobs (2001) provide a list of "do’s" and
"don’ts" for how physicians might interact with family members
following a patient’s death. These may also be useful to consider. The authors
recommend:
·
Direct expression of sympathy
·
Acknowledgement that the clinician does not know
exactly what the bereaved person is going through
·
Talking about the deceased, including saying his or her
name
·
Eliciting questions about the circumstances of the
death
·
Asking questions about feelings and about how the death
has affected the person
The authors also provide a useful list of cautions about things that are NOT HELPFUL, including:
·
A casual or passive attitude (e.g., Do not merely say,
"Call me if you want to talk," or ask "How are you?")
·
Statements that the death is in any way for the best or
acceptable (e.g., "He/she is in a better place," or "It’s God’s
will.")
·
An assumption that the bereaved is strong and
will/should get through this
·
Any kind of avoidance of discussion of the death or the
person who died
Even given its private nature, variable course, and usual resolution, there
are circumstances in which grief can be intense and prolonged, hindering
reengagement in daily activities. When this occurs, a focused intervention may
be needed. There is wide acknowledgment that bereavement can be prolonged and
that it can lead to other mental-health problems, especially depression and
anxiety. Therefore, professional intervention may be especially important if
the bereaved exhibits the risk factors discussed above.
Treatment strategies for complications of bereavement
Treatment should target the symptoms experienced by the patient. It is now
very clear that bereaved individuals who have Major Depressive Disorder (MDD)
respond to antidepressant medication and/or psychotherapy similarly to those
who are not bereaved. A very interesting recent study suggests that treatment
of MDD as early as a month after the death may be extremely helpful and prevent
later symptoms. Similarly, for those who meet criteria for PTSD, it makes sense
to provide treatment similar to that used with other PTSD patients. However,
the most common postbereavement problems center around traumatic grief
reactions, and unfortunately, few treatments have been developed or tested for
symptoms of Traumatic Grief. Studies of early intervention for grief document
some reduction in grief symptoms, with support groups showing efficacy equal to
that of active psychotherapy. An early study of a behavioral therapy
called "guided mourning" also appeared to have beneficial effects,
although grief outcome was not measured. A specific "Traumatic Grief
Treatment" (TGT) is currently undergoing randomized controlled testing. In a pilot study, TGT had a large effect size, even taking into
consideration individuals who did not complete the full course of the treatment
(Shear, 2001). Components of this treatment include:
·
Providing information about bereavement and grief to
bereaved individuals and their families
·
The bereaved describing the deceased and relating the
history of the relationship with the deceased
·
Relating the story of the death and its aftermath
·
Careful assessment of current grief levels, target
grief levels, and components of grief (i.e., cognitive, behavioral, and
somatic)
·
Reviewing the bereaved’s personal goals and determining
how the bereaved person will know when these goals have been met
·
Carefully managed imaginal exposure to the death and
related events
·
In vivo exposure to situations that are avoided and/or
response prevention for situations of preoccupation
·
Focusing on positive memories of the deceased
Therapists should undertake imaginal exposure only if they are familiar with
this technique and with emotion control techniques. The remainder of the
treatment may be of help alone, but it has not been tested. It is also
important to evaluate the bereaved person’s social support system and encourage
engagement with existing supportive people. To date, no treatment has been
proven effective in the early stages of bereavement, and there is some
indication that for some people formal grief counseling can do more harm than
good. In light of this, caution may be indicated.
Guidelines for early treatment in the acute phase of Traumatic Grief
include:
·
Allowing the bereaved person to talk about the nature
and circumstances of their loss according to their own readiness (without
probing)
·
Educating about the course of bereavement and what to
expect
·
Assessing for possible troubling symptoms like an
unusual intensity of grief reactions or intrusive thoughts
·
Encouraging, as much as possible without intruding, the
use of social support and the broadening of activities
·
Encouraging positive memories and a feeling of
connection to the deceased, which may help supplant traumatic memories
Pharmacotherapy may also be helpful for individuals suffering from Traumatic
Grief. However, little has been done to test pharmacotherapy. As with depression
and PTSD, it appears that serotonin active medications have some beneficial
effect (Zygmont, 1998). Given the available information, it is important that
clinicians learn to administer the techniques that appear to be efficacious.
Related Fact Sheets
Death
notification
Death notification procedure developed by MADD
Grief in veterans
Assessment and treatment of acute grief in returning veterans
Managing
stress
A brief guide to recognizing the symptoms of stress and managing traumatic
stress
Risk
factors
A fact sheet about the risk factors for adverse outcomes in natural and human-caused
disasters
Suicide
Examines the connection between PTSD and suicide
Surviving
disasters
A general fact sheet about the psychological problems one might experience
as a result of surviving a disaster and what survivors can do to reduce the
risk of negative psychological consequences
