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When Grief Is Traumatic

As Vicki looked at her son in his hospital bed, she didn’t believe he was close to death. He was still young, at 33. It had been a bad car accident, yes, but he was still strong. To an outsider, the patient must have looked tragic — unconscious and breathing through a ventilator. But to Vicki, he was only sleeping. She was certain, in fact, that he had squeezed her hand.

Later that day, doctors pronounced Vicki’s son brain-dead. And for the next two years, she couldn’t stop thinking about him. She felt terribly guilty about the circumstances of his death: He and a friend had been drinking before they got in the car. She knew he was a recovering alcoholic, and that he had recently relapsed. She couldn’t shake the thought that she should have pushed him harder to go back to rehab. Every day Vicki flipped through a scrapbook of his photos and articles about his death. She turned his motorcycle helmet into a flowerpot. She let housework pile up and stopped seeing her friends. “She seemed to be intent on holding onto him,” one of her therapists wrote about her case, “at the cost of reconnecting with her own life.”

Vicki is part of the 10 percent of grievers who have prolonged grief, also known as complicated grief or traumatic grief. Grieving is an intense, painful, and yet altogether healthy experience. What’s unhealthy is when the symptoms of grief — such as yearning for the dead, feeling anger about the loss, or a sense of being stuck — last for six months or more.

Very unhealthy. Over the past three decades, researchers have tied prolonged grief to an increased risk of a host of illnesses, including: sleep troubles, suicidal thoughts, and even heart problems and cancer. (That’s not to say that grief necessarily causes these conditions, but rather that it’s an important, and possibly predictive, marker.)

At the same time, there’s been a big debate among researchers about what prolonged grief is, exactly. Is it a bona fide disorder? And if it is a disorder, then is it just another variety of of depression, or anxiety, or post-traumatic stress disorder (PTSD)?

Prolonged grief is in a psychiatric class of its own, according to Holly Prigerson, director of the Center for Research on End of Life Care at Weill Cornell Medical College. When Prigerson first started studying bereavement, back in the 1990s, “psychiatrists thought that depression was the only thing you had to worry about,” she says. “We set out to [determine if] grief symptoms are different and actually predict more bad things than depression and PTSD.”

Her group and others have found, for example, that antidepressant medications don’t alleviate grief symptoms. In 2008, another group found that the brain activity of prolonged grievers when looking at photos of their lost loved ones is different than that of typical grievers. In 2009, Prigerson proposed formal clinical criteria for complicated grief, which include daily yearning for the deceased, feeling emotionally numb, identity confusion, or difficulty moving on with life.

When I first wrote about prolonged grief, for a Scientific American article in 2011, Prigerson and others were lobbying for prolonged grief to be added as a formal diagnosis in ­the Diagnostic and Statistical Manual of Mental Disorders (DSM), the “bible” of psychiatric disorders. That didn’t happen; instead the condition is mentioned briefly in the appendix. “It’s frustrating,” Prigerson says. She is hopeful, though, that the disorder will be included in the next version of the International Classification of Diseases (ICD), the diagnosis guide used by the World Health Organization.

Why all this hoopla over the clinical definitions of pathological grief? Because the determinations made by the DSM and ICD dictate what treatments insurance companies will cover. From Prigerson’s perspective, it means that the roughly 1 million Americans who develop complicated grief each year will have to pay for treatment themselves (assuming they even get properly assessed). That’s an important point from a public health perspective. But more interesting to me is what that treatment is — and how it might shed light on what grief is.

The best treatment for prolonged grief seems to be cognitive behavioral therapy (CBT), a talk therapy in which the patient identifies specific thoughts and feelings, ferrets out those that aren’t rational, and sets goals for the future. In 2005, Katherine Shear of Columbia University reported that a CBT tailored for complicated grief worked for 51 percent of patients.

Part of that tailoring is something called “imaginal exposure,” in which patients are encouraged to revisit feelings or memories that trigger their grief. A similar exposure approach is often used to treat PTSD: Patients will repeatedly recall their most traumatic memories and try to reframe them in a less emotionally painful context. About half of people with PTSD who try exposure therapy get better.

A spate of studies suggest that exposure therapy is also an important part of complicated grief therapy. A couple of weeks ago, for example, researchers from Australia and Israel published a randomized clinical trial of 80 prolonged grievers showing that CBT plus exposure therapy leads to significantly better outcomes than CBT alone.

“The findings from this paper make me think we really need to explore the benefits of making people confront, in some sense, their worst nightmares and fears,” Prigerson says.

This is somewhat counter-intuitive, she adds, because grief has historically been defined as a disorder of attachment and loss, not trauma. In fact, only about half of people seeking treatment for complicated grief meet criteria for PTSD. If grief is a disorder of attachment, then it wouldn’t make sense to encourage patients to think about their loss even more. And yet, somehow this repeated exposure does seem to work.

“We don’t really know the mechanisms here,” Prigerson says. It could be that many people with complicated grief are also dealing with traumatic memories. Or it could be that grief and PTSD are not the same thing, “but that there’s something to exposure therapy that appears to tap into the attachment bond.”

These are questions for future studies. I’m struck by how often CBT techniques — which, at their most fundamental level, are simply about identifying destructive feelings and attempting to reframe them — work, and work for a wide range of disorders. It makes some of the livid arguments over what counts as “real” pathology, or what’s grief versus depression versus anxiety, seem rather beside the point.

In any case, exposure therapy worked for Vicki. After two years of struggling with regular talk therapy, she began seeing a CBT therapist. These sessions included imaginal exposures of her most vivid and painful memories: seeing her son in his hospital bed, and remembering him squeezing her hand. In addition to recalling the scene to her therapist every week, every day Vicky listened to audio tapes of herself telling the story.

Every week these recollections became less painful for Vicki. Her scores on tests of anxiety and grief dropped rapidly, particularly from the fourth to eighth week. She started reading sympathy cards that she had previously avoided. She stopped looking through the scrapbook, and started reaching out to friends and family again.

The treatment led to a dramatic reframing of the way she remembered her son and their relationship. “She said that repeatedly telling the story of his death had helped her to realize that he lived a dangerous life and that he was an independent adult who made his own life decisions,” the case report reads. At her final session, she said the treatment had allowed her “to begin to enjoy her life again.”

**

I made up Vicki’s name. I found her story in this case report, in which she’s called “Ms. B.”.

16 thoughts on “When Grief Is Traumatic

  1. So grief has been constructed into good grief and bad grief, and bad grief requires the intervention of highly-paid therapists. On the other hand the insurance companies don’t want to pay for the therapists or the disability of the diseased (so defined), because they don’t have as much money as they would like.

  2. As you’ve pointed out, this field is kind of a mess — possibly overlapping diagnoses with criteria that are hard to quantify. I’m queasy about “prolonged grief,” because 6 months is nothing, no time at all. I like “complicated grief” better. I’ve seen what I think of as normal grief and as complicated grief and they’re not the same but the symptoms could sound the same. I won’t argue about CBT helping complicated grief. But for normal grief, revisiting the pain routinely would probably do more harm than good. Clearly I should write my own damn blog post. Thank you for writing about this and making it as clear as it can be.

  3. There are people who want to make men’s lives more difficult for no other reason than the chance it provides them afterwards to offer their prescription for alleviating life; their (Christianity) Psychology, for instance.
    Friedrich Nietzsche

  4. In my own experience, normal grieving does not end at six months, although it has already passed through several functional stages, during which the grieving person is able to return to an apparently normal life. It takes a full year, however, for the last functional elements to kick back in–for instance, I was able to start writing fiction again (I had a book left unfinished when the family member died) at about six months–and was doing all the busywork a mother, homeschooler, etc. does before that. But the quality of writing was markedly less (as the editor pointed out when I turned it in) and specifically lacked “vividness” in bringing the story clearly to the reader. Also missing was my awareness that there was something missing in the work–the ability to critique my own writing. That changed immediately after the first anniversary. I suggest that attachment is indeed a big part of grief–for me, the awareness that the year before, each day, the family member was still alive, right there–and it was hard to give up that awareness, that immediacy, especially around holidays and special days for the family. The loss–and the comparison to the whole family–was immediate every single day, past the point when anger, depression, etc. were involved. Once every day had a “skin” on it–a day in which that family member had not been alive and we’d managed without her–whatever part of the brain had been making those day-now to day-then comparisons quit doing so. Creativity returned, unclouded. I observed a similar sequence in our son–both his working through the initial shock, denial, anger, depression, anxiety, etc., in the first half of the year, and the return of his former “normal” state (he’s autistic, so the normal has to be in quotes) in about a year and a month (though anxiety about adults sleeping in the daytime remained for several years.)

    I have wondered if the modern (post-modern) urging to “get over it” and “put it behind you” and “get back to things” isn’t partly responsible for prolonged, complicated grief that seems stuck at the first stage, the stage at which coping with everything else feels impossible. I know other people who have lost close family and friends, and who are expected to be “over it” in a couple of weeks. (And I’ve seen the same reaction given to those with another major life event–a head injury, a divorce, anything that isn’t easily visible like loss of a limb.) Redesigning your life without a significant person is not simple. I’m at the age where I see a lot of deaths in my age group, and have observed a lot of people who’ve lost a spouse or parent or both…healthy grief doesn’t get over it in two weeks or two months–but there are changes toward restoration of function. It’s the lack of progress that suggests someone may not climb out of that pit by themselves. The PTSD model is more useful than depression, IMO, both because there was a triggering event, and because the individual is stuck in that event.

  5. I have a cousin who lost her soulmate/partner after he had gone to bed with chest pain and didn’t wake up. She had tried to get him to call an ambulance but he had told her he only had indigestion. Sadly he died in his sleep and she found him dead. This was five years ago and she has become a shadow of her former self. She is not the se person and her grief is never ending because I feel she blames herself. She is like she has a nervous disorder or post traumatic stress. She yearns for him everyday and visits his grave daily.. I believe there are definitely different types of grief as I really feel this grief will eventually kill her.

  6. When he or she dies on you two things happen: you inhabit that one elongated endless moment of loss, it just goes on and on and stretches you thin along with it until there just ain’t much of you left for anyone else;
    and two: you adopt bits of the lost — mannerisms, habits, idiosyncrasies. You become them, including the dying part.
    Not everyone of course.

  7. I’d be inclined to give Vicki a break on this one. He was her son. It doesn’t fit into our idea of “normal” to lose a child.

    I have noticed it helps to look at pictures of the deceased when you’re grieving, or to read, write, tell stories about them. At first the pain is terrible, but it becomes manageable.

  8. What a wonderful story. I cannot imagine I would lose my son. For Vicky, it had to be one of the worst things she could have experienced in her life. There is often a very strong connection between mother and son. I can tell. I imagine that she felt guilty when thinking about going on with her life. This is what in my opinion made her prolong her grief for such a long amount of time. I consider myself a lucky person that I haven’t experienced something similar. The last strong emotional experience happened to me when I was watchingHer. It really gave me a creeps and gooseskin. This makes me believe that I belong to the group of more susceptible people to the traumatic grief.

  9. I find it much harder to endure the sudden, violent death of a younger person. It is more traumatic & complicated, so the grief is too.

  10. Rather than viewing our understandings of trauma and attachment as being mutually exclusive, as this article seems to suggest, I would view them as interrelated; and would probably opt to work with someone like this client in a way that incorporates both. Perhaps the process of CBT trauma exposure ultimately allows the grieving person to create a new or reordered attachment bond with the one who was lost.

  11. My son died in hospital on 10th dec 2014 from uro sepsis.His dad and I were with him when he passed He became very ill from alcoholism and was in and out of hospital especially throughout 2014. We as a family stuck by him knowing he would die in the very near future. Nothing prepared us in his passing as it was a very traumatic end to his life as he gasped for breath to no avail we watched all this happen!!!. His end of life care was abysmal to say the least. It was and still is very difficult for all of us,and as with most families we are trying to deal not only with our own grief, but of children and young people in the family. I am always thinking about him and the way he died. I have a photo of him in living room and tell him good morning and good night every day, the thought of never seeing him again in this life is heartbreaking so I tell him things as though he were here. People deal with grief in different ways,as I learned to especially with my mom and auntie and the baby boy I lost 28years ago.But this time its been harder, i think it was went on before he died that adds to the grief the bond of a mother and son is unique and aI can empathise with her the guilt and all the emotions that go with it.Iknow its sounds selfish but I wish he was still here even though he was very ill as he still made me laugh through all his troubles.

  12. My son died three years ago. I suffer from ptsd and complicated grief. People think your just sad and miss the person you’ve lost when in actual fact your devasted. You cant sleep and when you do you have nightmares. You wake up full of dread realising you’ll have to face another day of
    Yearning, flashbacks and guilt that eats you to the bone. He was my baby my best friend.

  13. My son was murdered in Afghanistan in 2012 aged just 22. I have been through all the stages of grief, backwards and forwards, getting stuck, making a breakthrough then crashing back down. I realise I use avoidance as a way to get through each day. Numbing too. When I think about what happened and his last moments, away from home, losing his life for nothing, it is too much to bear. This will NEVER go away, he’s never coming back. I cry every day. I miss him so much. Other family members seem to cope better than me but they are going through their own grief. I find it hard that when I try to talk about him at family gatherings, people change the subject. Obviously it’s too painful for them and they are using avoidance as a way to cope too.
    I truly believe that the loss of such a major part of my life has changed me forever. I’m not the same. It’s like my DNA has altered. This trauma has devastated us all and has destroyed me. I don’t believe I will ever be whole again.

  14. As a mother whose 20 year old son died suddenly one day in a road accident on his bicycle, I can only say that you have to experience it, it seems, to truly get it. Why do the experts imagine that they themselves would get over the worst of their grief for their child in six months.. that they would by then have stopped yearning for them or feeling angry/guilty/confused whatever you will? The truth is that by six months after losing a child or close loved one unexpectedly, suddenly and traumatically, you will barely have got over the initial shock. Very unhealthy maybe.. but so let’s face it is being struck hard by a taxi on your bike. Fatal in fact.. to your own dear child. Which parent cares about what is arguably healthy for themselves only six months after their child has been killed? The healthiest thing you can say in any article is that what they feel at six months to six years on, be it tears every day, anger or numb shock, is normal. Very normal. There must surely be experts who have sadly experienced the real life problems that they write about.. anybody else’s opinion on the subject is ill informed and dangerous. It is for the professionals to learn from the real experts.. people who have had the experience.. and not the other way round.

    It would be hard to imagine how I could envisage the violent accident, knowing that my son was a beautiful, joyful and deeply caring friend to us and many many others and that he had huge talent and potential, and re-frame the loss. No.. the only way I cope is through believing he must be in heaven and that one day I’ll join him. Other people will have their own way of getting through each day. Please don’t patronise us with dangerous ideas about reframing the trauma and the loss by visualising it. I would throw up if I dare to think about it beyond writing the words here to make my point.

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