D Death, loss and grief are natural components of life. But when death comes suddenly and unexpectedly, such as in a suicide or a car accident, the intersection of the traumatic experience and the grief over the loss can overwhelm us.
Glenda Dickonson, a licensed clinical consultant in private practice in Maryland, describes traumatic grief as "a senseless event – a free fall into a chasm of despair". As she explains, the experience of their daily lives being torn apart by a sudden and unexpected death can cause people to plunge into steep decline. "They swirl down there," she says, "and experience all the problems that are part of grief – shock, disbelief, confusion."
In some cases people get stuck in their grief and don't seem to find a way forward. And in certain cases – like when someone loses their child – individuals may not even want to get out of that state because it makes them feel like they are leaving their loved one behind and moving on, adds Dickonson, a member of the American Counseling Association.
Elyssa Rookey, a Licensed Professional Counselor (LPC) at New Moon Counseling in Charleston, South Carolina, was working with a client who had suffered two traumatic losses. When the client was 15 years old, his stepfather died of suicide, and when the client was 20 years old, his mother died in a car accident in an impact. After his mother's death, the client developed nightmares and worried about the possibility of losing other loved ones in his life.
Rookey noted that the client frequently used “I” statements in meetings: “I should have done more to help you. I shouldn't have said that before she left. "The client blamed her death and thought he was cursed, says Rookey, who specializes in treating trauma, grief, and traumatic grief.
The death of his mother also triggered the client's feeling of abandonment in connection with his biological father, who had left him as a child. Sometimes the client wanted to avoid others and be alone, but this later increased their sense of isolation and fear of additional loss. He was also furious that he had to "grow up" and take on adult responsibilities, such as paying a mortgage and maintaining a property, before he was ready. In many ways, Rookey says, he was "trapped" in trauma and avoided feelings of grief and loss.
Identification of traumatic grief
Not every sudden or catastrophic loss leads to traumatic grief. Some people experience straightforward bereavement. But others can show signs of trauma and grief. They could avoid talking about the person they lost altogether, or they could fix themselves on the way their loved one died.
Because of the trauma embedded in the grief, it can be difficult to distinguish between post-traumatic stress disorder (PTSD), grief and traumatic grief. “PTSD is about fear, and grief is about loss. Traumatic grief will have both, and it will involve a feeling of powerlessness, ”explains Dickonson. “A person who experiences traumatic grief becomes a victim – a victim of trauma in addition to loss. … They will take on the qualities of trauma even as they mourn the loss. “She finds that people with traumatic grief tend to talk about physical pain, have trouble sleeping, and are anxious.
People experiencing traumatic grief could have distressing thoughts or dreams, hyperarousal or anhedonia / deafness, says Nichole Oliver, a private practice LPC at Integrative NeuroCounseling in Chesterfield, Missouri. She notes that some of the symptoms can be confused with other mental health problems. For example, a person going through traumatic grief may have loss of appetite and difficulty sleeping (which may resemble signs of depression) or have great difficulty concentrating (which may look like a sign of attention deficit disorder).
The Trauma Survivors Network lists common symptoms of traumatic grief on its website, including:
To be busy with the deceased
Experience pain in the same area as the deceased
Disturbing memories
The feeling that life is empty
Longing for the person
Hearing the voice of the person who died or "seeing" the person
To be attracted to places and things that are connected to the deceased
Experience disbelief or anger about death
I think it is unfair to live when this person died.
I feel stunned or dazed.
To be envious of others
Being lonely most of the time
have difficulty caring for or trusting others
Rookey, who works with the South Carolina Mental Health Department with the Charleston County Sheriff's Office, is always on the lookout for trauma as clients may have underlying problems that affect or complicate their grief . While working as a counselor in Miami, she noticed that some teenagers tried for substance use had also suffered traumatic loss (e.g., a friend who was shot). In these cases, besides the subject of substance use, the counseling sessions focused on grief, PTSD and fear,
Rookey meets with customers first to get a better feel for their story. These conversations often lead them to ask questions such as, "Have you ever felt this sense of loss or fear in the past?" The interview helps uncover underlying issues that could affect the person's ability to grieve in healthy ways, she explains. For example, a customer might reveal that the way they are currently feeling is a reminder of how lost they felt after their parents' divorce. This may lead to the discovery that the customer has never fully handled this loss at that point and this now affects how they process this new loss.
A new loss layer
"COVID-19 has given grief a brand new dynamic," says Dickonson, who specializes in treating trauma, grief, traumatic grief, and mood disorders. “People have lost jobs, relationships, businesses and homes. … There is an endless sense of loss that keeps increasing. "
The pandemic has also added a trauma layer to expected grief because it has restricted the way people can mourn death. Rookey, who is also a Florida LPC, had a client whose husband died not long before the COVID-19 virus hit the United States. After the husband's death, the client moved from Florida to South Carolina, where her husband came from because he had always wanted her children to live there. A few months later, the client's aunt died in Puerto Rico of natural causes, but quarantine restrictions prevented her from traveling to attend the funeral. All of these circumstances left the client helpless, frustrated, and isolated, says Rookey.
The COVID-19 pandemic has severely limited people's ability to grieve together, which can make even expected deaths more traumatic, Rookey notes.
"Losing a loved one to COVID-19 could definitely make the grieving process more difficult if people are unable to say goodbye or be with their loved one when they die," says Tamra Hughes , an LPC in Centennial, Colorado. "These experiences can torment a person trying to cope with the loss."
“And COVID-19 is in the foreground in everything we see and do right now. So there is a constant reminder of the circumstances surrounding the death of the loved one, ”she continues. "These clues can all act as triggers for the client and evoke negative emotions, physiological reactions and trauma reactions."
Grief is personal
Everyone grieves differently, so it is not always easy to identify traumatic grief in clients. Hughes, an ACA member who specializes in grief, traumatic grief, trauma, complex trauma, and fear, says no two cases are alike in grief work. She approaches her work through the lens of the adaptive information processing model of EMDR therapy (desensitization and reprocessing of eye movements). Areas she considers include the client's stability in their life, their attachment style, and their mental model of the world. These factors affect the way they deal with adversity and trauma, explains Hughes.
Working as a counselor in a funeral home helped Oliver, an ACA member who specializes in PTSD and grief, understand and appreciate how people's social and cultural factors (such as personality, spirituality, and race / ethnic Affiliation) affect them approaching loss and grief. For example, under some religious beliefs, shame is associated with suicide while others may celebrate it as an act of courage. And while some people view crying as a weakness, certain cultures incorporate wailing into their funeral ceremonies.
Hughes, the owner and therapist of the Greenwood Counseling Center, knows that some clinicians are afraid to ask clients about their spiritual beliefs about death. She encourages counselors to ask difficult questions like "What do you think happens to people after they die?" Otherwise, "it will be the elephant in the room," she says. "It's not about imposing their own religious or spiritual beliefs on the client. It's about understanding the context [client’s] … because then you can work in that framework to help them through the grief . "
Legal proceedings in connection with murders can further complicate a person's experience of grief. Sometimes people assume that the best way to process their grief and healing is to seek legal justice, Rookey says. But often, their grief doesn't really start until after they separate the legal aspect from their own grief and trauma, she notes.
Oliver uses the unique life experiences of individual clients to tailor their psychoeducational efforts and counseling techniques. For example, she can explain trauma symptoms to someone who works in information technology by comparing her body to a web browser that has too many open tabs. This visualization helps the customer to understand why his body and his emotions are overloaded. Then she will ask the client to choose which two or three tabs they would like to prioritize and work on that session.
Oliver also has customers compile a playlist of songs that express their current mood and feelings of sadness, which they may find difficult to convey verbally. In the session, clients can use these songs to explain how they are processing their grief in that moment. That helps regulate the limbic system, which is the part of the brain involved in behavioral and emotional responses, she says. Oliver also keeps a three-ring binder in her office with pictures – for example, a person bowed in shame or a person torn in half between their heart and brain. Sometimes she asks clients to pick an image that resonates with them in order to speed up their conversation.
Unspoken words
People can come to counseling immediately after a sudden loss or wait weeks or even months before seeking help. If the counselor works with the client shortly after the loss, his main goal during the first two or three weeks of therapy should be to "hear" the client's loss and confirm his or her feelings, says Hughes. Counselors could provide guidance on coping and self-care, but caution against making suggestions on how to "heal" because it can sound unwelcoming.
Dickonson finds “sacred silence” – sitting still and being with a client – a useful tool when working with traumatic distress. “We need to develop the ability to deal with our customers' fear, to remain fully present but not be intrusive, to speak, but also to know how to be calm and fully connect. We don't have to break the silence. … Sometimes that's what they need. We just have to be with them and show them that this is important to us, ”she says.
Dickonson also keeps a tissue box within easy reach for customers to use, but does not offer them a tissue if they start crying. "Tears are very cathartic and if I give you a handkerchief [insinuate] it may be time to stop crying," she explains.
Hughes finally offers customers the ability to speak unspoken words – what they would have liked to say to their loved one and what they thought their loved one would have said to them. "It has to do with articulating it and saying those words [out loud] … that helps the brain reconcile some aspects of [the grief]," she says. It also gives customers a chance to close something that feels so abrupt and unfinished, she adds.
One technique Dickonson uses with some of her clients when they emerge from their grief and set out for post-traumatic growth is to take the deceased's voice and then write or record how believing her loved one would comfort her. In response, she asks customers: "What would your lover say to you if she were here now?"
As customers share their interpretations of loved ones' words, Dickonson watches their face change in places and then asks, “How did you feel hearing what your loved one said to you could have said? “She finds that this exercise often leads to productive discussions and helps clients express things they might feel guilty about when telling themselves.
Processing the trauma
When helping clients deal with life challenges, including traumatic grief, Hughes addresses their trauma through EMDR. Hughes is an EMDR Therapy Trainer, Owner of the EMDR Center of the Rockies, a member of the Board of Directors of the EMDR International Association (EMDRIA), and an EMDRIA accredited consultant. “EMDR helps the brain organize information in a more adaptable way. In the case of traumatic grief, this can help promote healing and the completion of the grieving process, ”she explains.
If the relationship with the deceased was in conflict, clients may face challenges they had or feelings of guilt or shame that may arise after the loss, adds Hughes.
Traumatic loss can also trigger past trauma, which could be the reason for the client's current complicated grief response, says Oliver. She once worked with a man whose mother had just died. Although their relationship had been strong at the time of her death, the client's mother had been abusive as a child. Her death triggered this past childhood trauma, causing the client not only grief over her loss but anger over the abuse and past guilt over the relief he felt from not having to care for her. The client was afraid to admit these complex feelings to Oliver because he was ashamed to experience resentment, anger, and relief when he thought he should only experience grief. The client's cognitive dissonance disrupted their ability to grieve in a healthy way and further anchored them in a complicated grief response, notes Oliver. She confirmed his feelings and reminded him that expressing the full range of his feelings did not mean that he was attacking his mother's memory.
Rookey used exposure therapy to help clients come to terms with unresolved trauma related to firsthand losses. However, she cautions clinicians not to use the approach if they believe it could be triggering for a client, especially if the client does not have a good support system.
Rookey used the approach on a woman who was triggered by sirens after seeing her partner die in a traumatic accident. While the woman was sleeping, her partner went outside to smoke and he was shot after being caught in the middle of a botched burglary. When the woman woke up and realized what was going on, her partner had crawled into the kitchen and was slowly dying. She called 911 and held him while she waited for the ambulance.
It wasn't just the grief for the loss that was traumatic for the client, explains Rookey. It was the trauma of repeatedly asking yourself, "Why didn't I do anything to help him?"
The client began to operate in survival mode and avoided thinking about her loss. But sirens became a trigger for them. When she heard them, she would run into a bathroom and cry. So Rookey opted for in vivo exposure to help the client train her body and mind to get back to a healthy state.
First, Rookey asked the client, who worked near a hospital, to go outside when she heard an ambulance and listen to the sirens while engaging in calming activities such as deep breathing. After the ambulance drove by, the customer repeated positive statements (e.g., "It wasn't that bad"). This slowly and safely exposed the client to the trigger. After the client was comfortable hearing the sirens outside of work, Rookey had the client record herself narrating the traumatic incident as if she were reliving it, and she replayed that recording every day. "It's a way to show your body that you can be distressed, triggered, afraid, but you'll be fine," says Rookey.
In one session, Rookey asked the client which parts of the story affected her most. This interview helped Rookey find out that the client's guilt for not preventing her partner's death prevented her from fully grieving and moving forward. They worked together to redesign the event so the client could see that she was not responsible for the death: her partner would stay up late and smoke a cigarette before bed. She had called for help. She couldn't have done anything else.
Creating new meanings
What makes a loss traumatic is not just the way the person died, but also the importance attached to death, says Oliver. She worked with a woman who had developed an irrational thought linked to the traumatic death of her son. The son had struggled with a drug addiction for a decade, but the night before he died of suicide they had argued and the mother had said some rude things. She blamed herself for his death.
"Her core belief [that she was responsible for her son’s death] kept her anchored in the pain of grief so that we couldn't process the grief until we gave up this belief," says Oliver.
To begin the process of releasing the client's negative beliefs from her grief, Oliver presented another factor that contributed to the son's death. She told the client, “Numerous research studies show complex neurobiological changes in the brains of people who have committed suicide. Post-mortem autopsies show that these people have 1000 times the amount of cortisol in their brain and that other systems such as the HPA axis [hypothalamic-pituitary-adrenal] receptors and neurotransmitters do not function normally. That is, they have no access to the prefrontal cortex, the logical part of the mind. "
This information comforted the client. Often times, when it comes to traumatic grief, it's about planting seeds of hope and untangling the fragmented pieces in people's minds, Oliver says.
Oliver continued to help the client find and connect the fragmented pieces by reconsolidating the memory. This is the brain's innate process of converting short-term memories into more stable, long-lasting ones. Oliver made the client remember the memory of her son's death, and then they created inappropriate experiences in the brain by combining the client's belief that she was responsible for her son's death with the contradicting information that she was doing it had supported rehab and that he had tried suicide earlier.
Getting this information conflicted with the client's cognitive bias that the son's death was all her fault, explains Oliver. The process helped the client integrate more pieces of the puzzle until she had a clearer picture of the event and was able to break away from the negative thought. As a result, the emotionally charged memory (the client's self-blame) shifted from the amygdala to the hippocampus and reduced the trauma response by creating new learning (the realization that their son's death was not their fault), Oliver adds.
Finding a way forward
After the trauma of their loss has been alleviated, clients are ready to take a step forward. “Traumatic grief is about giving meaning to death and who they are now,” says Rookey. "You were on a course … and it got crooked and now you are on a parallel path." After working through the trauma and grief of loss, she lets herself imagine the clients moving forward the other way. The exercise encourages them to think about their future and gives them meaning as they embark on this new path, she says.
Hughes believes the goal is "to get to a place where grief is replaced by an increase in the person's positive memories and the essence of who they were". People will still be saddened by the loss, but that feeling should be more manageable and associated with gratitude for the time they share with the loved one, she explains.
With counseling and support, clients can emerge from the "Chasm of Despair" – the steep decline they fall into after traumatic loss – and begin to transform their pain into something positive and potentially powerful, says Dickonson. This could include becoming more involved with their families, developing a greater appreciation for life, or even seizing new opportunities that arise directly from the traumatic event. "They still feel the sadness," says Dickonson, "but they are ready to move forward."
This is the time when counselors could encourage – but not urge – clients to continue their transformation process from senseless free fall to a meaningful journey, advises Dickonson. Counselors should also keep in mind that once clients come out of the abyss of grief, they can replace their grief with other unhealthy coping behaviors, she warns. So counselors need to continue to support clients as they begin this journey forward.
Rookey and her client, who had all lost his stepfather and mother before he turned 21, had to address his negative beliefs about his responsibility for her death before he could find a way to move forward and in a healthy way to mourn. In the end, the young man's guilt and anger had subsided. He sold his mother's house, bought a truck, and set up automatic payment for his bills. These were small steps towards him to work out his new identity and to advance his parallel path.
****
Lindsey Phillips is the Senior Editor for Counseling Today. Contact them at [email protected].
****
Opinions and statements in articles appearing on CT Online should not be assumed to reflect the opinions of the editors or guidelines of the American Counseling Association.
