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Natural or violent dying may be followed by an intensely traumatic and confusing emotional aftermath for family members.
Following a natural death, a minority of family members may present with complicated grief (Prigerson and Jacobs, 1999 Horowitz et. al., 1997). This clinical syndrome refers to a dysfunctional response of traumatic distress subsequent to interrupted attachment in vulnerable individuals, i.e., complicated grief occurs in someone whose psychological integrity was dependent upon the relationship with the deceased.
When that relationship is no longer available, the survivor experiences a persistent state of self-devastation.
Prigerson and Jacobs have proposed measurable criteria for diagnosis of this syndrome -
eleven factors (including numbness, avoidance, purposelessness, disbelief, emptiness, hopelessness without the deceased, partial self death, shattered world view, facsimile symptoms, protestation of death) which they view as primarily related to traumatized self-integrity. Separation distress (or bereavement) is defined by mourning, pining and searching - thoughts, feelings and behaviors to reestablish the presence of the deceased. Complicated grief is defined by thoughts, feelings and behaviors of self-disintegration. Their data is largely drawn from community and clinical populations of adults following the death of a spouse, particularly widows.
In this model it is the event of terminal separation that is primarily traumatic. The model suggests a vulnerability to separation (irreversible separation triggers personal disintegration) as a necessary precondition for the occurrence of complicated grief.
Prigerson and Jacobs acknowledge the independent, "traumatic" effects of violent dying on bereavement, but ascribe it to a separate disorder, PTSD.
However, the traumatic effects of violent, unnatural or unexpected dying are not completely described by the criteria for PTSD. After violent dying, the PTSD phenomena (intrusive reenactment imagery of the dying, avoidance of reminders of the dying, physiologic hyper-arousal and persistent dysfunction) may describe some of the reactive signs and symptoms, but there are specific effects of violent dying not included in the list of criteria for Traumatic Grief or PTSD.
Specific Phenomena of Violent Dying:
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- Violent dying is a human act, associated with human intention or negligence. Suicidal, homicidal, accidental or terrorist "killing" is followed by a socially proscribed inquiry to investigate and determine who is "responsible" because this is a dying that should not have happened. This intense inquest by the medical examiner, the police and sometimes by the courts socially reinforces the personal demand for investigation, and retribution if investigation determines that the deceased was the "victim" of a crime. Natural dying is rarely followed by such an inquiry, and it is not normative for grief following natural dying to include persistent thoughts, feelings or behaviors of retaliation or retribution or dread of its recurrence.
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- Since violent dying is the most common cause of death before age 40, a disproportionate number of younger parents and siblings are forced to accommodate to the violent dying of a primary family member. Parents, particularly mothers, are over represented in every study (usually representing over half of the sample) who present for treatment.
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- Mothers seeking treatment after the violent death of their child may meet criteria for both complicated grief and PTSD, but they are also intensely remorseful because of their perceived failure in protecting their child from violent death. Mothers serve as the primary attachment provider to their child (different than the attachment dynamic within a spousal relationship) and because of their parental obligation of protection, mothers feel inordinate remorse for the dying.
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Clinical Differentiation:
There is not enough evidence to designate violent death bereavement as categorically distinct from complicated bereavement or PTSD; however, there are clinical phenomena and dynamics specifically associated with violent dying that need to be included in supportive guidelines and interventions:
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- The immediate aftermath of violent death demands an intense engagement of the family with community agencies of the media, police and eventually the courts and prisons if someone is apprehended and tried.
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- Guidelines for this public aftermath include active advocacy and education. |
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- Mothers and young children are particularly vulnerable to a prolonged bereavement after the violent death of a loved one.
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- Guidelines for their delayed adjustment include proactive outreach and follow up of family members (particularly mothers and children) for 18-24 months. |
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- Vulnerability to prolonged bereavement is associated with a syndrome of obsessive thoughts and flashbacks of the dying reenactment and secondary thoughts of remorse, retaliation and recurrence.
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- Guidelines for this traumatic aftermath include interventions that moderate distress, restore resilience and modify the obsessive narratives of dying, remorse, retaliation and recurrence.
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| Our purpose is to serve as a consultative resource for trainers, researchers and providers by providing contact information regarding innovative interventions, research design and an updated resource of references. |
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Recent Literature on Complicated Grief and Violent Death (update 4/27/07)
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| The body of literature and research data on the psychological effects of violent dying and its management is early and meager. Most of the reports are anecdotal with few studies that include objective measures or control groups to test the effectiveness of interventions. |
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Allumbaugh, D.L. & Hoyt, W.T. (1999) Effectiveness of Grief Therapy: A meta-analysis.
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Evidence-Based Guidelines for the Diagnosis and Treatment of Complicated Grief. Journal of Palliative Medicine, 9(5), 1188-1203. |
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Treatment Manuals: Violent Death Bereavement
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| Trauma/Grief-Focused Group Psychotherapy Program (children & adolescents) |
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UCLA Trauma Psychiatry Program, 2001
Layne, M.L., Saltzman, W. R., Pynoos, R.S.
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| Group Work with Adolescent Survivors of Homicide Victims (children & adolescents) |
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Children's Bureau of Greater New Orleans - Project LAST, 2001
Salloum, A.
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| Accommodation to Violent Dying (adults) |
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Separation and Loss Services, Virginia Mason Medical Center, 2003
Rynearson, E.K., Correa, F.
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NATIONAL CHILD TRAUMATIC STRESS NETWORK
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CHILDHOOD TRAUMATIC GRIEF
Reference and Resource List
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| Mental health professionals are encouraged to consult the following professional articles and resources to gain an understanding of childhood traumatic grief. Background information sheets about the condition, based on these materials, as well as assistance locating an appropriate mental health professional with expertise in childhood traumatic grief is available from the National Child Traumatic Stress Network (NCTSN) at (310)235-2633 or (919) 687-4686 x302 or at their web site, www.NCTSNet.org. |
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Manuals
(available from the National Child Traumatic Stress Network (NCTSN) at (310)235-2633 or (919) 687-4686 x302 or at their web site, www.NCTSNet.org):
Leiberman et al (preschool treatment manual)
Cohen et al (treatment manual)
Layne et al (treatment manual)
Websites:
National Center for PTSD, Managing Grief after Disaster.
www.ncptsd.org/facts/disasters/fs_grief_disaster.html
National Child Traumatic Stress Network
www.NCTSNet.org
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