Intersections Between Grief and Trauma: Toward an Empirically Based Model for Treating Traumatic Grief

RESEARCH COMMENTARY

Cheryl Regehr, PhD Tamara Sussman, MSW

Two divergent areas of study have focused on the experiences of grief, i.e., bereavement, and on trauma and its aftermath. The grief literature has its foundations in psychodynamic and relational theories, and thus treatment modalities have focused on resolving relationship issues through reminiscence and developing a new sense of the relationship and of the self, independent of the lost loved one. The trauma literature, while having some psychodynamic roots, has been founded primarily on biological and cognitive formulations. Again, while many different treatments are discussed, cognitive- behavioral approaches based on cognitive restructuring and symptom management dominate the practice efﬁcacy literature. But trauma and bereavement/loss are not mutually exclusive, and when a practitioner is faced with a client suffering from both, it is necessary to attempt to integrate these divergent theories and at times antithetical treatment approaches. This paper therefore seeks to address the issue of treatment efﬁcacy in traumatic loss and develop guidelines for evidence-based approaches to practice. [Brief Treatment and Crisis Intervention 4:289–309 (2004)]

KEY WORDS: traumatic grief, traumatic loss, posttraumatic stress disorder, evidence- based practice.

Two parallel streams have emerged in the focused on the process of mourning. The theory professional and academic literature—these in this area has concentrated on relational regard grief, i.e., bereavement, loss of a loved dimensions and bereavement accompanying one, and trauma. The grief literature has the experience of detaching from the deceased. Treatments recommended involve remember- ing the deceased, ‘‘working through’’ feelings, From the Centre for Applied Social Research and Faculty of Social Work, University of Toronto. and attaining a new relationship with the mis- Contact author: Cheryl Regehr, PhD, Centre for sing loved one. By contrast, the trauma Applied Social Research, University of Toronto, 246 Bloor Street West, Toronto, Ontario, M5S 1A1. E-mail: literature has examined responses to exposure [email protected]. to horrifying and life-threatening events. DOI: 10.1093/brief-treatment/mhh025 Theory and research in trauma have long

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considered both the psychological and physi- sional decision making (Sackett, Richardson, ological dimensions of terror and its aftermath. Rosenberg, & Haynes, 1997). More simply Distressing memories and physiological reac- defined, it is the use of treatments for which tions are viewed as symptoms of a disorder. there is sufficiently persuasive evidence to sup- Treatment is aimed primarily at symptom port their effectiveness in attaining the desired management and eradicating intrusive images outcomes (Rosen, Proctor, & Staudt, 2003) for of the traumatic event. Yet, trauma and grief are the particular problem and for clients with the often not mutually exclusive. People survive characteristics of those presently being accidents that their loved ones do not. Family served (Roberts & Yeager, 2004). This paper members are murdered. Children die suddenly. examines the intersection between trauma and Depending on the suddenness and violence and grief/bereavement and attempts to determine the sense of justice associated with the loss, as empirically based approaches for treatment well as the nature of the relationship between interventions in the event of traumatic loss. the deceased person and the survivor, people Considering the intensity of these tragic events may suffer trauma and grief simultaneously. and the depths of despair that may be This requires that we develop and test inter- experienced by individuals who encounter vention strategies that deal with these com- traumatic loss, it is imperative that mental plex situations. health professionals respond with approaches Despite the proliferation of theoretical and that do in fact assist to relieve suffering and do clinical literature in the area of grief studies, the not carry the risk of elevating symptoms. empirical basis for theoretical constructs and resulting treatment approaches in the area of grief work is quite weak (Jordan & Neimeyer, Foundations of Grief Theory 2003). In the area of trauma, outcome studies do point to the efficacy of some approaches, Throughout the past century, grief work has particularly those with cognitive-behavioral been the major theoretical construct to explain foundations (Follette, Ruzek, & Abueg, 1998; how people cope with bereavement. Due to the Harvey, Bryant, & Tarrier, 2003; Rothbaum & fact that virtually all humans can be expected to Foa, 1996). However, there is evidence that the experience significant loss at some time in their application of certain approaches with clients lives, grief is viewed as a normal, albeit who possess certain vulnerabilities or charac- distressing, process. High levels of emotion teristics may in fact be iatrogenic (Regehr, are experienced but are viewed as having 2001). Traumatic grief is an emerging construct, a clearly defined goal, that is, helping the and few treatment approaches specifically bereaved abandon the commitment to the address its issues, yet a growing body of relationship with the deceased (Freud, 1917). evidence exists upon close examination of Movement toward resolution is conceptualized inclusion criteria for grief and trauma inter- to occur in stages or phases during which vention studies. This research literature can individuals complete a series of mourning tasks. form the foundation for an evidence-based While the number of stages or tasks one passes approach to clinical practice with individuals through differs in the various conceptual suffering from traumatic grief. modes, commonalities exist. In general, the Evidence-based practice is defined as the first stage is described as acute grief, which is conscientious, explicit, and judicious use of characterized by numbness, frequent yearning the best available scientific evidence in profes- for the deceased, and denial of the permanence

290 Brief Treatment and Crisis Intervention / 4:3 Fall 2004 Intersections Between Grief and Trauma or reality of the loss. Although bereavement deal with social loneliness). Unlike stage theorists are hesitant to provide timelines for theorists, Stroebe and Schut do not propose that normal grief patterns, this stage is thought to one orientation necessarily proceeds another, typically last a number of weeks, generally 6 to but rather suggest that a balance between both 8 (Humphrey & Zimpfer, 1996; Worden, 1991). is normal and necessary during the course of Once the permanency of the loss becomes bereavement. What remains unclear is the ideal a perceptual reality, the bereaved typically is balance between confrontation and avoidance. thought to experience an extended period of These conceptual models for understanding disorganization and despair which can last bereavement have contributed to a view that several months (Shuchter & Zisook, 1993). people experiencing grief subsequent to loss Finally, as the intensity of loss-related emotion must confront and work through their reac- begins to subside, the bereaved individual tions. This notion that one has to process grief enters a phase of reorganization in which he can be traced back to Freud (1917), who or she must learn to function in an environment described the ‘‘work of mourning’’ as a process without the deceased and come to a new sense wherein the bereaved reminisces and emotion- of the lost relationship (Bowlby, 1980; Parkes, ally experiences the memories and significance 1996; Worden, 1991). This stage is still of the deceased, as a step toward letting go of accompanied by elevated emotions; however, involvement with him or her. Like Freud, the frequency of yearning and crying and the Stroebe (1992) defined working through as ‘‘a centrality of the loss in the bereaved individ- cognitive process of confronting a loss, of going ual’s life begin to diminish. According to many over the events before and at the time of the grief theorists, the process of normal grieving is death, of focusing on memories and working expected to last between 1 and 2 years and towards detachment from the deceased’’ (p. 20). varies depending upon the nature of the These definitions have been maintained by relationship between the deceased and the others (Rando, 1992; Sanders, 1993; Worden, bereaved and the circumstances surround- 1991). There are two assumptions articulated in ing the death (Humphrey & Zimpfer, 1996; this conceptualization. One is that individuals Worden, 1991). must express their emotions, particularly neg- A somewhat different interpretation of the ative ones, in order to resolve their grief; and process of grief is proposed by Stroebe and the second is that this highly painful and Schut (1999), who put forth a dualistic model of emotional process will help the bereaved to bereavement which suggests that grieving is detach from the deceased and achieve resolu- a dynamic process that reflects both the tion. The first assumption has guided most realization of the loss and the continued fight clinical grief interventions: The primary goal against the reality of the loss. These theorists for practitioners is often to help individuals propose that bereaved people have a tendency work through the process of grief by express- to oscillate between confronting and avoiding ing both positive and negative emotions di- loss at every stage of the bereavement process. rected toward themselves, the deceased, and Accordingly, people engage in both loss others. Failure to express these highly charged orientation, which concentrates on dealing emotions is assumed to put individuals at risk of with some aspects of the loss (e.g., yearning complicated grief, specifically delayed grief for the deceased, looking at old photos, crying reactions. about the death), and restoration orientation, Thus, clinical theorists consistently promote which concentrates on life changes (e.g., how to the need to confront grief-related emotions as

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a means of achieving ‘‘grief resolution.’’ trist Pierre Janet is quoted as writing in 1919: Clinicians offering grief therapy to individuals ‘‘All famous moralists of olden days drew evidencing both normal and pathological pat- attention to the ways in which certain happen- terns of bereavement are encouraged to facili- ings would leave indelible and distressing tate the expression of grief-related emotion by memories—memories to which the sufferer asking the bereaved to identify and experience was continually returning, and by which he feelings such as what they do and don’t miss was tormented by day and by night’’ (quoted in about the deceased and what negative feelings van der Kolk & van der Hart, 1989, p. 1530). In they have toward the deceased (Bowlby, 1980; the late 1800s and early 1900s many physicians Humphrey & Zimpfer, 1996; Worden, 1991). began describing reactions to traumatic events, Expressing both positive and negative emo- including both physical responses (such as tions regarding the deceased is seen as impor- ‘‘irritable heart’’ [DaCosta, 1871; Oppenheimer tant in grief resolution, as this phase requires & Rothschild, 1918]; posttraumatic spinal cord the integration of a balanced and realistic injuries due to nervous shock and without memory of the deceased rather than an apparent lesions [Page, 1885]; and ‘‘neurasthe- idealized or completely negative one (Hum- nia,’’ a physical disorder associated with fear phrey & Zimpfer, 1996; Worden, 1991). Fur- [Mott, 1918]) and psychological reactions such ther, guided by these stages of grief, counselors as ‘‘war neurosis’’ (MacKenzie, 1916) and ‘‘shell are advised to help individuals express their shock’’ (Southward, 1919). numbness and yearning so that the reality of Two main theories emerged out of this the loss can be actualized; to identify and work literature. The first was proposed by Freud, through their despair, including their feelings who suggested the concept of ‘‘anxiety neuro- regarding the lost relationship, so that the sis,’’ or ‘‘hysteria,’’ in which a horrific psycho- intensity and frequency of grief-related emo- logical event leads to physical consequences tions can dissipate; and finally to focus on the (Turnbull, 1998). The second suggested that the external world so that lost roles and self- impact of physical forces on the central nervous concepts can be re-formed. Although stages/ system experienced during a traumatic event phases are not necessarily meant to be linear, it such as a rail disaster or combat resulted in is a clear assumption that one cannot experience a temporary neurological dysfunction, which in the stage of reorganization without having turn leads to symptoms (Turnbull, 1998). verbalized and worked through the emotions However, this interest in the effects of psycho- identified in the first stages of grief. logical trauma on individuals subsided after the end of the First World War and did not resurface until the mid-1970s. At that time, Foundations of Trauma Theory interest in the effects of war on Vietnam veterans emerged, resulting in the concept of The experience of psychological trauma in ‘‘posttraumatic stress,’’ and interest in the response to exposure to horrific events is effects of rape on victims emerged, resulting a theme that can be found in the earliest of in the concept of ‘‘rape trauma syndrome’’ literature. Achilles in Homer’s Iliad and Hot- (Burgess & Holstrum, 1974). Together, the spur in Shakespeare’s Henry the IV are fre- pressures arising from the needs of these two quently cited as excellent portrayals of what we highly divergent groups of sufferers resulted in now understand to be traumatic stress reactions official recognition of posttraumatic stress secondary to involvement in combat. Psychia- disorder (PTSD) in the Diagnostic and Statistical

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Manual of Mental Disorders (DSM) (American develop PTSD, which requires that the symp- Psychiatric Association, 1980). toms continue for more than 1 month. For One aspect of trauma response is viewed as instance, a nationally representative study of neurophysiological. As a result of exposure to 512 Israelis who had been directly exposed to an experience of fear or danger, individuals a terrorist attack and 191 who had family undergo neurophysiological changes that en- members exposed demonstrated that while hance the capability for fight or flight. These 76.7% had at least one symptom of traumatic biological responses generally return to normal stress, only 9.4% met the criteria for PTSD levels within a period of hours. In individuals (Bleich, Gelkopf, & Solomon, 2003). In this suffering from posttraumatic stress, however, study, the majority of people expressed opti- several biological alterations remain, including mism and self-efficacy regarding their ability to an enhanced startle response that does not function in a terrorist attack. Similarly, a study habituate, increased activation of the amygdala, of Latino primary care patients in the United alterations in the hypothalamus, and decreased States revealed that of those who had experi- cortisol levels (van der Kolk, 1997; Yehuda, enced political violence in their homeland, 18% 1998; Yehuda, 2002). Thus, autonomic hyper- met the criteria for PTSD (Eisenman, Gelberg, arousal mechanisms related to the event con- Liu, & Shapiro, 2003). The lifetime prevalence tinually recur and are exacerbated by traumatic of PTSD in the general population of the United memories and images. The sufferers thus find States is reported to be 5% for men and 10% for themselves alternating between states of rela- women (Kessler, Sonnega, Bromet, Hughes, & tive calm and states of intense anxiety, Nelson, 1995). This is not to say that individuals agitation, and anger and hypervigilance (Rob- are unaffected by the events, but rather that erts, 2002). In part, the neurophysiological they have symptoms of distress that for the influence is evidenced by the disorganization in most part subside within a relatively short trauma memory and the difficulty in producing period of time. These findings provoked Shalev a coherent narrative (Brewin, 2001). As indi- (2002) to suggest that traumatic events may be viduals attempt to reconstruct events, they more appropriately called potentially trauma- discover gaps and experience spontaneous tizing events. Thus, the evidence is that most flashbacks, which they attempt to control by people are resilient and adaptive following manipulating the probability of their being a traumatizing event. triggered by stimuli (Brewin, 2001). Thus, in It has been suggested that the ability to order to cope with the symptoms, the in- contain disruption caused by trauma within dividual frequently attempts to avoid exposure reasonable boundaries is associated with a clus- to stimuli that are reminiscent of the event or to ter of personal attributes, including mastery, shut out memories of the event. From this control, flexibility, and optimism. This un- perspective, treatment focuses on controlling derstanding of trauma response is primarily stimuli and on symptom management. cognitive in nature. That is, a traumatic event What is problematic about the biological violates assumptions that individuals hold formulation, however, is that there is consider- about the world, such as, ‘‘If I drive safely, I able evidence that not all people will have will not get into a horrific accident.’’ As a result traumatic stress reactions to a catastrophic of this disjuncture between an individual’s event. Several studies have shown that 50% view of the world and the event that has to 80% of men and women experience potential occurred, his or her normal adaptive mecha- traumatic events but that the majority do not nisms fail to be activated. Sensory images of the

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event are stored in active memory, where they which close to 500 people died. Lindemann are repeatedly experienced. These intrusive observed and documented the reactions of the thoughts and images give rise to feelings of survivors, which included somatic responses, anxiety, guilt, and fear (Horowitz, 1976). From behavioral changes, and emotional responses this perspective, an individual attempts to cope such as grief and guilt. In describing the pro- with the traumatic imagery by (1) failing to cess of their recovery, he noted the impor- be sensitive to the discrepant information, (2) tance of grieving, adapting to the loss, and interpreting the meaning of the information in developing new relationships. Undoubtedly a way that is consistent with current beliefs, or these individuals experienced the trauma of (3) altering existing beliefs to match the near-death and witnessing death as well as grief experience (McCann, Sakheim, & Abrahamson, related to the loss of loved ones. Yet, despite the 1988). Those individuals who are able to main- overlap between trauma and grief (see Figure tain a sense of control and optimism regarding 1), the two experiences are conceptualized as the outcome of the event are thus expected to distinct by some theorists and indistinguish- fare better. Treatment therefore is aimed not able by others. Raphael (1997) has considered only at controlling symptoms, but in addition at the differences between the experiences of cognitive restructuring of the meaning of the trauma and grief. For instance, she notes that event and the degree of control that an although both have intrusive thoughts or individual has over the outcome of the event. memories, traumatic memories focus on specific These formulations, however, ignore other negative or horrifying aspects of the event, factors that influence the individual and his or while grief memories focus on the lost person her response to trauma, such as whether the and can be either positive or negative in nature. origin of the event is attributable to human Anxiety in traumatized individuals tends to be intention or to natural causes (Briere & Elliott, related to threat and fear rather than separation, 2000) and the secondary losses or stressors as it is in bereaved individuals. Further, while associated with the event (Brewin, Andrews, & traumatized people tend to be avoidant and Valentine, 2000; Green, 2000; Hobfoll, 2001). In socially withdrawn, bereaved people often seek addition, the degree of support in the environ- out reminders and social support. Unresolved ment is important, including the individual’s trauma reactions are seen to lead to chronic personal network and the community response PTSD, while unresolved grief issues are more to the event. associated with depression (American Psychi- atric Association, 2002). Conversely, Brom and Kleber (2000) suggest that ‘‘there is no need to Intersections Between Grief see the response to the loss of a close person as and Trauma essentially different than the response to other traumatic events’’ (p. 48). In the case of a natural While grief theory and trauma theory have death, the survivor may be preoccupied with differing perspectives on the etiology and out- images of the deceased and feel longing, sad- come of tragic events, clearly grief (bereave- ness, and depression. If the bereaved witnessed ment, loss) and trauma are not mutually a death by force or calamity, the images may be exclusive. Lindemann (1944), for instance, more violent and the emotional response one of conceptualized crisis and loss while following rage or helplessness. Nevertheless, in the the experiences of the survivors of a 1942 fire in researchers’ view, the altered content does not the Coconut Grove nightclub in Boston, in represent a distinct entity.

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FIGURE 1 The relationship between trauma and grief. Recent theorists and researchers have dis- based on PTSD criteria in the DSM, fourth cussed the conceptual links between grief and edition, revised (American Psychiatric Associ- trauma (Green, 2000; Pfefferbaum et al., 2001; ation, 2002). In Prigerson et al.’s model, Stroebe, Schut, & Finkenauer, 2001). Others are Criterion A requires the death of a signiﬁcant attempting to move beyond the distinctions other and a response to that death involving between grief and trauma and develop criteria intrusive, distressing preoccupation with the for a new category, that of traumatic grief. deceased person, such as yearning, longing, or Prigerson, Shear, and colleagues (1999) have searching. Criterion B requires a combination proposed consensus criteria for traumatic grief of the following symptoms: efforts to avoid

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reminders of the deceased; feelings of purpose- on the enormity of the event and from trauma lessness and futility about the future; a sense of responses based on the fact that the enormity numbness or detachment resulting from the includes a consideration of the intensity of the loss; feeling shocked, stunned, or dazed by the relationship with the deceased. Green and loss; difficulty acknowledging the loss; feeling colleagues, in studying the survivors of the that life is empty and unfulfilling without the Beverly Hills Supper Club Fire, which killed deceased; a fragmented sense of trust, security, 165 people (Green, Grace, & Gleser, 1985), and and control; and anger over the loss. Thus, while the survivors of a dam collapse at Buffalo Creek the symptoms parallel traumatic stress, there is (Gleser, Green, & Winget, 1981), found that the no discussion about the nature of the death as closeness of the relationship with people lost in a specific criterion. Horowitz and colleagues the disaster predicted similar or higher levels of (1997) have similarly proposed a new diagnostic distress as that of personal life threat. Other category of complicated grief disorder, which researchers suggest that the quality of the includes such symptoms as intense intrusive bond, ambivalence related to the relationship, thoughts, severe pangs of emotion, denial of or unhealthy attachments are important pre- implications of the loss to self, feelings of dictors (Field, Nichols, Holen, & Horowitz, exceptional aloneness and emptiness, excessive 1999; Worden, 1991). Similarly, when death is avoidance of tasks reminiscent of the deceased, violent, such as due to accident or homicide, sleep disturbances, and neglect of necessary bereavement has been found to be more adaptive activities at work or at home—lasting complicated in terms of prolonged symptoms more than 1 year postbereavement. Again, the of PTSD and depression (Kaltman & Bonanno, nature of the loss is not specified. Based on 2003; Thompson, Norris, & Ruback, 1998). conceptualizations of traumatic grief, Boelen, Factors which contribute to traumatic grief in van den Bout, and de Keijser (2003) have devel- individuals who have lost a loved one to oped the Inventory of Traumatic Grief, which murder include not only shock and disbelief, differentiates between traumatic grief and but also a sense of injustice regarding commu- bereavement-related depression and anxiety. nity and legal response to the event (Armour, Empirical evidence confirms that when 2002; Rock, 1998). In addition to the cause of trauma and grief occur together, subsequent death, factors related to perceptions of justice reactions are more prolonged and distressing. include the age of the deceased, whether or not Traumatic grief has been associated with a five- the death was expected, and the co-occurrence fold increase in the likelihood of suicidal of other losses or stressors. Death of a child is ideation in young adults (Prigerson, Bridge, et uniformly associated with prolonged and com- al., 1999). When compared with those who plicated grief in parents (Finkbeiner, 1996; experienced a traumatic event in the form of an Weiss, 2001). In the case of death during dis- assault, a sample of young women who had aster, other concurrent losses and disruptions experienced traumatic loss had higher rates of add to the experiences of loss and trauma intrusive symptoms, reexperiencing symptoms, (Najarian, Goenjian, Pelcovitz, Mandel, & and impaired school performance (Green et al., Najarian, 2001; Norris, Friedman, & Watson, 2001). It is important to attempt to distinguish 2002). which factors differentiate grief over loss from Thus, there is a movement to consider traumatic grief. Stroebe, Schut, and Finkenauer traumatic grief as a distinct entity that encom- (2001) suggest that traumatic grief can be passes elements of bereavement and trauma, distinguished from grief/loss responses based yet acknowledges that in combination these

296 Brief Treatment and Crisis Intervention / 4:3 Fall 2004 Intersections Between Grief and Trauma experiences result in higher levels of distress. There are four recent reviews of the bereave- This requires that we consider what treatment ment intervention literature (Kato & Mann, approaches might be of greatest benefit to those 1999; Litterer Allumbaugh & Hoyt, 1999; suffering from traumatic grief, as approaches to Neimeyer, 2000; Schut, Stroebe, van den Bout, trauma treatment and grief treatment are highly & Terheggen, 2001). Kato and Mann (1999) divergent from one another. conducted a qualitative and quantitative review of 13 randomized controlled bereavement studies, separating their analyses by interven- Empirical Evidence for Bereavement tion type (individual, family, or group). Ac- Interventions cording to their review, the 3 studies offering an individual intervention for grief found small As stated above, the central theme of grief but inconsistent improvement in the physical treatment is the notion of working through the health of the bereaved as measured by per- mourning through reminiscing and emotionally ceived health (Gerber, Wiener, Battin, & Arkin, experiencing memories of the deceased. At 1975; Raphael, 1977; Vachon, Lyall, Rogers, best, however, the efficacy of working through Freedman-Letofsky, & Freeman, 1980). Vachon the emotions of grief appears equivocal in and colleagues (1980) demonstrated improve- empirical research. Some studies have demon- ment in perceived health on the general health strated that the expression of grief-related questionnaire (GHQ) for bereaved women who emotion during the initial stage of bereavement were paired with other widows trained in does lead to lower symptomatology over time. supportive counseling and whose grief was For example, Stroebe and Stroebe (1993) found considered resolved. The widows who were that widowers who confronted their grief particularly distressed at the onset benefited during the first 4 to 7 months following their the most from the intervention. Kato and Mann loss suffered fewer depressive and somatic (1999) caution, however, that the difference symptoms after 2 years. Further, Lepore and between groups on perceived level of social colleagues (1996) found that parents who had support prior to the intervention may have lost a child to sudden infant death syndrome accounted for some of the differences noted in and who focused on disclosure of feelings the study. Gerber and colleagues (1975) and showed lower depression rates than those who Raphael (1977) studied interventions for acutely did not, if their social environment was bereaved individuals receiving individual perceived as supportive of such disclosures. counseling from a professional counselor. Conversely, however, prospective longitudinal Participants in the Gerber et al. study received studies have found no associations between a 6-month intervention which focused on both negative emotional expression during the first 6 emotional resolution and practical advice. months of a loss and grief symptoms 5 years While the control group had more visits to later, suggesting that failure to do ‘‘grief work’’ their doctor immediately after the intervention, in the initial stages of bereavement does not there was no difference upon long-term follow- necessarily lead to prolonged or delayed grief up 8–15 months after the loss. Further, (Bonanno & Field, 2001; Middleton, Burnett, individuals participating in the intervention Raphael, & Martinek, 1996). Other prospective did not differ from nontreatment controls in studies confirm that grief work is no more their medication use and reported health efficacious than avoidant strategies (Archer, during, immediately after, or 6 months after 1999; Stroebe & Stroebe, 1991). treatment. In the Raphael study, widows

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receiving a 3-month intervention were consid- that much of this effect is accounted for by ered at high risk because they either had an bereavement interventions offered to individ- unsupportive social network, the death had uals rather than in the form of support groups. been untimely or unexpected, they had had Further, those individual interventions which a highly ambivalent marital relationship, or were found to be effective were either offered they had a concurrent life crisis. Individuals to individuals more highly distressed (Brom, receiving the intervention were offered ego Kleber, & Defares, 1989; Gerber et al., 1975; support and encouraged to express their grief Raphael, 1977) or were most effective for those and to work through their ambivalent relation- individuals starting the intervention with ship with the deceased. Using the Goldberg higher levels of distress (Vachon et al., 1980). GHQ, individuals in the intervention group Litterer Allumbaugh and Hoyt (1999) focused were found to have improved more than on client factors associated with better or controls on measures of anxious symptoms, poorer outcomes. They found that younger depressive symptoms, and somatic symptoms. individuals (25–35 years) and the elderly (66– Less efficacious findings were reported by 85) experienced less helpfulness from inter- Kato and Mann (1999) on the eight group ventions. Further, spouses seemed to benefit interventions they reviewed. According to less from grief-related interventions than did these reviewers, six or eight group interven- nonspouses. Finally, individuals who voluntar- tions showed no beneficial effects (Barrett, ily sought treatment benefited more from 1978; Duran, 1987; Sabatini, 1988; Tudiver, interventions than did individuals who re- Hilditch, Permaul, & McKendree, 1992; Walls & sponded to study-recruitment strategies. Con- Meyers, 1985; Weidaw, 1987). The predomi- trary to expectations, the researchers did not nant intervention used in these group studies find a difference in outcomes for complicated was a combination of lectures about the bereavement and normal bereavement; how- grieving process and an open discussion of ever, it was suggested that this was due to grief-related emotions. All of these groups were inconsistent definitions of complicated bereave- led by professionals in psychology, nursing, or ment between studies. mental health, with the exception of Tudiver Noting that Kato and Mann excluded a num- and colleagues (1992), which was a self-help ber of studies in their review, Neimeyer (2000) model led by volunteer widows. While study conducted a meta-analysis of 23 randomized participants in the intervention conditions in controlled studies offering individual, family, all groups did improve over time, so did or group interventions to individuals who were individuals in the control condition. The study mourning the death of a loved one. Like Kato by Constantino (1988), one of the two group and Mann (1999), he concluded that the overall interventions judged to be effective by Kato effect upon all individuals seeking counseling and Mann (1999), consisted of bereaved following loss was positive but very small. widows long after the loss and may therefore According to his analysis, the average person more accurately be measuring individuals seeking counseling for bereavement was better experiencing more chronic grief. off than only 55% of bereaved persons re- Kato and Mann’s (1999) meta-analysis of the ceiving no treatment at all. This outcome did 11 studies found a very small positive effect for not appear to be related to treatment type physical health, and no effect for depression or (individual, family, or group) or treatment other stress-related outcomes. Their separation approach; however, most studies in his review of group and individual interventions reveals shared the common theme of facilitating the

298 Brief Treatment and Crisis Intervention / 4:3 Fall 2004 Intersections Between Grief and Trauma working through highlighted in the theoretical (Ogrodniczuk et al., 2002) and more psycho- literature. The author did find that individuals logical mindedness (Piper et al., 2001) did better who were seeking counseling for normal grief in both treatments. However, individuals with experienced no positive effect, while those higher-quality relations with all attachment seeking counseling for more complicated grief figures (i.e., better relational capacity) did (violent nature of the death, chronic bereave- better in the interpretive group, and individ- ment) showed a reliable positive effect. uals with lower-quality relations did better in Schut, Stroebe, van den Bout, and Terheg- the supportive group. gen (2001) conducted a review of the be- In summary, when the short-term efficacy of reavement literature separating studies bereavement interventions is studied, results examining interventions offered to all be- are somewhat positive for individuals experi- reaved individuals (to prevent grief-related encing normal patterns of grief. However, complications) from studies examining inter- examining results over time reveals that in- ventions aimed at individuals at higher risk dividuals who are experiencing higher than for bereavement-related complications and average levels of distress benefit from a variety studies examining interventions aimed at of interventions offered individually, while individuals experiencing some form of com- individuals with normal patterns of grief seem plicated grief. These authors concluded that to experience temporary gains only. Further, (1) people with otherwise normal patterns of even when individuals are deemed ‘‘at risk’’ for grief do not seem to benefit from bereavement grief-related complications (i.e., they had interventions in the long term, especially if ambivalent relationships with the deceased, they are grieving the loss of a spouse, and (2) were experiencing concurrent life crises, or the people showing signs of more complicated deceased died suddenly or violently), they do grief seem to benefit the most from inter- not necessarily benefit from bereavement ventions. They caution, however, that studies interventions unless they are actually experi- looking at individuals with complicated grief encing higher levels of distress. Treatment for offer interventions much later on in the grief individuals experiencing loss in tragic or process than other studies and that the traumatic circumstances will be discussed individuals participating in the intervention further in the section on interventions for studies tend to be help seekers (i.e., looking traumatic loss. for an intervention) rather than study recruits (i.e., accepting an intervention by agreeing to participate in a study). Two recent studies compared the effects Summary of Grief Treatment Research of two group interventions for individuals Limited evidence supports the view that deemed to have elevated levels of grief-related expression of grief leads to resolution. symptoms 3 months following the loss of a loved one (Ogrodniczuk, Piper, McCallum, Those with normal grieving patterns do Joyce, & Rosie, 2002; Piper, McCallum, Joyce, not seem to benefit from intervention, Rosie, & Ogrodniczuk, 2001). These researchers while those with complex grief seem to randomly assigned individuals to either a sup- benefit from individual treatment. portive treatment or an interpretive treatment. Those with ambivalent relations with the The researchers found that individuals with deceased may benefit from relationally more secure attachments to the deceased focused treatment.

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Those with lower relational capacity may Ng, & DeLisis, 2002; Solomon & Johnson, 2002). benefit more from therapy aimed at Pharmacological treatment for trauma sufferers providing immediate support and problem has yielded positive results in assisting with solving rather than interpretation and symptom management. In particular, selective conflict exploration. serotonin reuptake inhibitors have shown positive results (Albucher & Liberzon, 2002), and mood stabilizers have shown promise Empirical Evidence for Trauma (Albucher & Liberzon, 2002; Katz et al., 2002), Interventions as have beta-blockers (Katz et al., 2002). Follette, Ruzek, and Abueg (1998), Harvey, Similar to the process of evaluating grief Bryant, and Tarrier (2003), and Rothbaum and interventions, one of the issues in evaluating Foa (1996) provide extensive overviews posttraumatic stress interventions is the degree of the effectiveness of cognitive-behavioral to which symptoms spontaneously remit. For approaches for posttraumatic stress disorder. instance, Rothbaum, Foa, Riggs, Murdock, and They conclude that cognitive-behavioral ther- Walsh (1992) reported that while 94% of the 95 apy (CBT) is effective in reducing the severity of rape victims in their study met the criteria for PTSD symptoms in individuals who have PTSD at 1 week postrape, this reduced to 47% experienced a wide range of traumatic events at 94 days postrape. It has been suggested that and in those who suffer from both acute and once the 3-month marker is reached or sur- chronic symptoms. CBT has been demonstrated passed, symptoms of PTSD become relatively to have superior effects over supportive treat- persistent (Cohen & Roth, 1987; Kilpatrick, ment in the treatment of PTSD in a number of Resick, & Veronen, 1981). Nevertheless, Tar- controlled studies (Bryant, Sackville, Dang, rier, Sommerfield, Reynolds, and Pilgrim (1999) Moulds, & Guthrie, 1999). Cognitive therapies discovered that 11% of patients with chronic come in a variety of forms. Exposure therapy is PTSD improved with clinical assessment and based on the notion that the common strategy of self-monitoring to the extent that they no avoiding trauma-related memories and cues longer qualified for a diagnosis. Thus, while interferes with emotional processing of the there are hundreds of original reports de- event by reinforcing erroneous cognitions and scribing the effectiveness of treatments for fears. During imaginal and in vivo exposure and individuals who have been exposed to trau- recounting the event, individuals are assisted to matic events, the vast majority are not empir- manage the resulting anxiety and allow distress ically based studies (Solomon & Johnson, 2002). to habituate. Stress inoculation training, based Yet, the natural diminution of symptoms of on social learning theory, teaches individuals to PTSD requires that controlled studies be manage fear and anxiety through cognitive- considered when discussing efficacy. behavioral techniques. Cognitive therapy as- While many excellent reviews and meta- sists individuals to identify trauma-related analyses exist of the research related to dysfunctional beliefs that influence response treatment efficacy for traumatized individuals, to stimuli and subsequent physiological and it is generally acknowledged that only cogni- psychological distress. Some studies have pro- tive-behavioral and psychopharmacological vided evidence that exposure therapy in methods have been subject to rigorous evalua- combination with stress inoculation training tion with controlled trials (Ehlers & Clark, 2003; or cognitive therapy yields the most positive Hembree & Foa, 2003; Katz, Pellegrino, Pandya, results (Hembree & Foa, 2003); others have

300 Brief Treatment and Crisis Intervention / 4:3 Fall 2004 Intersections Between Grief and Trauma provided evidence that inoculation does not significantly higher rates of anxiety, depres- necessarily enhance other cognitive methods, sion, and PTSD 13 months following their which, of themselves, are equally effective injury compared with burn victims who did not (Harvey, Bryant, & Tarrier, 2003; Tarrier, receive debriefings. It has been suggested that Pilgrim, et al., 1999). It is important to note that the exposure elements of this group interven- exposure methods are more selective in the tion are responsible for the iatrogenic effects in criteria for inclusion, and it is suggested that this victims (Regehr, 2001). model of treatment be used only when a sound Longer-term group models using CBT have therapeutic alliance has been formed and a thor- more promising results. Foy and colleagues ough assessment completed (Calhoun & Atke- (2000) reviewed six studies of CBT group son, 1991). Individuals in this type of treatment treatment with trauma survivors (three wait- group should be assessed to have the capacity to list control and three single group pretest– tolerate high anxiety arousal and to have no posttest) and indicated that all showed positive active suicidal ideation, comorbid substance outcomes on PTSD symptom measures. Re- abuse, or, most importantly, current life crises ported effect sizes ranged from 0.33 to 1.09, (Foy et al., 2000). Thus, if they are equally with a mean of 0.68. Larger treatment effects effective, CBT methods without exposure may were reported for avoidance symptoms than yield a lower risk of iatrogenic effects. intrusion symptoms. Group treatment methods are less clear-cut. Thus, while trauma-resolution treatment One form of group treatment is the single- approaches described in the literature are session debriefing, which has been the subject diverse, there is evidence that cognitive- of much controversy regarding efficacy. In behavioral methods are effective in symptom general, however, findings suggest that profes- reduction. Several different models of CBT sionals exposed to trauma in the context of their exist, some focusing on cognitive restructuring, job subjectively find single-session debriefings some on symptom management, and some on to be helpful and supportive, although such exposure to traumatic imagery followed by sessions do not relieve trauma symptoms and anxiety management. As evidence suggests that may in fact exacerbate them (Regehr, 2001). each method may be effective, the concern that When applied to victims of trauma, however, exposure therapy may increase distress and the results raise more concerns. Mayou, Ehlers, increase treatment dropout in high-risk groups and Hobbs (2000) randomly assigned traffic suggests that this method should be used with accident victims to a psychological debriefing caution. Pharmacological treatment for indi- group or a no-treatment group. At 4 months viduals with extremely high levels of distress postinjury, the researchers reported that the should also be considered. psychological debriefing was ineffective, and at 3 years, the intervention group remained significantly more symptomatic compared with Summary of Trauma Treatment Research no treatment. They concluded that patients Good evidence exists that individual who initially had high intrusion and avoidance CBT treatment reduces trauma symptoms remained symptomatic if they re- symptoms. ceived intervention but recovered if they did not receive intervention. Bisson, Jenkins, Single-session groups may exacerbate Alexander, and Bannister (1997) reported that symptoms. burn victims who received debriefings had Exposure treatment, while effective with

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treatment completers, may require instructed to avoid painful memories and screening out of individuals with high fearful bereavement cues. In both studies, anxiety, suicidal ideation, or other individuals in the intervention group im- concurrent life crises. proved more than those in the control condition; however, both groups improved. Mawson and colleague’s 6 participants specifically Toward an Empirically Based Model for improved in phobic symptoms and phobic Treating Traumatic Grief distress and on the Texas Grief Inventory. Sireling, Cohen, and Marks’s 26 participants In reviewing existing studies on traumatic had a significant improvement in cue avoid- grief, it is difficult to differentiate those who ance, avoidance distress, and somatic symp- have complicated grief due to relational issues toms compared with the antiexposure group. with the lost loved one from those who lost an However, both the exposure treatment group individual in a traumatic manner such as in and the group instructed to avoid triggers a natural disaster or by murder, accident, or improved on the Texas Grief Inventory and suicide. Based on our conceptual model of the measures of anxiety, depression, work func- co-occurrence of trauma and loss, we have tioning, and social functioning, lending some included the few studies that evaluated treat- support to the notion that both grief confron- ment of individuals experiencing both in this tation and grief avoidance can lead to grief section. As with grief and trauma, we must be resolution (or that symptoms remit regardless cautious not to assume that all those who are of intervention). Brom, Kleber, and Defares confronted with traumatic loss will require (1989) evaluated a treatment intervention for intervention. For instance, despite a common individuals with loss-related instrusions, de- belief that losing a family member to homicide nial, avoidance, anxiety, sleeplessness, and is highly traumatizing, one study (Freedy, guilt. Individuals were randomly assigned to Resnick, Kilpatrick, Dansky, & Tidwell, 1994) a wait-list control; a trauma desensitization found that only 16% of those who had intervention, in which they were helped to experienced such an event sought treatment. relax and then confront their grief; a hypnosis While it may be tempting to attribute this therapy intervention, in which they were absence of treatment seeking to negative causes hypnotized and then encouraged to confront such as denial or avoidance, this finding may their grief; and a psychodynamic intervention, also reinforce the notion that individuals have in which the therapist focused on discovering a remarkable capacity to deal with the after- and solving psychological conflicts related to math of tragedy. loss. Compared with the control, all three Four studies utilized confrontation and treatment groups had fewer symptoms as exposure techniques for traumatic or compli- measured by the Impact of Events Scale; cated grief. Both Mawson, Marks, Ramm, and however, these results were not statistically Stern (1981) and Sireling, Cohen, and Marks significant. Individuals in intervention and (1988) studied an intervention of guided control groups did not differ on somatization, mourning for bereaved individuals who were social inadequacy, anger, trauma symptoms, or identified as having experienced chronic grief hostility. Shear et al. (2001) report the results of for at least 1 year. The behavioral intervention a treatment protocol involving exposure and involved exposure to feared and avoided interpersonal therapy with 21 people experi- bereavement cues. The control group was encing traumatic grief. While those who

302 Brief Treatment and Crisis Intervention / 4:3 Fall 2004 Intersections Between Grief and Trauma completed treatment had significantly lower symptom management appears to be levels of anxiety and depression than the effective. control group, of note was that the 8 individ- Those with traumatic loss may experience uals who did not complete treatment were increased distress in exposure therapy. more likely to be grieving violent deaths by accidents, murder, or suicide, suggesting that these individuals may not have been able to Conclusions tolerate treatment. Thus, it is not clear that exposure treatment is superior to avoidance In summary, two divergent areas of study have or no treatment in individuals with complex focused on the experiences of bereavement and or traumatic grief. Further, those in the grief and on trauma and its aftermath. Begin- Shear et al. study who had the most traumatic ning with the treatment efficacy literature in forms of loss did not complete treatment, grief, several important issues emerge. First, perhaps because exposure was too anxiety there is little empirical evidence to suggest that provoking. individuals must work through their loss by Murphy and colleagues (1998) studied the expressing negative emotions and evaluating effects on parents who had recently lost a child their relationship with the deceased. In partic- to homicide, suicide, or accident. Identified as ular, sharing these experiences with others in a high-risk group, these parents were randomly a group-treatment format does not appear to assigned to a combined emotion-focused and relieve symptoms of distress. Of note is that problem-focused group or a no-treatment con- those who are experiencing normal grief (that trol. Of note was the trend that mothers start- is, grief that does not interfere with social, ing the intervention with high amounts of physical, or emotional functioning for pro- grief symptomatology and high levels of longed periods of time) seem to not benefit from distress improved more in the intervention treatment. However, those with more complex group than control. Conversely, those experi- forms of grief do appear to benefit from encing low symptomatology were worse off in some individual models focused on relational the intervention than those in the control components. group, suggesting again that for those with From the trauma treatment efficacy research, normal grieving, intervention may in fact be there is evidence that individually focused iatrogenic. Fathers did not show long-term cognitive behavioral methods do lead to symp- improvements from the intervention. tom reduction. There is some cause for caution surrounding exposure treatment methods, however. While exposure treatment has demonstrated efficacy when used appropriately, it may Summary of Treatment for result in iatrogenic effects for those who are Traumatic Grief highly distressed or have concurrent chal- lenges. These iatrogenic effects may be partic- Not all people with traumatic loss require ularly problematic in single-session groups. treatment. Pharmacological treatments can be of benefit Those with unresolved relationship issues when symptoms of distress are overwhelming. toward the deceased may benefit from Integrating the findings from grief and relationally based therapy. trauma, it is first necessary to acknowledge CBT aimed at cognitive restructuring and the spontaneous remission of symptoms expe-

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