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This article focuses on conceptual issues and empirical studies regarding the topic of traumatic loss (i.e., loss that occurs suddenly and under violent circumstances) as a method for linking the field of trauma, and that of grief and bereavement. Several definitions of trauma are presented that include the concept of loss, and additional concepts are suggested that may be helpful in thinking about the two areas together. Also, modes of death associated with poor recovery are noted, and it is argued that these modes are those that make a bereavement more "traumatic." Some empirical studies on the psychological outcomes associated with traumatic loss are reviewed, and preliminary findings from a new study of traumatically bereaved women are briefly presented.
Generally speaking, the clinical and research fields of psychological trauma
and of grief and bereavement have proceeded independently, with few links between
those who study these issues or in the design of research studies. While this
has begun to change in recent years, the overlap remains small. Yet, there
are important conceptual and clinical reasons to encourage more links between
these two areas. The purpose of this article is to draw attention to the overlap
between the two fields. This is done by focusing on traumatic loss, loss in
which the mode of death is sudden, violent, or unexpected. This specific topic
would seem to have the most potential for bridging the two areas and to be
of high interest to both fields. Conceptual/definitional issues are covered
first. Next, aspects of the nature of the death associated with poor recovery
are noted, and it is argued that these characteristics are those that make
a bereavement more "traumatic." Empirical studies of traumatic loss
are reviewed, focusing on posttraumatic stress disorder (PTSD) symptoms when
possible. Some preliminary findings from a new study of traumatically bereaved
women are briefly presented.
Hobfoll (1991) has proposed conservation of resources (COR) theory as a means of understanding how individuals deal with stressful situations. In the context of his work, he describes the motivational tenet that individuals strive to obtain, retain, and protect that which they value. Stress occurs when resources are threatened, when they are lost, or when there is an inadequate increase in resources following investment of resources. COR theory proposes that trauma, relative to stress, is a situation of rapid resource loss, especially of those resources most highly valued by individuals. Traumatic stressors attack people's most basic values, occur unexpectedly, make excessive demands, and are outside of the usual realm for which coping strategies have been developed. This conceptualization clearly includes the concept of loss and, in fact, is based on that concept.
In a recent article proposing a cognitive conceptualization of PTSD, Brewin, Dalgleish, and Joseph (1996) defined trauma as follows:
Trauma generally involves a violation of basic assumptions connected with
survival as a member of a social group. These include assumptions (not necessarily
conscious) about personal invulnerability from death or disease, status in
a social hierarchy, the ability to meet internal moral standards and achieve
major life goals, the continued availability and reliability of attachment
figures, and the existence of an orderly relation between actions and outcomes.
In 1993, I proposed eight generic dimensions of traumatic events (Green, 1993), one of which delineated the violent and sudden loss of a loved one. This conceptualization was in keeping with the Diagnostic and Statistical Manual of Mental Disorders (DSM) American Psychiatric Association, 1987, 1994) and focused on traumatic or violent circumstances surrounding the death. At the same time, however, I noted that an important underlying theme in the conceptualization of trauma in general, not just bereavement, was that of death. Lifton (1988) referred to the "death imprint" as an important aspect of the (trauma) survivor syndrome. He defined the death imprint as the "radical intrusion of an image or feeling of threat, or end, to life" (p. 18), which has a high degree of unacceptability of death in the image--of prematurity, of grotesqueness, or of absurdity. This imprint makes it impossible for the survivor to deny the reality of death and brings him or her face to face with feelings of personal vulnerability and consequent anxiety. This definition, applied to traumatic loss, suggests that the survivor may face an existential encounter that is conceptually distinct from the loss itself. This may be true even in an "expected" death, again suggesting similarities between the two experiences.
Several authors have addressed the similarities or differences in outcomes that might be associated with trauma versus loss, or how these might interact in the recovery process. As noted earlier, Horowitz (1986) organized symptomatic responses to traumatic events, including bereavement, into two categories, those associated with intrusions of the event into consciousness and those associated with attempts to avoid or deny the experience. The intrusion experiences include hypervigilance, startle reaction, flashbacks, intrusive thoughts, and searching for the lost person. The denial symptoms include amnesia, inability to visualize memories, disavowal of meaning, numbness, and withdrawal. More recently, arousal has been conceptualized as a third symptom cluster in the DSM (1994), and new versions of the Impact of Event Scale are composed of the three types of symptoms (Weiss & Marmar, 1997). These signs and symptoms are seen as common to both traumatic stress and loss.
Raphael, in contrast, has emphasized the differences in symptomatology between responses to trauma and responses to bereavement (e.g., Raphael, 1997). She suggests that while the types of symptoms may be similar, their content is different, and aspects of the reaction may be diametrically opposed. In a recent paper, Raphael and Martinek (1997) compared and contrasted posttraumatic reactions and bereavement reactions. These authors suggested that intrusions, preoccupations, and memories differ in the two types of events on the basis of content: In trauma the content is the scene of the trauma, whereas in loss the intrusions are of the lost person. In trauma, anxiety is related to the threat experienced and to reminders; in loss, the anxiety is specifically separation anxiety with regard to the lost person. They argue that yearning and sadness are present in bereavement but usually absent following trauma. In terms of avoidance symptoms, these authors see trauma survivors as more often avoidant of affect and reminders of the trauma and as withdrawing from others, while bereaved individuals may seek out reminders, as well as others, for support and often want to talk about the deceased. Arousal is seen to be present in both conditions but oriented differently. Raphael and Martinek point out that they are hypothesizing these differences and that much more research is needed before this typology can be empirically supported. They also note that, in traumatic bereavement circumstances, the survivor would be expected to experience both types of reactions together, or alternately. Therefore, certain types of bereavement would bridge their hypothesized gap.
Pynoos and Nader (1988) examined reactions to trauma and bereavement separately within the same study of children who had been exposed to a traumatic event: a sniper attack at school. They found that the severity of the exposure to the life-threatening aspects of the event was more highly associated with PTSD symptoms. Conversely, the closeness of the child to the children killed was a better predictor of grief.
The interplay between symptoms that may be more clearly linked to the traumatic than to the loss aspects of an event may have clinical as well as conceptual/theoretical implications. A few authors have specifically recommended that, therapeutically, the trauma must be dealt with first, before the grief is able to be experienced (Lindy, Green, Grace, & Titchener, 1983; Pynoos & Nader, 1988). These authors indicate that the intrusive images and the fears of death and dying associated with the traumatic nature of the death, or of the scene of the trauma, interfere with the grieving process and must be addressed before the grief itself can be accessed. Other authors, without suggesting a specific order, have noted that the two must be separately addressed for the person to recover and that one may mask the other (van der Hart, Brown, & Turco, 1990). These types of comparisons, of course, depend to a great extent on our definitions of these constructs and how we operationalize them. Their uniqueness and overlap will depend, in part, on these definitions.
I would like to suggest a few concepts that may be useful in thinking about similarities between trauma and bereavement. The first is disorganization or disruption. Both loss and life threat have the capacity to produce significant disruption in the continuity of day-to-day existence. This disruption may occur in a number of domains, including one's daily routine and orderly functioning, in one's beliefs and assumptions about how the world "is," and in one's capacity to cope or to access social and other types of resources. If one suffers a loss, both day-to-day routine and coping resources may be interrupted through the loss (Stroebe, 1997). Beliefs and assumptions may be disrupted as well. If the loss is more "natural," schemas about the world involving trust, safety, and so forth may not be interrupted. However, especially if the loss is sudden or violent, or another type of trauma such as a rape or assault occurs, the disruption of beliefs may be more profound (Janoff-Bulman, 1992).
The second, and related, concept is attachment and the protection that it provides. Bowlby (e.g., 1982) has suggested that the biological function of attachment is protection. This is most obvious in early development when a young child literally needs to be fed and cared for. But as he also points out, to have access to a familiar individual known to be ready and willing to come to one's aid is clearly an important asset, regardless of one's age. While the concept of attachment is an easy "fit" to the area of bereavement and loss and is often applied to it (e.g., Middleton, Raphael, Martinek, & Misso, 1993), it is a bit more subtle with regard to its applicability to trauma and life threat. However, focusing on the notion of protection, it seems clear that trauma often disrupts one's sense of being protected, and even the possibility of protection, perhaps forever. One of the sequelae of a traumatic encounter, as pointed out by a number of authors, especially Janoff-Bulman (1992), is that it is not possible to view the world in the same way after such an event. Since we tend to feel that we are somehow protected from terrible events and that they will not happen to us, experiencing these events shatters our assumptions about this invulnerability and makes it clear that we were not--and cannot be--protected from such events. This may affect our view of the attachment figures in our life, since we may understand, in a more fundamental way than before, that they cannot protect us. So trauma may disrupt our attachments. Furthermore, some of the symptoms of PTSD, such as numbing, loss of interest and pleasure, and alienation, may interfere with our attachments and distance us from the social resources that might help us cope.
A third concept is that of annihilation. A number of trauma theorists refer to the threat of annihilation as a central aspect of trauma, and life threat is the threat of annihilation, or loss of one's self. Annihilation, along with the fear and terror that accompany it, clearly applies to traumatic exposure. However, the literal loss of self with which trauma may confront us may have a parallel in the psychological loss of self that may be associated with bereavement for some individuals. In cases of violent bereavement, such as homicide, there may be basic safety and survival issues (e.g., if a murderer is still at large) that would complicate the situation further. However, even with a more "normal" bereavement, the individual may have to confront fears that he or she cannot go on without the other person, cannot care for himself or herself, or cannot form another bond in the future that would share psychological components with the fear of annihilation associated with trauma.
The fourth concept has to do with helplessness and loss of control. Both life
threat and loss through death may result in potential feelings of helplessness
and loss of control, or feelings of being out of control and not being able
to influence the course of events. There are undoubtedly other concepts that
link the experiences of trauma and bereavement and reactions to them. Furthermore,
there are likely differences that will distinguish the two, such as the direct
assault to the life and body that constitutes a trauma, as compared with the
more indirect experience of losing a person to whom one is psychologically
Grief and Bereavement: What Psychiatrists Need to Know
- Zisook, S. and Shear, K. Grief and Bereavement: What Psychiatrists Need to Know. World Psychiatry, 209, 8. p 67-74.
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