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GriefConnections
March
2005
GriefConnections is provided to you by
Callanan
Mortuary
1301 N. Western Ave.
Hollywood, CA 90027
(800) 901-0090
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free! Simply send an email to pawilliams@stei.com and write SUBSCRIBE TO
CALLANAN GRIEF CONNECTIONS in the subject line.
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HOSPICE TELECONFERENCE FACES END OF LIFE ETHICS
No topic for the annual teleconference seems more appropriate this year than the
one that was chosen some time ago: Ethics and End of Life Care. The annual
teleconference will be hosted across the nation by satellite downlink and can is
sponsored locally by Kaiser Permanente from 10am to 1pm on Wednesday, April 20.
For more information, please contact Peggy Callanan Williams at 800/901-0090 or
by email at pawilliams@stei.com.
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SORTING OUT GRIEF AFTER TRAUMA
Harold was 79 when he stopped at the counter of the senior center in his
community and told the receptionist he was looking for some help dealing with
his grief. "Is there a group here for people like me?" he asked her,
and then told her of his wife's death about six weeks earlier. When he told the
receptionist that he thought life was no longer worth living, she summoned the
executive director.
What the director learned as she found a quiet corner for she and Harold to talk
was that he was the driver in the car crash that had taken the life of Lucille,
his wife of 56 years. The highway patrol had not yet assigned fault in the car
crash, but it was clear that Harold lost control of the car, causing it to leave
the road and roll over several times. He had almost no memory of the accident
and really "came to" as the paramedics were extracting him from his
car.
Even though Harold recounted that he asked if his wife was okay, as he looked at
her body slumped next to him in the front seat, "deep down, I knew the
answer." His wife died of massive head trauma, probably from striking her
head on the doorpost of the car. The coroner's report revealed that her death
came nearly instantly.
Harold's experience parallels the story of a growing number of people that
counselors are called on to help as they process unspeakable losses. The
difficulty in providing care to these people, however, is in sometimes confusing
the trauma of the event with the grief over the loss. Trauma and bereavement are
two related but separate issues. That's one reason that when the media report
after a mass tragedy that "grief counselors" are on hand, what they
are really saying is that trauma counselors-usually those with some training in
Critical Incident Stress Management (CISM) techniques have been summoned.
For the counselor or caregiver who seeks to help people after a traumatic loss,
it helps to separate the traumatic material from the accommodation of loss.
Reminding oneself of the goal is paramount. In other words, is your (and your
client's) goal right now to reduce the symptoms of the traumatic event or is it
to help accommodate the loss and facilitate living without the deceased? It is
probably not possible to work much on the loss issues until the traumatic
experiences are under control.
This is one reason in my assessment of people for bereavement groups, I listen
to their story for the material on which they focus. If they are focused on
detailed facts of the death (how, when, where, etc.), they are probably more
appropriate for individual trauma intervention than for a bereavement group
experience.
So what does trauma actually look like? Research and clinical practice gave rise
to the current diagnostic criteria for Acute Stress Disorder (ASD) and it's
close cousin, Post -Traumatic Stress Disorder (PTSD). Among other criteria
listed for these disorders, trauma responses will include:
Intrusive thoughts. By nature, trauma involves an experience for which we
don't have a psychological framework to cope. In other words, it is most
unusual. In order for the brain to accommodate this trauma for which it has no
framework for processing, the traumatized person tends to "reexperience"
the trauma through nightmares, intrusive thoughts during awake times, and
"flashbacks."
These episodes of reexperiencing the trauma actually cause psychological
distress and physiological reactions (like faster pulse, rapid breathing, etc.)
It is highly probable that the "rush to closure" in our society may
actually magnify this reexperiencing of the traumatic event. Since it becomes
socially unacceptable to talk about the experience weeks or months following the
event, the brain looks for a way to process the traumatic material, often
leading to intrusive nightmares.
Avoidance and numbing. Traumatized people often exhibit avoidant
tendencies including things such as avoiding the scene of the trauma or places
that remind one of it. In addition, the client will often avoid talking about
the trauma or will even be unable to recall significant components of the
traumatic event. The markedly diminished interest in activities previously
enjoyed and the restrained hope about the future that are part of this
"avoidance" parallels full-blown clinical depression. Withdrawal from
others and a blunted affect are also part of this constellation of symptoms in
trauma.
Clinicians who did much of the early work on PTSD with Vietnam-era veterans saw
the avoidant part of the trauma response as an adaptation. In other words, the
avoidance helped numb the pain of reexperiencing more of the trauma than the
overwhelmed psyche could accommodate. It can be understood perhaps as our
"on-board defense mechanism."
Hyper-arousal. Finally, people who have been traumatized often have an
exaggerated startle response, like the classic story of the war-traumatized
veteran who dives for cover at the sound of a car backfiring. Hyper-vigilance
(like one is "standing guard"), insomnia, anger outbursts, and
difficulty concentrating or focusing on an at-hand task are also common
experiences for people who have been traumatized.
Of course, clinical evaluation and diagnosis of trauma disorders like Acute
Stress Disorder and Post-Traumatic Stress Disorder should only be made by an
experienced mental health professional. It appears that the vast majority of
traumatized people work through the symptoms of trauma in the context of a
supportive community (see van der Kolk's work in the resources below). However,
recognizing the symptoms that are part of the trauma matrix is important for
everyone involved in bereavement care because of the confounding nature of
trauma on grief, and the need to refer bereaved to professionals who can
intervene with the trauma symptoms.
One helpful "clinical clue" to separating trauma from grief is
considering the focus of the client's story. People who are still dealing with
the traumatic elements of the loss (like our 79-year old widower, Harold) will
tend to focus their story on the event itself-what could have been done to
prevent the trauma or change its outcome. Traumatized people tend to replay the
facts of the death over and over in the telling of the story. Certainly in the
early part of the grief process, retelling the circumstances of the death is a
way to come to terms with the death's reality (J. William Worden's "first
task"), which is paramount in reconciling the loss.
People who are working through grief issues, however, will tend to talk about
the relationship lost and the changes that have come about in one's life as a
result of this death. When the counselor asks a question like, "What do you
suppose is the hardest part of this experience for you right now?" listen
for the answer to be either a retelling of the events of the death (trauma) or a
reflection of the loneliness, sadness, long evenings, and other changes that are
occurring as a result of the loved one's death and the accommodation of that
loss.
NEXT MONTH: Understanding Today's Trauma Treatment Strategies
The
Author: William G. (Bill) Hoy directs the bereavement program for children,
teens, and adults at Pathways in Long Beach, California. In addition to his
graduate education, Bill holds the CT (Certified Thanatology) designation from
the Association for Death Education and Counseling, and continuing education
provider credentials from the California Boards of Registered Nursing and
Behavioral Sciences. He speaks in more than 35 cities across North America each
year and teaches on the health science faculty at Cypress College.
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RESOURCES FOR WORKING WITH THE TRAUMATICALLY BEREAVED
You will find extra perspective in your work with people bereaved after trauma
in the following resources. . .
Death and Trauma: The Traumatology of Grieving, edited by Charles R.
Figley, Brian E. Bride, and Nicholas Maza. (Hemisphere: 1997) One of the
defining books on trauma and grief, there are excellent tools and therapeutic
approaches here including brief introductions to some of the newer approaches to
treating post-traumatic stress disorder (PTSD).
Treatment of Complicated Mourning, by Therese A. Rando. (Research Press,
1993). A lengthy treatment of a complex issue, this volume is a valuable
reference to the caregiver who works with people grieving after deaths from
complicated circumstances. Included are ideas for counseling with people after a
traumatic death, ambivalent relationships, and a host of other issues. After
reviewing what uncomplicated grief looks like, Rando proceeds to an historical
review of the topic from some of the great bereavement thinkers of the 20th
century. The book is filled with suggestions for working with people who
evidence significant risk factors for complicated grief.
Traumatic Stress: The Effects of Overwhelming Experience on Mind, Body, and
Society, edited by Bessel A. Van der Kolk, Alexander C. McFarlane, and Lars
Weisaeth. (Guilford, 1996). This extremely helpful volume surveys the landscape
of trauma through the writing of more than 30 contributors. Some of the most
helpful chapters include those on understanding Post Traumatic Stress Disorder (PTSD),
cultural considerations in treating trauma, and trauma treatment through several
contemporary therapeutic modalities. This is a useful reference for anyone
providing counseling support or therapy to people following a diversity of
trauma including deaths resulting from traumatic circumstances. Long-term
unhealthy consequences can often be avoided, the contributors suggest, by
effective early intervention. But more than being simply descriptive, these
authors explain practical strategies for providing such intervention.
Trauma in the Lives of Children by Kendall Johnson (Hunter, 1998). Even
though this book isn't focused on death-related trauma alone, Johnson's
principles for helping traumatized children are excellent and practical. His
overview of children's reactions to trauma (chapter 2) and the chapter profiling
practical actions to be taken or avoided in school situations (chapter 3) alone
make this book worth it's price.
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GriefConnections is published monthly by Grief Resources, Inc. expressly
for Callanan Mortuary. Copyright ©2005. All rights reserved, including
publication or distribution in any form, electronic or printed. For reprint
permissions or suggestions for content, please email us at GriefResources@cs.com.
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