TERRORISM and PTSD
Resources for Clinicians
Managing Grief after Disaster
A National Center for PTSD Fact Sheet
The recent terrorist disasters left many people suddenly bereaved of spouses, children, parents, close friends and co-workers. In the immediate aftermath, some have been numb and/or unable to accept the loss. Many have felt shocked, lost, anxious, depressed and physically unwell as a result of this loss. For many, the pain has been intense and unrelenting. In the acute aftermath of violent death of a loved one, a sense of disbelief and/or intense, uncontrollable emotionality is very frequent. Distressing physical symptoms are also common (Lindeman, 1944; Strobe & Strobe, 1993). These emotional and bodily reactions may be very strong and can themselves be traumatizing, especially if unfamiliar and unexpected. Such a secondary reaction can further amplify the pain caused by the loss, and can be mitigated by information about grief and stress reactions. It is important to realize that intense and unfamiliar emotionality is entirely normal and does not necessarily have implications for long term emotional stability or health. The fact that a popular internet book site lists 2,776 titles on the topic, attests to the fact that grief is both common and difficult. In ordinary, peaceful times millions of people die every year, each leaving friends and family bereaved. Many experience numbness and/or intense pain in the immediate aftermath. For most, this initial reaction subsides with time, and the bereaved person finds a way to again engage fully in life. However, studies show bereaved individuals, as a group, are at risk for longer term mental and physical health problems. It is a good idea to provide ongoing support, monitor outcome of grief and to know that professional intervention can be helpful.
Given the universality of bereavement, there has been relatively little research to characterize its course, develop a nosology for bereavement problems, identify risk factors, or guide treatment. The information provided below draws upon what has been done and upon ongoing work.
The Course of Bereavement
Somewhat surprisingly, the course of bereavement is not well understood. There are no consistent outcome measures in the field, and few studies have targeted a full range of ages and circumstances of death and bereaved. Most of the information available refers to elderly and/or widows. However, younger individuals, and especially men, may be at highest risk for complications, relative to a comparison group of same age and sex (Ball, 1977; Strobe & Strobe, 1983). A model of the type of study needed is provided by research by Stroebe and colleagues (1993. This group compared widow and widowers under the age of retirement to a married control group, interviewing subjects at 4-7 months following their loss, at 14 months and at two years. They found widows who participated were more depressed than widows who did not while the reverse was true for widowers. It is important to keep in mind that most studies of bereavement have succeeded in recruiting only about a third of eligible individuals, so all data needs to be viewed in light of possible differences in who participates. Given this caveat, studies consistently find bereaved individuals to have higher levels of depressive symptoms than matched controls in the first 6-12 months after the death. Most of those with milder levels of depression improve by year 2, while those who are clinically depressed (about 20%) remain depressed. Somatic symptoms are reported at a rate of nearly 10 times that of controls in the initial 6 months, and are still 4 times as high at two years. Less is known about the course of bereavement following violent death, but available studies consistently find that symptoms and impairment are more prolonged and sense of resolution less likely (e.g., Murphy, 2000). A recent study of women college students (Green, 2001) found those who experienced a violent loss had symptoms and impairments similar to those who experienced assault. A dissertation study by Pivar documented grief symptoms in 70% of veterans and found that these could be differentiated from symptoms of PTSD and of depression. Taken together, this work suggests that sudden violent bereavement is a very intense stressor. While many people will find a way to cope without intervention, skilled professional assistance may be important in decreasing the morbidity and even mortality of the disaster bereaved. In order to provide such assistance, a professional needs to be informed about grief and about treatment strategies that have been developed and tested.
The Experience of Grief
Grief is the process by which we adjust to the loss of a close relationship and so is an inevitable companion to love and attachment. The lives of those we love are interwoven with our own in thousands of small and large ways. One’s immediate family, in particular, contribute to a sense of comfort, security and happiness and serve as reinforcers of behavior. Endocrine function can become entrained to cues from another person. If so, losing that person requires a period of physiological adjustment. In all cases, loss of a loved one engenders feelings of loneliness, sadness and vulnerability. The death of someone close also makes one’s own death imaginable, thus evoking fear of dying. Acute separation distress and confrontation with mortality, are always present, to a greater or lesser degree, in the aftermath of the death of someone close. Sometimes, there is also guilt about being alive when the other person has died, or about failure to save the person who died or to make their life or their dying easier.
While grief is not the same for every person, there are certain commonalities. During the initial phase, the bereaved person is preoccupied with the deceased, with feelings of yearning, longing and searching for him or her. While grieving, most people withdraw from the world and turn inward. Grief entails a host of painful emotions that can sometimes be very strong and persistent. Strong feelings of sadness and loneliness almost always occur following the death of a close friend or family member. Fear and anxiety are also common, especially in confronting death. Difficult feelings of resentment, anger, and guilt can occur. Experiencing any or all of these emotions following the loss of a friend or family member, is perfectly normal.
As the transition to life without a friend or family member progresses, the intensity of grief subsides. The bereaved person accepts the death and begins to take some comfort in positive memories, establishing a permanent sense of connection to the person who died. It becomes possible to re-engage in activities and relationships, keeping memories and a sense of closeness to the deceased. The period over which this adjustment occurs is variable, depending on circumstances of the death, characteristics of the bereaved, and the nature of the relationship. In some circumstances, intense grief persists for many months or even years. Intrusive images and disturbing ideas inhibit the healing process, and there is a sense that the death is unacceptable and unfair. For some who have difficulty coping with the death, grief sometimes seems to all there is left of the relationship. For others, decreasing intensity of grief feels like a betrayal of the person who died. Still others have persistent feelings of guilt. When a death is sudden, violent and untimely, difficulties are more likely to occur. The condition in which unmanageably intense and/or persistent grief symptoms occur is called Traumatic Grief. Symptoms of Traumatic Grief are listed in Table 1. Work is underway to establish diagnostic criteria and develop treatments for this condition. Traumatic Grief may predispose to other psychiatric, medical and behavioral problems that can complicate bereavement. These are generally treatable conditions and need to be recognized by professionals, as well as bereaved individuals themselves.
Complications of Bereavement
Bereavement is a risk factor for a range of mental and physical health problems. Among these are the following:
Prolonged or "Traumatic" Grief
- Onset or recurrence of Major Depression
- Onset or recurrence of Panic Disorder or other Anxiety Disorders
- Possible increased vulnerability to PTSD
- Alcohol and other Substance use
- Smoking, poor nutrition, low levels of exercise
- Suicidal ideation
- Onset or worsening of health problems, especially cardiovascular and immunologic dysfunction
Traumatic Grief
Disruption in mental functioning from grief is inevitable following death of a loved one. It may be helpful to draw an analogy to a physical illness. An illness is not a characteristic of a person, it is a state a person is in at a given time. Many illnesses are very treatable. Traumatic Grief bears some similarity to an infectious disease, an illness caused by exposure to an environmental pathogen. Individual resistance to illness varies, but some pathogens are so virulent that almost anyone will become ill upon exposure. Another analogy is to an acute injury. People are more or less vulnerable to disability from injury, but some types of injury are so severe that they always cause impairment. Using such analogy, it is possible to see that following a disaster, it is entirely normal to experience Traumatic Grief, just as it is quite normal to develop tuberculosis upon exposure to a virulent organism, and normal to be unable to walk on a broken leg. It is also clear that it is a good idea to diagnose and treat these conditions. No one would tell a person with pneumonia to pull "yourself together" or "get on with it" or expect a person with a deep cut or a broken bone to heal themselves. Although labels can be hurtful if misused, they can also be helpful. An ill person needs to have a "sick role" and to receive treatment. An ill person benefits from support and assistance from family and friends, as well as treatment by a trained professional.
- Preoccupation with the deceased
- Pain in the same area as the deceased
- Memories are upsetting
- Avoid reminders of the death
- Death is unacceptable
- Feeling life is empty
- Longing for the person
- Hear the voice of the person who died
- Drawn to places and things associated with the deceased
- See the person who died
- Anger about the death
- Feel it is unfair to live when this person died
- Disbelief about the death
- Bitter about the death
- Feeling stunned or dazed
- Envious of others
- Difficulty trusting others
- Lonely most of the time
- Difficulty caring about others
Risk Factors for Complications of Bereavement
Risk factors can be seen as those that tend to increase vulnerability to complications and those that may slow recovery. Existing studies suggest that risk factors related to characteristics of an individual, the nature of the relationship to the deceased, the circumstance of the death and the social context. Some risk factors are general, in that they are related to more symptoms and impairment in the population at large and some are specific to bereavement. While both raise the distress level of the bereaved person, it is useful for the clinicians to be aware of what might be specific for the bereaved individual.
The following risk factors have been identified:
Demographic factors: Socioeconomic status: Lower socioeconomic status is related to poorer health status in general. Bereavement appears to affect those of different socioeconomic status similarly.
Age: Bereavement appears to be somewhat more stressful for younger than for older individuals, with the exception of the elderly who already have health problems. Gender: There is some evidence that men, especially widowers have more bereavement-related health problems than women, especially following spousal bereavement. Loss of a child may be more difficult for mothers than fathers. However, clearly both men and women are deeply affected by loss of close family and friends. Recognition of the effects may be easier for women than men. Coping may differ.
Individual Characteristics: Individuals who score low on emotional stability (i.e. high on "neuroticism") are more likely to have health problems. Low internal locus of control is associated with more depression, generally. This is not specific for bereavement. On the other hand, high internal locus of control does not act as buffer for bereavement related distress. Anecdotal evidence suggests a belief in life after death may be protective. However, when this has been examined in a study, a protective effect was not found (Strobe & Strobe, 1987).
Relationship Quality: There may be gender differences in the effects of the relationship as a risk factor for bereavement difficulty. A good marriage may be associated with more bereavement-related problems in women, while the opposite may be true for men. In general, clinical lore that problems occur because of ambivalence or problems in a relationship is not supported by data. It is very clear that in some instances an especially positive relationship may be associated with very difficult bereavement reactions.
Circumstances of the death: Not surprisingly, sudden death (e.g. less than 1 days notice) is associated with more symptoms in the first 6 months after the loss. In some studies this difference disappeared at later interviews, while for others it did not. Endorsing low scores on a measure of internal locus of control was a powerful risk factor for younger bereaved spouses. In some studies, there is evidence of continuing distress from the loss for many years following a sudden, violent loss. It is clear that many of those bereaved by the WTC disaster may experience treatable psychiatric difficulties for a long period of time. It is important for professionals to be vigilant to this possibility.
Social Context: Both perceived and received social support are related to lower symptoms of depression in the general population, but there does not appear to be a specific relationship between social support and bereavement outcome. However, it is important to note that often bereaved individuals perceive others to lack empathy and to be hostile with regard to continued symptoms. This is likely related to a poorer outcome, but has not been specifically studied.
Treatment of Bereaved Individuals
Grief support groups and grief counseling is widespread and undoubtedly highly variable. Little information is available related to its outcome. There is specific controversy regarding the importance of confronting the death (also called "grief work") in the early phase of grief. In one study (Stroebe) investigators developed a measure to assess the extent to which individuals confronted or avoided their loss and used scores on this instrument to predict outcome at later times. They found that low scores for widows did not influence outcome, but low scores for widowers predicted poorer outcome. There is some evidence that the occurrence of symptoms of major depression in the first month following the death predicts a worse course later, especially for suicidally bereaved (e.g., Jordan, 2001).
It goes without saying that the loss of a close relationship permanently affects the bereaved person. It is not reasonable to think that one would "recover" from such a loss, nor to think one could "resolve" the loss. Such as loss is permanent and has permanent effects on the bereaved. Still, it is possible and probably important that the bereaved person eventually feel interested and able to engage in life and to have comforting memories of the deceased. Weiss (1993) provides a list of reasonable expectations, including 1) ability to give energy to everyday life, 2) psychological comfort, or freedom from pain and distress, 3) ability to experience satisfaction and gratification in life, 4) hopefulness for the future, and 5) ability to function adequately in a range of social roles. How then can a professional assist in achieving these goals?
The role of a professional in the early phase of disaster bereavement
There is little data on the effectiveness of early intervention for grief, but it is clear that early intervention is a good idea following a disaster, provided it is administered by a skilled, empathic clinician. Though data suggests that even after sudden, violent death, most people eventually grieve successfully, this can take a long time. Many people consider grief to be personal experience, similar to love. Most people do not turn to mental health professionals to tell them how to love, nor do they look for help with grief. However, when a loss is sudden and violent, the intensity of emotions can be frightening and the need for support and outside intervention greater. In response, the professional needs to use a skilled, supportive intervention. Useful components of such intervention include
- Providing information about grief, its symptoms, course and complications
- Evaluating the nature of the individual’s distress,
- Helping to identify and problem solve practical matters,
- Providing strategies for management of intense affect
- Assist the person to think about the death in a way that leads to emotional resolution
Affect-evoking interventions must be used with care and expert skill, balanced with containing and soothing strategies. During the early phase a brief intervention providing information and strategies for thinking about the death may be very useful, it is best if the professional provides some follow-up and remains available for consultation and support, should this be needed.
Prigerson and Jacobs (2001) provide a useful list of "do’s and "don’ts" for physicians following a patient’s death. These can also be useful to consider. They suggest:
- Direct expression of sympathy
- Acknowledgement that the clinician does not know what the bereaved person is "going through"
- Talking about the deceased, including saying his or her name
- Eliciting questions about the circumstances of the death
- Eliciting questions about feelings and about how the death has affected the person
A useful list of cautions about things that are NOT HELPFUL is also provided and includes:
A casual or passive attitude (e.g. "call me" or asking "how are you") Statements that the death is in any way for the best, or acceptable (e.g. "He/she is in a better place" or "it’s God’s will" Assumption that the bereaved is strong and will/should get through this Any kind of avoidance of discussion of the death or the person who died
Even given its private nature, variable course and usual resolution, there are circumstances in which grief can be intense and prolonged, hindering re-engagement in daily activities. When this occurs, a focused intervention may be needed. There is wide acknowledgment that bereavement can be prolonged and also that it can lead to other mental health problems, especially depression and anxiety. Thus, for a high risk group professional intervention may be especially important.
Treatment Strategies for Complications of Bereavement
Treatment should target the symptoms experienced by the patient. It is now very clear that bereaved who experience Major Depression (MDD) respond to antidepressant medication and/or psychotherapy, similarly to those who are not bereaved. A very interesting recent study suggests that treatment of MDD as early as a month after the death, may be extremely helpful and prevent later symptoms. Similarly, for those who meet criteria for PTSD, it makes sense to provide treatment similar to other PTSD patients. However, the most common problems post-bereavement center around traumatic grief reactions, and unfortunately, few treatments have been developed or tested for symptoms of Traumatic Grief. Studies of early intervention for grief document some reduction in grief symptoms, with support groups showing efficacy equal to that of active psychotherapy. An early study of a behavioral therapy called "guided mourning" also appeared to have beneficial effects though grief outcome was not measured. A specific "Traumatic Grief Treatment (TGT)" is currently undergoing randomized controlled testing. In a pilot study, TGT had a large effect size, even taking into consideration individuals who did not complete the full course of the treatment (Shear, 2001). Components of this treatment include
Information about bereavement and grief for bereaved individuals and their families Description of the deceased and history of the relationship with the deceased Story of the death and its aftermath Careful assessment of current grief levels, target grief level and components of grief (i.e. cognitive, behavioral and somatic Review of Personal Goals and how the bereaved person will know when these have been met Carefully managed imaginal exposure to the death and related events In vivo exposure to situations that are avoided and/or response prevention for situations of preoccupation Focus on positive memories of the deceased
Therapists should undertake imaginal exposure only if they are familiar with these technique and with emotion control techniques. The remainder of the treatment may be of help alone, but has not been tested. It is also important to gain an idea of the social support system of the bereaved person and to support engagement with existing supportive people.
Pharmacotherapy may also be helpful to individuals suffering from Traumatic Grief. However, little has been done to test pharmacotherapy. It appears that, as for depression and PTSD, there is some beneficial effect of serotonin active medications (Zygmont, 1998). Given available information, it seems important that clinicians learn to administer techniques that appear to be efficacious. Training programs are under development in the affected areas.
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