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Recovery From Unnatural Death
Edward K. Rynearson, MD
|This is written for someone who has experienced the death of a friend or family member by an unnatural dying-accident, suicide, or homicide. Helpful information is included in a condensed and organized way so you can find what you need quickly. Another reason for brevity is our determination to present accurate information. This is not the place for complex theory or explicit instructions that tell you what you should or should not do. In our view, it would be misleading to promise short-term answers to something so overwhelming. Instead we emphasize that one should not be burdened by the expectation that they will quickly recover. Recovery suggests regaining who you were before the death. You will probably be changed by this event and will spend the rest of your life accommodating to what has happened; unnatural dying of a friend or family member is the sort of life change that will change you.|
The Uniqueness of Unnatural Dying
When someone close dies, it is natural to mourn their loss-to think of them with sorrow and miss their presence in your life. If they died from a natural death (from disease or old age), then the dying would be understandable. One could understand what was going wrong in their body and why they couldn't be saved-and if the natural dying went on for weeks, months, or years, you would have time to adjust to what was happening and could begin to say goodbye.
This is not the case with unnatural dying; when someone close dies an unnatural death, you not only mourn their loss but are forced to adjust to the unnatural way that they died. It is a double blow: not only have they died, but the way they died is senseless. Unnatural dying is abrupt, and traumatic. There is no time for goodbye.
Unnatural dying contains unique dimensions that make it different than natural dying:
Violence-The dying is injurious and often mutilating.
These three V's of unnatural dying (violence, violation and volition) give a different meaning to death. Family members may not quietly and peacefully accept what has happened. Even if they wanted solitude and tranquility, their surrounding community would not allow it. There will be an immediate response for the media and police whenever an unnatural death occurs. This demands a thorough investigation to document how this happened, who was responsible, and punishment that promises redemption. Unfortunately, this social response promises more than it delivers. Family members have no choice-they must cooperate with the media, the police and sometimes the courts.
Obviously this is not fair. It is already "too much" to accept such a dreaded dying. It is hard enough to remain resilient and stable without the media and police questioning-questions that often suggest that the victim was somehow at fault for what happened. Besides, these are questions you would be bound to seek answers for yourself-this is a part of the never-ending search for meaning to the dying.
Early Response To An Unnatural Death
There seems to be at least two distinct reactions to unnatural dying: the first and most primary is traumatic distress to the unnatural dying and a second, underlying response is separation distress to the loss of the relationship. To illustrate the descriptive differences, the distress patterns are listed below.
Thought Reenactment of dying
Behavior Avoidance of reminders of the dying
Reunion with the deceased
Pining and Sorrow
|Trauma distress is the stronger and more immediate response. In the initial days or weeks after an unnatural death, it is common to avoid the reality of the dying-to be enveloped in a numbness that cannot admit to what has happened. This protective numbness is challenged by a reconstruction of the way that the person died. Often, our minds construct events in the form of a story with a beginning, middle, and an end. The story of an unnatural dying, even though it was not witnessed, may become an intense and terrifying reenactment. This reenactment story of the dying often includes the last thoughts, feelings and behaviors of the person who died. Even though you weren't there, your imagination of what your loved one experienced may become a dreaded replay or reenactment. During the initial weeks of adjustment, these reenactment fantasies may occur on a daily basis, and also recur as nightmares at night. These reenactments make it difficult to concentrate because of the accompanying terror that you and other family members are now at risk for an unnatural dying as well. It is the persistence of this traumatic story of the unnatural dying for many months that may distort your view of the world as no longer safe, trustworthy, or caring.
Intertwined with this initial response of trauma distress are waves of separation distress. In most instances, the permanent loss and separation from the relationship is a major disruption. A close friend or family member is an important part of your own identity and in losing them; you lose a part of yourself. It is difficult to begin accepting the finality of this loss until your mind is less preoccupied with the terrible fantasies of the dying. Acceptance of the loss will be delayed until your mind is able to calm and divert itself. Separation distress follows the realization that your friend or family member will never return as a tangible, physical presence. If you have an established religious or spiritual belief system, the permanency of this loss will be softened by the promise of continual spiritual existence and reunion at the time of your own spiritual release with death. But that belief system will only serve to soften the despair, and place it in a more hopeful context. It will not allow the total denial of your loved one's "here and now" absence. Just as the mind composes stories of the trauma of the dying, so it creates stories about separation. With separation distress, the theme of the story is different from traumatic reenactment: most commonly, the theme involves an intense fantasized reunion with the lost person. The image of the deceased becomes a persistent figure in one's mind and there is a strong yearning for their return and a reconstructive fantasy of rescue and repair. The yearning often involves an active "searching"-to places (including the grave site) associated with the deceased and an involuntary visual scanning for their face in a crowd, or an anticipation of hearing their voice when you return home. Your mind is acutely alert for any sign of their presence and the fantasy that once found, you will comfort them and protest that they no longer put you through something so traumatic again!
A minority of individuals will experience little, if any, trauma or separation distress. They respond with a stoicism and grudging acceptance of this tragedy. While stoicism may be followed by a delayed response of grief months or years later, this is a rare occurrence. Long-term study of stoic responders suggests that stoicism is a favorable sign and should not be challenged. Adjusting to an unnatural death does not always mean the acknowledgement and expression of traumatic or separation distress. Not everyone cries or struggles with fantasies. It is best to respect the uniqueness of any response and not expect that others experience what you are experiencing-especially other members of your family.
An even rarer explanation of muted or absence of distress is when the deceased was burdensome, hated, or feared. Under these circumstances, their death may be followed by a sense of relief more than distress. This relief is difficult to share with others and may cause some secondary guilt or shame because, "I am feeling relieved that this person can't make me suffer any more." Under these circumstances, relief is a natural feeling.
There are several factors that are associated with very intense and prolonged responses of trauma and separation distress-distress that will last for many months and will handicap functioning at work or at home:
When Does Distress Become a Disorder?
The difference between distress and disorder has major implications for management. Distress refers to a nonspecific pattern of subjective signs and symptoms of discomfort that last for a short time, have a minor affect on one's functioning, and spontaneously disappear without treatment. The majority of individuals who are coping with an unnatural death match this definition.
A significant minority of individuals who have experienced an unnatural death of a friend or family member will develop a psychiatric disorder within the first year after the death (estimates range from 25% for depression to 40% for anxiety disorders). Unlike distress, a disorder presents with a predictable syndrome of specific and objective signs and symptoms that last for a much longer period of time (months or years), have a major impact on function for which specific treatment has been developed.
The two psychiatric disorders that are commonly associated with complicated or unrecovered grief are major depressive disorders and anxiety disorders. These disorders are defined by the process of self-report interviews and psychiatric examination. There is no objective laboratory or pathologic test that will define a psychiatric disorder. Other sorts of tests define diseases (like diabetes or cancer) where there are measurable, physical changes. Instead, psychiatric disorder is defined by the presence of sufficient signs and symptoms to meet rigorous criteria for the diagnosis. Listed below are the criteria for major depressive disorder and the type of anxiety disorder (posttraumatic stress disorder) most commonly associated with trauma.
Major Depressive Disorder
Five (or more) of the following symptoms have been present during the same two week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure.
The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hypothyroidism).
The symptoms are not better accounted for by bereavement, i.e., after the loss of a loved one, the symptoms persist for longer than 2 months or are characterized by marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation.
Posttraumatic Stress Disorder
The person has been exposed to a traumatic event in which both of the following were present:
The traumatic event is persistently reexperienced in one (or more) of the following ways:
Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma), as indicated by three (or more) of the following:
Persistent symptoms of increased arousal (not present before the trauma), as indicated by two (or more) of the following:
Duration of the disturbance is more than one month.
The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
If you meet criteria for one or both of these disorders, consultation with a mental health professional is strongly advised. Prospective studies of family members during the first year of bereavement show that 25% of subjects will meet criteria for major depressive disorder and 40% will meet criteria for anxiety disorder (and many family members have both major depressive and anxiety disorders at the same time).
There is no definitive treatment for bereavement after an unnatural death. Beware of anyone who claims certainty about what should or should not be done. Respect the uniqueness of your own response and search out the sort of support that meets your own needs. With the sensitive encouragement of family, friends, work associates, and spiritual support, most individuals will spontaneously improve. Their distress will linger for many years (particularly at commemorative times-birthdays, anniversaries, or the specific time of the year when the person died) but these responses of distress will no longer be so intense nor so preoccupying and the memory of the deceased will be more tranquil and positive.
This form of assistance has the clearly defined, short-term goals of restoring one's sense of self-esteem, safety, and confidence of recovery in the future. The essential components for support are a trusting relationship, clear and concise information about the crisis, a nonjudgmental acceptance of responses, and a realistic and reassuring preparation for the future.
Support is inherent in most families, friendships, and social and religious groups who offer support during the early phase of bereavement. For most, a month or two of this intense concern and attention is sufficient, but for those who need longer term support, it is surprising to realize how impatient and intolerant the surrounding support figures can become.
Support groups offer free care. Most major metropolitan areas contain groups of family members and friends who meet to support one another after an unnatural death. These groups offer a particularly relevant resource in that all members have experienced the same form of traumatic loss. Members are able to empathize readily with one another. Leaders and member of the group are especially well informed regarding:
Some individuals remain distressed for several months after the death and are more comfortable in individual counseling. Finding an appropriate individual therapist may be challenging. A minority of therapists have been trained in the management of complicated, unnatural death recovery. A knowledgeable therapist will recognize that trauma distress leads to more dysfunction than separation distress. The presence of recurrent reenactment imagery and feelings of intense fear are strongly associated with the need for treatment. Once treatment begins, it is this trauma distress that takes priority in management. If the individual therapist is unaware of this need, therapy may reach a sudden impasse of heightened frustration, resistance, and termination.
The unnatural death of a family member may have significant impact on the relationships between family members. Since the family system is a primary source of support during recovery, it may be helpful to have one or several family sessions. The objective of these sessions will be supportive-to allow family members to clarify how they are dealing with this tragedy and reinforce the acceptance and respect for individual differences. The entire family will be traumatized by the death. This is not the time to deal with long-standing issues of conflict. An inexperienced family therapist may create the same scenario of heightened frustration, resistance, and termination if they fail to deal directly with the shared traumatic distress.
The use of medications during bereavement challenges some commonly held beliefs:
Recent studies citing the use of medications during the first year or two of bereavement disprove these absolute assumptions. The reader will recall our promise that we would not become imperative in our recommendations: we are not recommending that medications should always be considered with bereavement after an unnatural death. Their use is indicated for a distinct minority (those with diagnosed disorders of depression and anxiety) and are an addition to on-going psychotherapy. Studies have shown that medications will not supersede or replace therapy because they are selective in only relieving depression and anxiety-they have no direct effect on the distress of separation or trauma. This would suggest that the management of complicated grief reactions that did not include supportive therapy or individual therapy would be negligent and incomplete.
Basics About Medications
This is not the place to present detailed information about medicines for sleeping, anxiety, or depression. Those details should await your decision to try medications. The consulting physician can present information about the specific medication at the time it is prescribed. However, there are some basic underlying principles that will reassure you of their use:
Copyright: E.K. Rynearson, M.D. is cofounder and medical director of Separation & Loss Services/Homicide Support at Virginia Mason Medical Center, Seattle Washington. Through his career-long work with family members and friends who have lost a loved one due to unnatural death, he has developed the Restorative Retelling Group approach to treatment. Dr. Rynearson is the author of Retelling Violent Death. He is a member of Gift From Within's Professional Advisory Board. Gift From Within is a nonprofit organization for people with PTSD. GFW has trauma resources for survivors and counselors. Dr. Rynearson is the Director of the Mason Dart Trauma Project headquarted in Seattle, WA. A new program featuring Dr. Rynearson is "Resiliency After Violent Death: Lessons For Caregivers."
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