Supporting Individuals and Families Affected by Traumatic Bereavement Brake FLO Seminar, Birmingham, October, 2015 Centre for Trauma, Resilience and Growth (CTRG) stephen.regel@nottshc.nhs.uk stephen.regel@nottingham.ac.uk
Some aims of the talk The impact of of different types of traumatic bereavement on individuals, families and communities Brief overview and understanding of PTSD, the impact common reactions to trauma, traumatic bereavement and the course of those reactions over time Risk and vulnerability factors A clearer understanding of the need for professional help when counselling helps.and when it won t! Illustrative case examples
Casualties: 116 Children aged 7-10 28 Adults Compensation paid to each family - 500 Prosecutions - none
Traumatic bereavement Sudden Violent Unexpected Usually a lack of control Potential for long lasting problems
Contemporary view of bereavement Shock -Numbness (predominant feelings: shock and disbelief) Acute grief Disorganisation and despair (anxiety, loneliness, ambivalence, fear, hopelessness, helplessness) Yearning (Reminiscence, searching, anger guilt) Straightening up the mess Re-investing and re-engaging in life Reorganisation (acceptance, relief)
Myths about grieving The existence of different phases or well defined sequence of emotional responses There is a defined and predictable response to loss Grief is a process with a beginning and an end The mourning never ends. Over time, you just feel it a little bit less Traumatic loss leads to marital breakdown
Schoolgirl was strangled The body of Paige Jones was found on Tuesday A six-year-old girl murdered in Nottinghamshire had been strangled, a post mortem examination has revealed. Paige Shacklock from Hucknall died early on Tuesday morning. The body of her stepfather Mark Jones, 29, was found in a field nearby a few hours later. Mr. Jones had died from hanging, Nottinghamshire Police said in a statement. Detectives are not looking for anyone else in connection with the deaths. Paige's family are being counselled by specially trained police officers. A special assembly was held at her school on Tuesday to pay tribute to Paige. She was described by head teacher Jonathon Jones as a "bright, popular pupil..
In some cases the physical expression of a special emotion, such as fear or terror, persists for a long time without much change. This condition is usually associated with an emotional state produced by the constant intrusion of the memory of some past incident they know they are irritable, that they are unable to interest themselves or to give a maintained attention to a given subject..all this is very real to them and leads to a condition of anxiety which is increased by their not being able to understand their condition; they worry because they fear how far this sort of thing may go. Major R. Rows, 1916, Maghull Military Hospital
Common responses to trauma Sadness Anger Helplessness Guilt Numbing Tension and restlessness Reliving the event Fear and anxiety Physical reactions Difficulty sleeping Impaired concentration Irritability Euphoria/elation What ifs.. Mental and behavioural avoidance
The course of common reactions to trauma Relationship problems 4 8 weeks Financial considerations Physical injury Common reactions Bereavement Pre trauma factors Risk factors The event Post trauma factors Perceived lack of justice Context Litigation Scale Role of media Role of social and other agencies Employer attitude and lack of duty of care Accumulative trauma Other idiosyncratic factorshistorical/social/political
Post Traumatic Stress Disorder: DSM V 1. Experiencing the event (s) him/herself 2. Witnessing, in person, the event (s) as they occurred to others 3. Learning that the event (s) occurred to a close relative or close friend; in such cases, the actual or threatened death must have been violent or accidental 4. Experiencing repeated or extreme exposure to aversive details of the event (s) (e.g., first responders collecting body parts; police officers repeatedly exposed to details of child abuse); this does not apply to exposure through electronic media, television, movies, or pictures, unless this exposure is work related.
B. Intrusion symptoms that are associated with the traumatic event(s) (that began after the traumatic event(s)), as evidenced by 1 or more symptoms B. Persistent avoidance of stimuli associated with the traumatic event(s) (that began after the traumatic event(s)), as evidenced by efforts to avoid 1 or more symptoms B. Negative alterations in cognitions and mood that are associated with the traumatic event(s) (that began or worsened after the traumatic event (s)), as evidenced by 3 or more symptom B. Duration of the disturbance (symptoms in Criteria B, C, D and E) is more than one month. G. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. H. The disturbance is not due to the direct physiological effects of a substance (e.g., medication or alcohol) or a general medical condition (e.g., traumatic brain injury, coma)
Risk Factors Proximity Experiencing a loss of control Subjective life threat Guilt Event involves death, serious injury or near miss Previous psychological problems Previous stressors Poor social (and organisational) support Substance misuse Accumulative stressors Acute stress reactions
Shattered assumptions The impact of traumatic reactions are exacerbated by basic assumptions about self and the world being shaken or shattered. the belief in personal invulnerability a perception of the world as meaningful and comprehensible a positive view of self and others
Common responses to traumatic bereavement Sadness, anger and rage, shock, numbing Guilt Anxiety, tension and restlessness Pervasive fear associated with dread of anticipated violence toward self/others, sense of vulnerability Compulsive behaviours of self protection, hypervigilance Compulsive need for a tangible reassurance of family presence and safety of other family members Behaviours and emotions directed towards retribution Reconstructed memories of an event not witnessed Difficulty sleeping, impaired concentration, irritability Mental and behavioural avoidance
Factors affecting the course of common reactions to traumatic bereavement Pre trauma factors Risk factors TB 6 24months Common reactions Post trauma factors Pre-existing family relationships and dynamics healing or pathological Financial considerations Perceived lack of justice Context, scale, role of media Role of social and other agencies e.g. CICA, Police, NHS, FCO etc Other idiosyncratic factorshistorical/social/political Knowing/not knowing the perpetrator The helper variable Misconceptions from research not being ill The justice system Reactions of the community Reactions of the school Cultural factors
Other reactions Mood regulation (e.g. persistent dysphoria, anger etc) Changes in self perception (e.g. sense of helplessness, guilt etc) Perception of perpetrator (e.g. preoccupation with revenge, emotional ambiguity and conflict) Relations with others (e.g. isolation and withdrawal) Changes in systems of meaning (e.g. loss of faith, sense of hopelessness and despair) WHY? Changes in relationships Exaggeration and exacerbation of existing problems and issues Development of other adverse psychological reactions
Routines and Rituals Important for the creation and reinstatement of a sense of order and stability in everyday life The value of re-establishing ordinary daily rhythms Activate social support For children it provides continuity and security The expression of emotion in symbolic, meaningful ways Rituals make the unreal real alleviate grief and repair the loss Gives the death a meaningful frame of reference defining the deceased person s new position and identity Rituals have a social function through the redefinition of roles and the resumption of activity Collective (common) rituals make participation in grieving less threatening for peripheral networks has a support function at the time and in the longer term
Reading Dyregrov, A., and Regel, S (2012) Early interventions following exposure to traumatic events- implications for practice from recent research. Journal of Loss and Trauma: International Perspectives on Stress & Coping, 17:3, 271-291. Regel, S and Joseph, S (2011) Post traumatic Stress: The Facts. Oxford University Press, Oxford Dyregrov A. (2008) (2 nd Ed) Grief in Children: A Handbook for Adults. Jessica Kingsley, London. Dyregrov A. (2010) Supporting Traumatized Children and Teenagers: A Guide to Providing Understanding and Help. Jessica Kingsley, London Harris-Hendriks J., Black D, Kaplan T., (2000) When Father Kills Mother - Guiding Children Through Trauma and Grief. (2 nd ed) Routledge. London..