Tuesday, September 3, 2013

The Paradox of Traumatic Grief


Take the light, and darken everything around me
Call the clouds and listen closely, I'm lost without you
Call your name every day when I feel so helpless
I'm fallin' down but I'll rise above this, rise above this
~“Rise Above This,” Seether

The lead singer for the rock band Seether wrote those lyrics in the aftermath of his brother’s suicide. The video for the song depicts what many people feel upon hearing the news that their loved one has died.  A mother, a father, a sister – all going about their normal daily lives -- are suddenly blown completely off their feet by an unseen force. 

The course of a complicated bereavement, like the process that often follows suicide, usually does not follow the straightforward path outlined by Elizabeth Kubler-Ross so many decades ago, but rather twists and turns and circles back on itself through mazes of denial, sadness, anger, shame, blame, and multiple physical reactions.  Several authors have described an “oscillating process” in complicated bereavement – a moving back and forth between loss-orientation and restoration orientation[1], between growth and depreciation[2]. In this oscillating process survivors of suicide loss can move closer to some people and further away from others. They may simultaneously experience increased symptoms of distress and feelings of adaptation as these states appear to be independent dimensions.
As survivors of suicide loss learn to adjust to the empty chair and redefine life without the physical presence of their loved ones, they can feel like they have lost a part of themselves.  Not everyone is debilitated by this loss, however, and the bereaved often fall into one of three clusters:
  1. Quick recovery.  Those who recover quickly without assistance and can return to functioning as before.  Some of these people are not distressed because they had only superficial contact with the deceased, while others are often internalizing and suppressing pain, anger or guilt.  In the latter case, maladaptive strategies of coping may emerge such as substance abuse or other compulsive behaviors.
  2. Modest support needed.  Most people who were functioning well before the suicide need only a modest level of support for anywhere from a month to a couple of years.  This level of support might include outpatient therapy or support groups.
  3. Psychiatric disability. Some people may develop a mental disorder, such as post-traumatic stress disorder or depression, in reaction to the trauma and loss and may require extended or intensive treatment.
For the first couple of years after my brother Carson’s death, I moved in and out of these three states. Sometimes I would feel like I was functioning well, other days I would get through with a call to a friend or a visit to a support group, and some days I would be so consumed with the sadness of what had happened that I would benefit from periods of counseling.
In the aftermath of an unexpected death, especially suicide, traumatic grief is a common reaction.  When this occurs both trauma and grief reactions are experienced together, and elements of this combined level of psychological distress are often debilitating and complex. 
A number of circumstances about a suicide death may influence traumatic grief reactions[3]:
  • Suddenness or lack of anticipation.  The unexpected death offers no opportunity for goodbyes, unfinished business, resolution of conflict, or answers to questions.  Very often the bereaved are left with endless “whys” and “what ifs.”  When loved ones die from a prolonged illness, by contrast, we have time to prepare ourselves for their absence.
  • Violence, mutilation, and destruction.  Deaths that involve suffering or extreme pain may cause horrifying traumatic imagery and intrusive thoughts – whether or not the bereaved actually witnessed the death or the body. If the death occurred in a familiar or personal space of the bereaved, that space will most likely continue to trigger traumatic reactions.
  • Preventability or randomness of death. The randomness of such a loss can trigger a greater sense of vulnerability and anxiety. This is often the case when there were no apparent warning signs before the person died.
  • Multiple deaths (bereavement overload) or multiple losses. In addition to the primary loss of the person, secondary losses may include loss of an income, loss of a home, or loss of all things familiar.  The resulting disorganization can strain the family and social system.
  • Contact with first responders or the media. Sometimes the reactions of first responders – who need to rule out homicide in every suicide case – can increase confusion and distress among those bereaved. If the events surrounding the death were newsworthy, the bereaved may also be dealing with the intrusion of the media.
Trauma reactions and grief work are often at odds with each other. On one hand, the trauma experience leads to continual intrusion of the death event.  That is, survivors of suicide loss can’t stop thinking about the death scene (even when they are dreaming), and disturbing images may flash before the mind’s eye when they least expect it. The horror can be overwhelming and the natural impulse is to stay away from anything that reminds them of the trauma.  Sometimes survivors develop post-traumatic stress disorder (PTSD) in the aftermath of a violent or unexpected death. 
When I first started reading about trauma as a graduate student in the 1990s, I was moved by Ronnie Janoff-Bulman’s book Shattered Assumptions.[4] Her basic premise is that traumatic events shatter three world views that all people tend to hold:
·         Benevolence of the world – people are generally good
·         Meaningfulness of the world – good things happen to good people
·         Self-worth – I am good and can keep myself and those who love me safe and healthy.

All three of these assumptions are usually deeply challenged, if not shattered, after a suicide death. The traumatic responses of re-experiencing intrusive thoughts through flashbacks and ruminations are the mind’s way of rebuilding new world views about the self and the world. When Randy and I were in Hawaii just months after Carson’s death, we were hiking along the Napali Coast – one of the most beautiful places on Earth – and I could not stop ruminating about the horror of my brother’s suicide. I remember saying to Randy, “In the last hour, I have imagined Carson’s final moments at least 40 times and have only thought of our children once. What is wrong with me?”
On the other hand, the grief experience works in phases as survivors of suicide loss come to accept the reality of the loss, and the tendency is to move toward things that remind them of the deceased. The intense sadness can feel like it will never go away; and I like to reframe this grief reaction as honoring our loved one. Kahlil Gibran once said, “When you are sorrowful look again in your heart, and you shall see that in truth you are weeping for that which has been your delight.” 
The alternating cycle of horror and loving memories, of avoiding and embracing things related to the loved one, makes traumatic grief complicated.  Not everyone is incapacitated, however, and many find unexpected twists in the journey can lead them to “rise above it” and integrate their experience into a deeper understanding of themselves, their purpose, and their world.
For more information on getting support in the aftermath of a suicide death, please visit: http://www.suicidology.org/suicide-survivors/suicide-loss-survivors
[1] Stroebe, Margaret & Schut, Henk (1999). The dual process model of coping with bereavement: Rationale and description. Death Studies, 23(3), 197-224.
[2] Baker, Jennifer, Kelly, Caroline, Calhoun, Lawrence, Cann, Arnie & Tedeschi, Richard (2008). An examination of posttraumatic growth and posttraumatic depreciation: Two exploratory studies. Journal of Loss and Trauma, 13, 450-465.
[3] Ambrose, J. T (n.d.) Traumatic grief: What we need to know as trauma responders. Retrieved October 30, 2005 from http://wwwctsn-rcst.ca/Traumaticgrief.html

[4] Jannoff-Bulman, R. (1992). Shattered Assumptions: Towards a New Psychology of Trauma. New York: Free Press.

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