life after death: grief therapy after the sudden traumatic death of a family member

TOPIC. Survivors of the sudden traumatic death

of a family member are at increased risk for

complicated grief and bereavement.

PURPOSES. To present the complicating factors

inherent to sudden traumatic death in order to

promote adaptive grieving in the survivors.

SOURCES. A comprehensive review of the

existing bereavement literature, clinical

anecdotes, and therapeutic experiences.

CONCLUSIONS. Grief is a process and not an

endpoint. The goal of grief is not to forget about

the loss, a commonly stated goal of survivors;

rather, the goal is to remember the decedent,

understand the changes created by the loss, and

determine how to reinvest in life.

Search terms: Bereavement, grief, sudden

traumatic death

Perspectives in Psychiatric Care Vol. 40, No. 4, October-December, 2004 149

Paul T. Clements, PhD, APRN, BC, DF-IAFN, isAssistant Professor, University of New Mexico, College ofNursing, Albuquerque, NM. Joseph T. DeRanieri, PhD,RN, CPN, BCECR, is Assistant Professor, ThomasJefferson University, Philadelphia, PA. Gloria J. Vigil,LMSW, is Trauma Consultant, Office of the MedicalExaminer, Albuquerque, NM. Kathleen M. Benasutti,MCAT, ATR-BC, LPC, is Trauma Consultant andResearch Coordinator, Treatment Research Institute at theUniversity of Pennsylvania, Philadelphia, PA.

When a family member dies as a result of suddentraumatic death, the immediate shock and chaos that fol-low can lead toward complicated grief and bereavement(DeRanieri, Clements, & Henry, 2002; Doka, 1996). Be-cause death is an issue that creates great discomfort inmany clients and therapists, successful therapeutic inter-vention after sudden traumatic death depends on an un-derstanding of such a devastating event. Additionally, anunderstanding of the complicating factors associated withsudden traumatic death can enhance therapeutic guid-ance and intervention.

Survivors, also known as co-victims (Spungen, 1997),often describe the path of grief as a lonely trek. Evenwhen family and friends are supportive, survivors arepainfully aware that the grieving process is overtlyunique to them. It is not possible to generalize the waythat grief affects individuals. In this same light, there isfrequently discomfort and often an avoidance of dis-cussing the pain and heartache that individual survivorsexperience in the shadow of sudden and traumatic loss.Many surviving family members describe a seeming�don�t ask, don�t tell� attitude toward deaths that are par-ticularly sudden and violent in nature. For example, theacts of homicide and suicide continue to carry negativestereotypes about those who die in this manner (Clements& Burgess, 2002; Clements, DeRanieri, Fay-Hillier, &Henry, 2003; Doka, 1996; Mericle, 1993), whereas car acci-dents and occupational deaths often carry repulsive gorydetails of the last moments of life (Bendersky-Sacks,Clements, & Fay-Hillier, 2001; Marshall & Oleson, 1996),

Life After Death: Grief Therapy After the SuddenTraumatic Death of a Family Member

Paul T. Clements, PhD, APRN, BC, DF-IAFN, Joseph T. DeRanieri, PhD, RN, CPN, BCECR,Gloria J. Vigil, LISW, and Kathleen M. Benasutti, MCAT, ATR-BC, LPC

and now the nation is confronted with violent and calcu-lated deaths related to war and terrorism (Clements,2001; Fillion, Clements, Averill, & Vigil, 2002). Whetherthese attitudes and circumstances exist, the reality for thesurvivor is that a loved one has died a sudden, unex-pected, and often violent death, leaving the survivingfamily members in the turbulent tasks of reassessment ofa new world without the decedent (Attig, 2001). This newworld may affect the survivors psychologically, emotion-ally, physically, socially, and financially.

Case Study

The Rev. Leroy Allan (pseudonym) was the ministerof his church for more than 35 years. In the early after-noon hours of Good Friday, he told his wife he needed togo to the bank. His wife, Maddie, smiled and remindedhim that he needed to be back in time to prepare for thefirst in a special weekend of religious services. Maddiewas overtly concerned at 7 p.m. when she had still notheard from him and the church services were about tostart. Maddie had already called several hospitals and thepolice (who told her that missing person reports could bemade only after 24 hours). So, there they sat: a congrega-tion of church members, wondering what could havehappened to their beloved minister.

Many surviving family members describe a

seeming �don�t ask, don�t tell� attitude

toward deaths that are particularly sudden

and violent in nature.

After 30 minutes of prayer, Maddie awkwardly an-nounced the conclusion of the confused and impromptuGood Friday services, and returned to the parsonage to

150 Perspectives in Psychiatric Care Vol. 40, No. 4, October-December, 2004

find a message on the answering machine from the medi-cal examiner�s office. Her husband had just been pulledfrom the river, having been witnessed, by a family hav-ing a picnic on the bank of the river, to park his car on thebridge and jump to his death. Devastated, Maddie andher three adult children arrived at the medical examiner�soffice during the late hours of that Good Friday to posi-tively identify the body of their beloved husband and fa-ther. �Surely this is some sort of mistake,� was Maddie�sonly comment. In light of suicide being deemed an unfor-givable sin in their religion, Maddie was devastated atthe collision of her beliefs and her love for her now deadhusband.

Grief Therapy

Nurse psychotherapists may encounter survivors suchas Maddie in their practice. It is important to understandthe complicating factors inherent to sudden traumaticdeath in order to promote successful navigation throughthe grief process by educating the survivor about the nor-mal reactions to grief as well as those factors that may re-sult in complicated bereavement.

In our society, it is common for the sorrow that followsdeath to be hidden behind the closed doors of the familyunit or as memories within a person�s own mind. Theworld of grief can be a lonely and secret place, frequentlymisunderstood by those who may not have personallyexperienced the pain of an overwhelming loss. Survivorresponses may vary based on age, cultural and religioustenets, and/or past experience with loss, and may be re-lated to an available repertoire of adaptive coping meth-ods that have worked previously (Clements et al., 2003;DeSpelder & Strickland, 2001; Doka, 1996).

Rando (1993, 1996) stated that complicated grief andmourning occur when the grieving process has hadsome compromise, distortion, or failure in one or moreof the �six Rs of mourning�: recognizing the loss, react-ing to the separation, recollecting and reexperiencing thedeceased and the relationship, relinquishing the old at-tachments of the deceased and the old assumptiveworld, readjustment to move into the new world with-

Life After Death: Grief Therapy After the Sudden Traumatic Death of a Family Member

out forgetting the old, and reinvestment into the currentworld and life.

Sudden Traumatic Death

All deaths are assigned to one of five medicolegal cate-gories: homicide, suicide, accident, natural, and undeter-mined (DiMaio & DiMaio, 1993). A review of the be-reavement literature reports that those deaths involvingsuddenness, interpersonal violence, trauma, suicide, and,most significantly, an act of �human design� (Clements &Burgess, 2002; Doka, 1996) are more likely to create exag-gerated, and potentially complicated, grief responses.These deaths are perceived as �untimely� and �unfair,�often intensifying the feelings of disbelief, shock, andanger (DeRanieri et al., 2002).

While for the victim pain and suffering end with death,for the loved ones left behind they are just beginning(Clements, Benasutti, & Henry, 2001; Clements & Weisser,2003). These surviving family, friends, and co-workers canbe referred to as �co-victims� (Spungen, 1997), as many ofthem express feeling victimized as a result of the traumaticevents that led to the sudden death. Without the ability ortime to prepare mentally and emotionally, the survivor canbe overwhelmed by an emotional wave following a sud-den traumatic death (Clements & Henry, 2001; Clements,DeRanieri, et al., 2003).

In the beginning, shock and numbness are typical re-sponses. Accomplishing the unanticipated encroachingnecessities of notifying friends and family, preparing forthe funeral and burial, and attending to myriad tasksbrought about by the loss are of utmost importance andoften result in utmost chaos. Sudden traumatic death fre-quently brings dramatic change to a family system, trig-gering an unexpected need for evaluation and recalibra-tion of roles and structure (Clements et al., 2003). Suddenand traumatic death allows no anticipation or prepara-tion for the loss, which often results in impulsive and dis-organized attempts to regain homeostasis for both the in-dividual and the family system (Clements & Burgess,2002).

Survivors typically present for therapeutic interven-


tion when the complications of bereavement derail theability of the family to function or to reequilibrate withinthe parameters of the �new� and �altered� family sys-tem�that is, a system without the presence of the dece-dent. This reinforces the importance of therapists ac-knowledging that the experts on grief are truly thesurviving family members who are seeking the expertiseof the therapist to guide them on their unique and painfuljourney (Clements et al., 2003). Survivors are often over-whelmed by both emotions and practical matters. It isoften very helpful to provide concrete educational infor-mation about the grieving process, along with supportand genuine appreciation of their loss. The educationalinformation can help validate what they are experiencingand help quell the anxiety related to the frequently askedquestion, �Is it normal to be feeling this way?� Becauseconcentration and comprehension may be impaired atthis stressful time, it is helpful to provide educational ma-terial, both verbally and in writing. This allows the sur-vivors to refer to the information as needed.

As shock, numbness, and disbelief or overt denial aretypical reactions to sudden traumatic death, a helpful firststep is to encourage the survivor to talk about the loss.Such expression can promote validation that the loss hasoccurred and can facilitate reinvesting in life. Emphasizethat telling the story, not only to the therapist but also toother family members and friends, can facilitate this pro-cess. Remind survivors that as they find themselves con-fronted with the realities of the loss, it is possible for griefto affect them mentally, emotionally, physically, and spir-itually. It is normal for grief responses to vary amongfamily members, even as they grieve together as a unit.Grief responses are not �wrong� or �bad�; instead, cul-turally sensitive assessment can prevent unnecessary con-cern or conflict among family members already burdenedwith such great emotions (Clements et al., 2003). For ex-ample, all men do not need to cry to be considered effec-tively grieving, yet many people believe that not cryingduring the grief process is unacceptable behavior. Just be-cause some people simply do not allow themselves to cryin the presence of others does not mean they are grievingimproperly.


Survivors often experience affective disturbances. Twopresentations that are typically observed in emotionaland behavioral responses are internalization and exter-nalization of exaggerated or volatile feeling states(Clements & Burgess, 2002; Clements, DeRanieri, et al.,2003). An internalized response by the survivor may beexhibited in depression, avoidance, or withdrawal. Onthe other hand, an externalized response may consist ofanger, outbursts, or labile mood (DeRanieri et al., 2002).The nurse psychotherapist must be prepared to toleratethese response patterns, which may vary from silence tohostile outbursts. As a clinician, it is important to remem-ber not to personalize these responses.

One myth often encountered by surviving

family members is that there is an

established timetable for grief.

One myth often encountered by surviving familymembers is that there is an established timetable for grief.Although not always clear what this timetable actuallyshould be, many family members will report being con-founded with �why am I not over this yet?� Grief-relatedsymptoms are typical for at least the first year, especiallyas the date for the 1-year anniversary of the death nears.Contrary to the common belief that at 1 year survivorsshould be feeling better, it is actually more likely thatmost people feel worse as the 1-year anniversary ap-proaches because they are reminded of the event thatcaused the loss of their loved one (Clements & Henry,2001, 2002; DeRanieri et al., 2002). Grief symptoms maycontinue into the second year and still be considered nor-mal. However, at any point in the grief continuum,where grief-related symptoms are extreme to the point ofdisruption of activities of daily living or medical or men-tal health, intervention may be required. Finally, the use

of drugs, alcohol, and violence are not a normal part ofthe grieving process, and anyone displaying such behav-ior should be referred immediately for additional assess-ment and possible intervention (Clements & Henry, 2001,2002; DeRanieri et al., 2002).

Remind survivors that others cannot define the loss forthem. Only they can determine what the loss means tothem. Even when friends, family, or colleagues have ex-perienced a similar loss, this does not mean that the lossand the impact of the loss are the same. In this light, mostsurvivors find themselves repeating the story of their lossover and over again. During this repetition, the explo-ration and identification of what the loss really means tothe survivor can begin.

Strategies for Therapeutic Goal-Setting

Goal-setting should be a concrete and reassuringmethod of stress reduction during the chaotic aftermathof sudden traumatic death. Goal-setting provides direc-tion with tasks on which to focus and accomplish,thereby providing an underlying message of future ori-entation as well as some sense of control over an other-wise seemingly out-of-control life.

Bearing in mind that the surviving family membersare the experts on their own grief, it is the role of thenurse psychotherapist to use expertise in guiding clientsalong the continuum of adaptive coping and functionalgrief (Clements et al., 2003). Begin by asking the client toidentify some important goals for emotional and func-tional stabilization. Identification and commitment tosmall short-term goals can provide a sense of accomplish-ment, a sense of control, and a sense of �getting better.� Itis critical to validate that any �grief work� toward accom-plishment of these goals will most likely be painful andthat this pain may manifest itself in many different ways.Many families fear the reality that the only way to get tothe �other side� of grief is to �go all the way in and all theway through� (Clements & Henry, 2001). During thisearly phase of the grief process, it is important to mournthe loss by allowing a full range of emotions while avoid-ing the minimization of what the loss means in an at-



lives, and decision making is easier. Psychosocial reinte-gration may be described as feeling more at ease beingaround people.

As the inner pain begins to decrease, survivors typi-cally begin to feel increasingly comfortable talking aboutthe loss. There may be a visible return of a sense of humor.Survivors may report that decision making now occurswithout feeling the need to second-guess themselves.

Conclusion

Even as survivors progress through the grieving pro-cess, there are going to be times when they feel the acutepain of the loss. This only means that instead of experi-encing acute grief for days, weeks, or months, the painwill be fleeting moments.

Grief is a process and not an endpoint.

Inner healing occurs over time. Survivors may recognizethat they have completed the process when they find them-selves reinvesting in life. Survivors should not be alarmedor surprised to find themselves saddened during the holi-days and special occasions, or as they near the anniversarydate of the loss. These are typical times for thoughts to bedrawn to the loss. As healing progresses, the sadness willdecrease (but may never completely go away).

One final and significant tenet for therapists to bemindful of is that the goal of good grieving is not to for-get the loss, but to put the loss into perspective in one�sown particular life history while reinvesting or seekingout what is enjoyable in life (Clements & Henry, 2001).One must remember the decedent, understand thechanges created by the loss, and determine how to rein-vest in life. Grief is a process, not an endpoint.

Author contact: [email protected], with a copy to theEditor: [email protected]

tempt to please others. Although tears are not necessaryfor functional grieving, crying should be validated as atypical and acceptable form of expression.

Many survivors will become deeply introspective anddevolve into a state of loneliness. Survivors can experi-ence problematic beliefs of uncertainty, inadequacy, per-ceiving the world as dangerous, and feeling an overt lackof control (Vigil & Clements, 2003). Although introspec-tion and assessment are normal facets of grief, survivorsshould be reminded to accept, rather than avoid, the sup-port of those who care. Teaching survivors to be proac-tive can maximize the acceptance of the help of familyand friends who may want to help but who may be un-sure of what to do. Encourage survivors to share whatthey need with their supporters and how they can help.The pain and emotion that accompanies loss and griefcan be mitigated when emotional support is readily avail-able and utilized. At the same time, many well-wishersmay recommend major changes or decisions as a methodof coping or �getting over it.� Educate survivors thatmajor decisions should be made only after significantevaluation because the highly charged emotional situa-tion can cloud judgment, and decisions made under theseconditions can result in negative, long-term implications.

Evaluation

Grief is a process and not an endpoint. This sometimesmystifying goal of an endpoint contributes toward signif-icant confusion for many survivors. The goal of grief isneither to forget about nor to �get over� the loss, a com-monly stated goal of survivors. Rather, the goal of grief isto remember the decedent, understand the changes cre-ated by the loss, and determine how to reinvest in life.There are many ways to identify progress in functionalgrieving. Survivors may display an ability to talk aboutthe loss without feeling overwhelmed or bursting intotears. Energy levels improve and participation in variousactivities (including work, school, or social activities) in-creases. Sleep and dietary pattern disruption, commonsymptoms among survivors, begin to normalize. Sur-vivors begin to describe a sense of reorganization in their


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life after death: grief therapy after the sudden traumatic death of a family member

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