Trauma, Loss, & Bereavement

Loss, disappointment, failure, and grief are normal and natural accompaniments of the human experience. Bereavement, the response we have to grief and loss, is also familiar to most of us. Little has changed in terms of the emotional response to the pain of loss across the centuries. There are many kinds of loss, death is but an extreme example. There is still the agonizing experience of separation and the subsequent wrestling with the aftermath of unfinished business, and unanswered questions related to

Why? and Why me?

Having one’s comfortable and stable world rocked by uncertainty, chaos, and anguish ushered in by death leaves one feeling helpless. There continues to be the struggle to deal with the uncomfortable psychological reactions of anxiety, anger, despair and the impact on one’s self-esteem. Confusion, disorganization, and depression are the natural results of having one’s world shattered by the death of a loved. It is normal to resist the onslaught of unexpected feelings and the fear of facing an uncertain future without the loved one. Everyone is touched by the experience of feeling mortal and vulnerable which occurs in an encounter with the finality of death. Most, despite all of this, submit to the necessary process of loss, grief and bereavement and work to rebuild the old world into a new, post loss world.

However, while the actual experiences of mourning and its inherent demands have not changed over time, what has changed is the climate in which they now occur. This changed environment is charged with potentials for complicated grief and mourning. The reason for this is quite simple. Death has become more frequent, unnatural and violent with less of a social context in which it can be integrated. The social conditions under which we exist are characterized by increased violence, accidents, terrorism, disasters, holocausts, accidents, plane crashes, and seemingly random shootings.

Today deaths are more frequently of a type known to complicate mourning. In particular these include sudden, unexpected deaths, expecially when traumatic, violent, mutilating, or random; death resulting from an overly lengthy illness; death of a child; and death the mourner believes preventable.

Loss, and bereavement, then, become even more problematic, when it occurs under traumatizing circumstances. Recent studies have shown that when death occurs from sudden, unexpected circumstances such as accidents, suicide, or murder, bereavement reactions are more severe, exaggerated and complicated. The individual mourner’s capacity to cope and adapt are overwhelmed. Research has shown that those who mourn the willful, intentional act of murder of a loved one--bereaved homicide survivors--experience the unique intrusion by many outside forces in our society.

The American Psychiatric Association has defined Trauma as follows,

The person has experienced an event that is outside the range of usual human experience that would be markedly distressing to almost anyone. For example: serious threat or harm to one’s children, spouse or other close relatives and friends; sudden destruction of one’s home or community; or seeing another person who has recently been or is seriously wounded, or killed as a result of accident or physical violence.

The result of these kinds of experiences results in a condition known as Post Traumatic Stress Disorder. PTSD is a normal response to abnormal circumstances. Failure to recover or adquately deal with traumatic loss and restore one’s life to normal functioning is often referred to as Complicated Grief Response.

There are a whole host of factors which lead to complicated grief subsequent to trauma.

The first is that the suddenness of the trauma overwhelms the person’s coping abilities and leaves him or her in shock.

The second is that our commonly held beliefs about the justice, orderliness, safety, meaningfulness, stability, predictability, and our ability to control our destinies, is violently shattered.

Thirdly, because of the type of loss we experience intense reactions of fear, vulnerability, helplessness, and loss of control.

A fourth factor is that the mourner experiences a profound loss of security and confidence in the world which affects all areas of life. This is likely to increase many kinds of anxiety.

Fifth, traumatic death leaves mourners with relatively more intense emotional reactions, such as greater anger, ambivalence, guilt, helplessness, death anxiety, vulnerability, confusion, disorganization, and obsession with the deceased along with strong needs to afix blame or make the death meaningful.

Sixth, the traumatic death leaves the mourner with many secondary losses and problems to deal with as a result. Unfinished business, and not being able to say goodby make it difficult to complete the mourning.

Seventh, traumatic death leaves the victims with profound feelings of mistrust, shattered beliefs, and inability to reattach to a future with hope and meaning. A sense of foreshortened future and recurrence are common.

Eighth, traumatic death compounds and exaggerates all of the other normal ongoing stressors of life.

Ninth, traumatic death often creates many post traumatic reactions of a physical or psychological kind. Shock, numbing, headaches, sleep disorders, digestive disorders, inability to feel loving feelings, depression, anxiety, and intrusive thoughts, flashbacks, fatigue, tension, weakness, sweating, hyper-vigilance, irritability, amnesia, and difficulty in concentration are all common.

And finally, the tenth factor has to do with the mourner’s attempts to cope and restore order which may turn out to be ineffective. Quite often failed attempts to cope lead to addiction, avoidance, phobias, chronic depression, compulsive- destructive behaviors, and failed relationships. Failed attempts to cope may lead to the mourner getting stuck, or suffering from a complicated grief reaction.

Trauma, loss and bereavement reactions are a complicated interaction of numerous factors; the individual mourner, the type of death, and the social context in which the death occurs. Recent events provide numerous examples of how all of these previously discussed factors interact: case in point, Littleton, Colorado.

I, along with millions of other Americans watched the unfolding horrors of the massacre at Columbine High School. I watched at two levels. The first level was that of a highly trained, sophisticated trauma specialist. I was observing all of the events and at the same time cataloguing them according to what was likely to be the short and long term effects of that event. I was also observing the efforts of the emergency responders and the way that they handled the victims. They were doing their best while they themselves were being traumatized in the course of doing a very difficult job. I saw an entire comunity being simultaneously traumatized. The concentric circles of victimization extended out from those immediately under fire to their fellow students, the families frantically searching for their children, emergency responders trying to save lives, protect themselves, and evacuate a booby trapped building. All the while the entire scene was being documented by live television reportage. Death, terror, chaos, shock, disbelief, and horror mounted as the body count went up.

How could this happen?
We’re supposed to be safe in school.

How could the police not know about this ahead of time?
I knew they were angry and a little weird, but I couldn’t believe they were capable of this.

Tearful reunions, crying, stunned survivors telling of pandimonium and fear behind barracaded doors. Helpless, we all watched a school, community, families, and children being shattered before our very eyes. In just a few short minutes, the whole world of Littleton, Colorado and all those whose lives touched on the people of that community were changed forever. I also watched all of this as a person who has had several traumatic losses in my own life. I was touched by the shock, I remembered my own experiences, I could feel their helplessness and terror. I could feel their numbness and disbelief. I also knew how long it was going to take to heal.

There were more than lives lost that day. Students reported that they could never go to that school again. Their beliefs in a safe, just, serene, stable, orderly, meaningful universe were shattered. Their trust in the ability of adults to protect them was shattered. Their beliefs in a future in which they could control their destinies was lost. Random, sudden, intentional murder on a mass scale was committed by students who were known to them. These acts of savagery are incomprehensible yet we try to make sense of them. Shortly after the event began to wind down people were already busily engaged in trying to find answers to how this could have happened, the why and why here and why now questions were asked incessantly. One school, the next day banned trench coats. Everyone in their way was trying to make sense of what happened and regain control of a world which went upside down and inside out.

The trauma that day was magnified by the savagery, brutality, and shere number of fatalities. This event fits the catagory of a catastrophic community trauma. Intentional, multiple, horrific murders commited by people known to us are the most difficult of all traumas to integrate, assimilate and recover from. Children were exposed to horror, blood, death, and were in fear of their own lives. They were rendered helpless while simultaneously experiencing the most primitive feelings of terror, shock, confusion, and bewilderment. One of their own wanted to kill as many as possible. This kind of a loss cannot be understood, absorbed or made sensible. There is no way to get closure, say goodbye, or deal with unfinished issues. The sustaining context of hope, the envelope of security, trust and mutuality, the shared experiences, values and beliefs which bind a community and its citizens together was shredded by two young men, who for reasons unknown, felt isolated, allienated and uncared for enough to plan and carry out a vendetta of rage and revenge.

Shattered beliefs, shattered emotions, shattered relationships, shattered innocence, shattered covenants, shattered lives: all who were even marginally involved were rendered helpless and subjected to unspeakable, unimaginable horrors and death. Trauma of this magnitude will not heal by itself. Trauma of this magnitude will scar this town and its people forever. The work of healing must be immediate, well planned, and executed systematically in order to minimize secondary trauma and injury. The presence of the press and national attention has already traumatized vulnerable children by subjecting their most intense and personal reactions to scrutiny. It is not possible to heal or even mourn with microphones and cameras present. It can only be done in a safe and caring environment created by knowledgeable, compassionate professionals. The services and memorials were well intentioned and may have had some benefit in demonstrating community solidarity and emotional catharsis, but the real work of mourning will be done in the next few days, weeks, and yes, even years.

As a further example of the potential devastation this kind of community disaster has on its victims not only for the short term but even years later, I cite the Oklahoma City bombing. Four years after the worst act of terrorism in the United States, at least a half dozen people linked to the bombing have taken their own lives. These include two rescue workers, a federal prosecutor, an army Captain who made it out of the building, a bomb-blast survivor, and the husband of one of the victims. At least twice as many have attempted it, and who knows how many more have thought of suicide. Four years later the legacy of the bombing lingers on, more than 500 were injured physically, far more have lingering psychological trauma. Many survivors--building workers, paramedics, police officers--are haunted by survivors guilt --they lived but they were unable to save others. The resulting traumatic impact is everywhere: spousal abuse, failed marriages, ruined careers, school problems, nightmares, and drug and alcohol dependence. One police officer was arrested for writing illegal prescriptions, another spends his days on a bar stool. One woman rescued from the building now cannot leave her home. Another is addicted to gambling. Others carry weapons and are constantly afraid of another incident. Trauma professionals who worked the incident have warned that the suffering would likely reach its peak in three to five years after the formal memorial services concluded.

In summary, loss, mourning and bereavement, are a part of life. Most of us are able to struggle through the difficult emotions, accept the loss, and rebuild our lives into a new configuration. Trauma, when added to the grief experience, adds whole new dimensions to bereavement. Traumatic loss is most often a life changing experience. For its victims life will never be the same again. There will be no turning back. The old life will not be recaptured. Littleton, Colorado illustrates the magnitude of the problem of trauma by the shere size and scope of the devastation. Multiple fatalities, violence and mutilation, random and perhaps preventable violence, exposure of hundreds to death and horror, intentional murder commited by associates in a sudden and unanticipated manner, all of these factors meet the criteria for traumatic loss. In fact, just the presence of one of these factors contribute to the likelihood of the death being traumatic and places the victim at a high risk for complicated grieving.

In order for the victims of the Columbine High School massacre to recover they will need to go through the following stages of mourning. These stages are outlined by Therese Rando, a leading expert on complicated mourning. These stages also apply, of course, to other kinds of traumatic loss.

Task 1. RECOGNIZE THE LOSS
Acknowledge the death, understand the death

Task 2. REACT TO THE SEPARATION
Experience the pain, feel and express all reactions to the loss.
Identify and mourn all secondary losses.

Task 3. RECOLLECT AND REEXPERIENCE THE DECEASED AND RELATIONSHIP
Review and remember realistically
Revive and reexperience the feelings

Task 4. RELINQUISH the old attachments
Release and work through the attachment
Release and revise the old world

Task 5. READJUST,
move adaptively into the new world without forgetting the old.
Reconcile old beliefs with new experiences.
Resolve the incongruity, dissonance and conflict in beliefs.
Develop a new relationship with deceased.
Adopt new patterns and structures in your life.
Form a new identity.

Task 6. REINVEST
Form new attachments.
Develop new relationships.
Learn to care and live a new life.

In all likelihood many of the more severely traumatized individuals at Littleton will experience some form of complicated bereavement. This in effect means that he or she will get stuck at one stage and be unable to move on to the next. Many will try to skip the whole process and just get on with their lives.

A word of caution: by the time mourning has become complicated, mere grief facilitation will be insufficient. The individual will require more.

In conclusion, confronting trauma is not only necessary in order to move beyond it, it is necessary because it reduces the necessity for avoidance, repression, and reduces the risk of pathological consequences. Getting stuck in trauma means that we want to either deny, avoid, or hold on to what was. We do not want to feel the grief and other related feelings. Mourning, I must caution is not optional, it is something which calls out to us and wont leave us alone until we heal the wounds. If we try to avoid it we run the risk of having our lives stop at that very place where the trauma occurred. We must find the way, and the situation which will facilitate the process of healing. It can be done, it must be done.