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Sudden bereavement:responses and care after a month

It may be that after a month the responses being displayed by someone suddenly bereaved are 'normal' grief responses common following any kind of death including expected deaths, and which don't require any sort of specialist care to aid recovery.

For example, feelings of sadness, feelings of desperation at the death, pangs of grief, yearning for the person who died, and crying. The suddenly bereaved person might seek out places, or do things, that remind them of the person who died. They may feel irritable, or suffer insomnia, or have other responses that are unpleasant, but also accept help, do not feel demoralised about the future of themselves or others they love. They accept the death, and can move forward with their life while still feeling sad at times.

However, it is not uncommon, or unusual, to suffer more than this following a sudden death, and to suffer from traumatic grief, or post-traumatic stress, or both. This guidance provides information on traumatic grief and post traumatic stress, and appropriate care. 

Traumatic grief

Traumatic grief is the bereavement profession's way of defining grief thoughts and reactions that are more traumatic, and consequently challenging, than those generally suffered after a bereavement, and which last longer than two months. A sudden bereavement is more likely to result in traumatic grief reactions than an expected bereavement.

Medical professionals give examples of challenging thoughts and reactions typically suffered. These can vary between individuals in terms of type and intensity, but may include:

  • Excessive irritability
  • Anger and bitterness, sometimes in sudden bouts
  • Continued insomnia and nightmares
  • Feeling of unfairness at the death or issues around the death
  • Strong feelings of personal responsibility for the death, and/or unfinished business with the person who has died
  • A sense that the world as they understood it has been shattered
  • Intrusive thoughts about the bereavement, that happen suddenly, when trying to get on with other things
  • Difficulty socialising and avoidance of social situations
  • Difficulty functioning; difficulty doing daily tasks such as finding it hard to cope with stressful moments at work or stresses when caring for children
  • Feelings of futility about the future: what is the point of it all? Disinterest in planning for the future
  • These reactions and behaviours lasting more than two months after the bereavement

People suffering from traumatic grief are likely to have a strong desire to be reunited with the person who died, and a difficulty accepting the death. They are likely to have intrusive thoughts that revolve around thinking about the person who died all the time, and seeing the person who died everywhere they look.

They may also have depressive or suicidal thoughts. They may also suffer phobias and fears associated with the bereavement, such as not wishing to travel by car if bereaved by a car crash.

People with traumatic grief may also develop addictions, such as a tendency to turn to alcohol, cigarettes or drugs (legal or illegal). They may suffer weight loss or weight gain. They may have on-going physical reactions such as pains, illness, or manifestations of stress such as stuttering.

Sometimes, traumatic grief symptoms are referred to as complicated, or prolonged, grief symptoms.

Post-traumatic stress or Post-traumatic stress disorder (PTSD)  

PTS or PTSD is a medically-defined condition applied to people who are suffering challenging thoughts and reactions following a stressful event. Anyone bereaved suddenly is recommended to be assessed for PTSD because a sudden bereavement is definitely a stressful event [1].

Medical professionals give examples of thoughts and reactions typically suffered. These thoughts and reactions generally start within a month of the stressful event, and it is thought that in about a third of cases are still being suffered more than a year later if appropriate care is not provided.

Many of the thoughts and reactions typical of PTSD are the same as those given to explain what it is like to suffer traumatic grief. It is possible for a suddenly bereaved person to be defined as suffering from traumatic grief and PTSD.People diagnosed as suffering from PTSD are defined as firstly having suffered a traumatic event, which can include a sudden death of a loved one. The bereaved person has recurring thoughts about the horror of that event. This often manifests through vivid flashbacks, when it feels as though the event or events surrounding it are happening again, traumatic nightmares, and intense distress when reminded of the event.

Exaggerated startle responses in response to perceived threats, such as loud noises, are common.

People suffering PTSD often suffer fears that similar events might happen, or even a belief or omen that they will happen. This sense may be reinforced if the person has had more than one traumatic event happen to them in their life.

There is avoidance of things associated with the event and reminders of the event arouse intense distress and a sense of detachment and unreality. For example, someone bereaved by a road crash and suffering PTSD symptoms may find it very hard to be near roads or in cars. These people have a loss of a sense of safety and feel particularly powerless and isolated, but also may display self-destructive or reckless behaviour.

Usually these reactions and behaviours start within a month of the traumatic event.[2]

Finding out if someone is suffering from traumatic grief or PTSD

Even now, there is still some ignorance about traumatic grief and PTSD. Some medical professionals, such as some family doctors, may have limited understanding of the possible thoughts and reactions of, and appropriate help for, suddenly bereaved people who may be suffering from traumatic grief or PTSD. Some friends and family members of suddenly bereaved people may have limited understanding of what they are going through; even if they have suffered a sudden bereavement themselves their thoughts and reactions may have been different, or lasted a different amount of time, or occurred at a different time. The easiest way to combat this lack of awareness is to ask others to read this website or other reliable sources of information about traumatic grief and PTSD.

Diagnosis for traumatic grief or PTSD is usually carried out using a questionnaire, based on accepted diagnostic criteria for traumatic grief or PTSD, as defined by respected organisations such as the American Psychiatric Association or the British Psychological Society. The USA diagnostic criteria is published in its Diagnostic and Statistical Manual of Mental Disorders (DSM-5), and in the UK, guidance on PTSD is given by the National Collaborating Centre for Mental Health and commissioned by the National Institute for Clinical Excellence. These criteria and guidance are subject to change over time as research into traumatic grief and PTSD develops.

To consider if someone would benefit from PTSD assessment, find out if they answer 'yes' to a combination of, or all, of the following questions:

1. Do you have very distressing thoughts or flashbacks about the traumatic event when you don't want to, or have nightmares about it?

2. Do you avoid situations that remind you of it?

3. Are you easily startled and feel as though there are threats around you?

4. Do you feel detached from other people or activities?

5. Is it more than a month since the event?

If they answered 'no' to the above questions, they may still be suffering traumatic grief, particularly if they answer 'yes' to the below questions:

1. Do you have intrusive and frequent thoughts about the death of your loved one, when you are trying to think about other things?

2. Is it more than two months after the death and you are still finding it very hard to accept the death has happened and consider the future positively?

Talking to a suddenly bereaved person about traumatic grief or PTSD and tailoring their treatment

Defining the responses suffered by suddenly bereaved people as traumatic grief or PTSD can be useful as it can aid understanding of the gravity of their needs and help them to access help from medical practitioners and other carers in the community such as bereavement workers. It can also, at a more strategic level, help decision makers such as politicians and health care leaders assign resources to help suddenly bereaved people. 

However, it is also important to keep emphasising that the underlying cause of the traumatic grief or PTSD is the sudden bereavement, and that traumatic grief and PTSD are common following sudden bereavement. It is not a sign of weakness, or unusual, that the bereaved person is suffering these definable responses. The bereaved person should accept appropriate support for their responses. 

It is essential that treatment delivered to the suddenly bereaved person for their traumatic grief or PTSD responses addresses the sudden bereavement centrally, recognising that this is the cause of the responses.

It is also essential that treatment is devised and delivered that is appropriate for the suddenly bereaved person's situation. It is not uncommon for suddenly bereaved people to be suffering other life challenges that make it harder for them to recover from thoughts and reactions resulting from their grief, traumatic grief and / or PTSD. Some of these challenges may pre-date their bereavement, but others may be a consequence of the trauma caused by their bereavement. Some of these challenges may be appropriate to deal with first, before providing care for identified traumatic grief or PTSD, for example alcoholism. However, other challenges, such as some marriage difficulties, may be made easier to deal with by providing care for traumatic grief or PTSD first.

Consideration should be given to: 

• the responses being displayed in the past and now and the amount they occur and therefore the amount of disruption they cause to normal happy living 
 
•  any previous traumatic events that have happened to the person in their life that may also need addressing and that may be worsening or helping the person's reactions. A previous traumatic event may not have been recovered from, and may reinforce for someone that "terrible things happen to me and will happen again". Or conversely, someone may have recovered from a previous traumatic event and learned from that experience that recovery is fully possible and recovery can happen again.   

• the stability of this person's personal situation; for example, their support network of friends and family, their financial stability, any problems being faced at work, and whether they have a home. Some factors may be apparent, and others may be hidden, such as relationship difficulties or domestic abuse

• the responsibilities of this person; for example their work situation, or whether they are having to care for dependents such as children,  elderly people, or a disabled person

• any other major issues in the person's life that impacts upon them; for example, chronic physical or mental illness, or addictions. 

Sometimes suddenly bereaved people have medical conditions that also make it harder to recover from their grief, traumatic grief and / or PTSD. These conditions may pre-date your bereavement or be associated with the bereavement. Physical illnesses that are permanent and pre-date the bereavement, such as asthma, heart conditions, epilepsy or diabetes, mean there are existing pressures on the suddenly bereaved person in addition to suffering traumatic grief and/or PTSD. Sufferers of clinical depression may be taking medication or suffering suicidal thoughts or both, again adding to the challenges faced in addition to the effects of the bereavement.

Examples of medically-defined conditions include:

  • Clinical depression, often treated with anti-depressants
  • Injuries, sometimes caused in the same event (such as a road crash) that caused the death
  • Existing permanent illnesses, such as heart conditions, epilepsy or diabetes
  • Alcohol or drug addiction 

Achieving this full understanding of a person's situation will enable carers to devise support that is tailored to the individual and therefore more likely to be of benefit. In some cases, it may be necessary to address other challenges in a person's life, such as drug addiction, before traumatic grief or PTSD can be treated effectively. 

Care for people suffering traumatic grief and/or post-traumatic stress disorder 

It is current best practice to treat traumatic grief and / or PTSD with therapy (sometimes called counselling) using cognitive behavioural techniques specifically tailored to the individual's needs. This means talking through things with a therapist (sometimes called a counsellor) in a number of one-to-one sessions (usually between 10 and 25, and usually lasting about an hour each). In these sessions it is usually the case that the suddenly bereaved person will:

1 Address the event and try to come to terms with what is known to have happened. This can be achieved through talk, writing, visiting the scene, or other methods.

2 Talk about any painfully-upsetting aspect of the event that is presumed (imagined) and therefore may not be true, to enable these thoughts to be corrected and stopped [3]

3 Talk about any unfinished business with the person who has died. For example, any feelings of guilt or lost plans

4 Talk about the future and find a way to think positively about it

The therapist assigned will need to be qualified and experienced in providing this therapy. Ask them how many times they have worked with people suddenly bereaved, and the success of their work. It is also important for the suddenly bereaved person to feel they have a trusting and positive relationship with their therapist. If they don't like their therapist, it may be possible to change, and suddenly bereaved people should be encouraged to keep trying therapy with a different therapist, and not be "put off" by an unsuccessful first attempt. 

It may or may not be possible to get this therapy for free, depending on the health care systems in your country. There may be local charities or other services that can help you access this therapy, or provide other relevant support that acknowledges traumatic grief and / or PTSD.

Drugs

Medical professionals who are not familiar with PTSD or traumatic grief may offer drugs, particularly anti-depressants, sleeping tablets, or anti-anxiety drugs. Generally, while drugs may offer some immediate relief from some symptoms, this is not believed at present to be the best first route of care[1]. It can be harder to consider and address grief and trauma responses while taking medication.

Copyright: Brake 2013

[1] Post-traumatic stress disorder The management of PTSD in adults and children in primary and secondary care, 2005, 2.3.5.1 National Collaborating Centre for Mental Health, commissioned by the National Institute for Clinical Excellence, pub British Psychological Society

[2] American Psychiatric Association (2013) Diagnostic and statistical manual of mental disorders (5th ed) Washington DC

[3] Treatment of complicated grief, Rita Rosner, Gabriele Pfoh, and Michaela Kotouová, Department of Psychology, Ludwig-Maximilians-Universitaet, Munich, Germany, 2011

Copyright: Brake 2013

 

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