Interview:

Grief After Traumatic Loss

Roxane Cohen Silver, Ph.D., is professor of psychology and social behavior at the University of California, Irvine. Dr. Silver studies how individuals cope with stressful life experiences, such as loss of a spouse or child, divorce, childhood sexual abuse, physical disability, war and natural disaster. In this work, Dr. Silver seeks to examine cognitive, emotional, social and physical responses to stressful life events, and to identify factors that facilitate successful adjustment to them. Her research also explores the long-term effects of traumatic life experiences and considers how beliefs and expectations of one's social network impact on the coping process.

Q. Can you define the distinctions among bereavement, grief and mourning?

A. It is difficult to draw firm distinctions among these terms, particularly when grief and mourning are used interchangeably. Nevertheless, bereavement is the term typically used for the state of having experienced a significant loss of any kind. The usual response to bereavement is called grief, which can include emotional, cognitive and physical reactions following the death of a loved one. Mourning, as distinguished from grief, can be defined as the social expression of grief shaped by a society or culture.

Q. What are some of the psychological consequences we might expect as a result of September 11, 2001?

A. We might expect grief responses would only occur among people who experienced a direct loss either through death or injury as a result of the terrorist attacks. However, even if we did not know anyone who died that day, we have all been touched - at least indirectly - by their deaths. In fact, the psychological consequences don't come merely from the loss of life and the physical damage and destruction of buildings. Distress can also result from the disruption of life, from alterations in our daily routines and from alterations in our views of the world as a result of this disaster. The attacks of 9/11 have interrupted the rhythm, cycles and entire social fabric of our country. The consequences could last months, years and, for some people, the rest of their lives.

Q. What symptoms of grief may be evident?

A. Shock or emotional numbness may have been initial reactions on first learning about the attacks, together with a sense of unreality. Over time, other symptoms can emerge, including depression, anger, guilt and helplessness. Fatigue, crying and social withdrawal may also be present.

Sleep disturbances, loss of appetite, gastrointestinal upset or chest pains are other common physical symptoms. Yet we're now understanding that a wide range of behaviors is encompassed by "normal grief." In fact, data collected over the past 15 years does not conform to assumptions about a universal pattern of grieving.

Q. You have done extensive research on the myths of coping with loss. What are the common misconceptions about grief?

A. There is a mistaken assumption that grief is characterized by extreme distress shortly after loss and that the grieving individual can work through the distress and return to a pre-loss state in a relatively short time, say, six months to a year.

However, rigorous research for over a decade reveals a variety of ways in which people respond to bereavement. Some individuals appear not to respond with much distress following a loss, and many can experience positive emotions, often triggered by positive social contacts. Other individuals respond with more severe distress for a lot longer than would be judged normal under the circumstances.

Q. What unique factors might intensify grieving following September 11?

A. Loss of life perceived as unfair. The type of losses that occurred on 9/11 challenge our view of the world most strongly. We find that losses that seem particularly unjust, such as the death of a child or the death of an innocent victim in a car crash when the drunk driver walks away unscathed, can be among the most difficult to cope with.

Even in unfair or unexpected loss, however, some people respond with intense distress; others do not. However, there is a greater element of enduring, or complicated, grief (see sidebar, page 3) associated with particularly unjust losses.

Q. What helps people cope with loss?

A. A strong, solid support system is key. Close family ties or membership in a religious organization can provide such support, as can clearly defined rituals for grieving such as exist in many cultures. Giving people as much opportunity as they need to talk through their feelings is also important. When one's social network doesn't support listening, or when a grieving person is told to "pull yourself together," he or she is given the feeling that the reaction is abnormal. This appears to increase distress over time.

Q. How well are Americans communicating with each other regarding the September 11 attacks?

A. There appear to be some barriers preventing more open communication about the events of 9/11. Initial findings from a major study our team is conducting show that a number of respondents are reluctant to initiate conversations about the attacks. They sometimes get the feeling that others don't want to hear about their feelings or their worries about the future.

Q. Does religious belief make grieving less difficult?

A. There is evidence that some people experience loss and come through the grieving process relatively unscathed. We suspect that their philosophical or religious world view enables them to incorporate loss more easily. Religion can assist some people in making sense of death. It can also provide a religious community that is available to offer social support.

Q. What unique challenges to the nation's psychological health are presented by the events of September 11?

A. Studies of the psychological repercussions of 9/11 are only just emerging. We will know more about the challenges and how to address them in the next six to eight months. The scale of the distress is challenging. In New York City, 26 percent of people in our random sample were experiencing symptoms of post-traumatic stress disorder two months after the attacks. Outside New York City, over 17 percent of our national random sample of almost 1,000 people were experiencing these symptoms at Thanksgiving.

The vast majority of these people had not directly suffered loss as a result of the attacks. Highlighting myths and providing education about what is normal grieving will be useful now, for the general public as well as professionals.

Q. What else can professionals and communities do to address grief following the attacks?

A. I think it's important to keep challenging our assumptions. We shouldn't expect a set time for working through grief. We shouldn't label prolonged grief or indeed the absence of distress as pathological. We shouldn't assume that only those who suffered direct loss will be deeply affected. We need to recognize and respect people's need to respond to this trauma as individuals with their own timetables.

The Biology of Grief

Grieving following bereavement takes its toll on the body as well as on the mind. Physical symptoms of grief include stomach pain, loss of appetite, intestinal problems, sagging energy levels and too much or too little sleep.

The relationship between bereavement and sleep has generated great interest among researchers as a factor in increased psychiatric and medical conditions and mortality. The strong link between sleep and the immune system suggests that disrupted sleep following bereavement can indirectly affect health by suppressing the immune system. (13)

"Sleep is a vital element in overcoming grief," says Martica Hall, Ph.D., assistant professor of psychiatry at University of Pittsburgh School of Medicine.

Grieving individuals experience more sick days and hospital admissions in the year following their loss than non-bereaved individuals, particularly where depression is a factor. (13) In fact, depression is a significant contributor to disrupted sleep, whether the individual is bereaved or not. Intrusive thoughts and avoidance of reminders of the deceased that often accompany prolonged, more intense grief, also impair the quality of sleep and health.

"Disrupted sleep is lighter, and studies show that the brain appears more 'awake'," says Hall. "We also see increased sympathetic nervous system activity during sleep, including changes in heart rate variability and adrenaline release that accompanies the 'fight-or-flight' syndrome." These factors contribute to poor-quality sleep with resulting fatigue and vulnerability to poor health.

Younger people and those already showing symptoms of stress and depression are most at risk of health consequences following bereavement. Conversely, the most physiologically resilient individuals are those who have worked out effective coping strategies, have good social support networks and maintain a healthy sleep profile. (13)

While there are many variables based on age, expectations and other factors, sound physical and mental health before loss predicts that a grieving individual will cope more easily when loss takes place. "Re-establishing and maintaining regular eating and sleeping patterns is important to maintaining overall health," says Hall.

Interview #2: : Effective New Treatments for Grief

Karl Goodkin, M.D., Ph.D., is professor of psychiatry and behavioral sciences and professor of neurology at the University of Miami School of Medicine and psychology at the University of Miami Graduate School. He is also a founding member of the International Society for Neurovirology. Dr. Goodkin serves on a number of committees and is conducting research in several specialized areas of neurology and psychiatry.

Q. What sets the fatal attacks of September 11 apart from events such as the Oklahoma bombing or the Columbine school shootings?

A. The loss of life, personal injury and damage to property through a single act of aggression was on a huge scale, unprecedented in this country. If this attack had occurred in a country that had a history of violent events, it would already have been momentous, but coming from the baseline of almost uninterrupted security Americans had enjoyed, it has had a yet more profound effect on the whole nation. In addition, the attack launched us into an unpredictable future of potential danger.

Q. What personal strategies should individuals be adopting to work through grief following the events of September 11? Who should be undertaking "grief work?"

A. Many people nationwide who experienced the event through the media are distressed and grieving, not just those directly involved. Personal strategies will vary according to age, culture, previous ways of coping and other factors. However, across all groups, it's important that we process our feelings and fears rather than bottling them up. Returning to "business as usual" is not the best remedy in the long term.

Q. How can people treat their own grief?

A. To begin with, it's important to normalize our response to this tragedy, that is, to feel and extend to each other acceptance of our mutual sensitivity and vulnerability. Talking through feelings with family and friends is important. I would like to see people given the opportunity to discuss the attacks in the groups most appropriate to their daily life, such as school or the office setting.

Q. Can you hypothesize on future national well-being and treatment needs?

A. Unresolved communal grief is the single biggest challenge to our future well-being. In studies of resilience during grief, a high level of social support is key to effective psychological adjustment after bereavement. In the absence of this support, we can expect negative outcomes in mood state, changes in the body's immune system and related diseases. These include infectious diseases, specific cancers and recent evidence suggests cardiovascular disease as well.

These effects are more pronounced for those who have a high level of burden from other stressful events in their lives (death of loved one, divorce, illness). Those who lack social support and typically rely upon passive coping strategies, with denial or substance abuse to evade grief, are also more susceptible to prolonged grief and distress and, related to this, the physically harmful effects caused by excessive drug, alcohol or cigarette use.

Q. Do you think there will be any positive psychological outcomes that emerge from September 11?

A. Yes. If there is available, satisfactory and sufficient social support; a minimum of other stressors; and active coping strategies, positive outcomes might include a deeper appreciation of life as it is, better communication between people, more empathy, altruism and greater compassion.

Q. How can you distinguish between normal grief and complicated, or enduring, grief that needs treatment?

A. First, more research is needed to define the many variables involved in "normal grief." However, severity and duration of grief, as well as some symptoms that differentiate grief from depressed mood, can help to define more intense grief. One element that distinguishes grief from depression generally is the yearning for the deceased person that is inherent in grieving. In complicated grief, that yearning continues to drive other dysfunctional behaviors; for instance, an inability to take part in everyday activities.

Q. At what point should a grieving individual seek treatment. Is there a timeline? What are the treatment options?

A. There is no universal rule for seeking professional help with grieving. Estimates of the time line required for normal grieving have been variable and have proven to be problematic to rely upon for judgments related to treatment need. However, the specific responses of the bereaved individuals to the loss can be examined for several indications of treatment need. These indications would include guilt other than that over actions taken or not taken by the survivor at the time of death; thoughts of death other than being "better off dead" or that one should have died with the deceased person; being overly preoccupied with a sense of one's own worthlessness; severe slowing of thought and activity overall; and hallucinations other than hearing the voice of or transiently seeing the image of the deceased. However, any symptoms related to the loss that result in prolonged and severe functional impairment would be included among those indicating treatment is needed.

Treatment should not be sought with a view to merely "get over" overt distress but rather to resolve and find meaning in the loss. The treatment options proven best include individual and group psychotherapy, pharmacotherapy -with antidepressants and/or anti-anxiety agents - or a combination of these.

Q. What are the effects of grief on the immune system?

A. Grief results in deleterious effects on the immune system by reducing the function of cells that defend against viral infections and tumors and help keep the body healthy. Grief impairs both the function of white blood cells processed in the thymus gland -- which rapidly proliferate when they come in contact with molecules identified as from outside the body -- and of "natural killer" cells -- which are responsible for attacking and destroying viruses and tumor cells. Hormones that are produced by both the body's "fight-or-flight" and stress-response mechanisms also play a major part in mediating the effects of grief on the immune system. As a result of these immunological deficits, studies indicate that grief is associated with a rise in the frequency of health care visits.

Q. How does a professional determine what treatment or combination of treatments a grieving person needs? What role do prescription drugs play in treating grief?

A. Treatment strategies are based on complex factors, because we now understand that processing grief does not take place in orderly and clearly defined stages. Our culture supports self-sufficiency where possible in overcoming grief, and the majority of people don't require any intervention. When treatment is required, most benefit from group psychotherapy alone (or individual psychotherapy). A smaller group may also require pharmacotherapy with anti-anxiety agents or antidepressants.

Q. What role do peer support groups have in the treatment of someone who is grieving?

A. Peer-support groups can have an important salutary effect on bereavement adaptation. Peer-support groups can either be led by other peers or by mental health professionals. Those led by mental health professionals may be more likely to generate therapeutic responses for all participants and to avoid any potential for nonbeneficial responses to group therapy. We have studied a bereavement support group intervention in which we have shown that a brief group psychotherapy intervention not only reduced distress and grief but also reduced cortisol level, improved immune measures and improved physical health status.

Q. Are alternative therapies for treating grief gaining acceptance with professionals?

A. There is increasing acceptance of alternative therapies as part of the treatment armamentarium, but many more studies need to be done in this area. Alternative therapies for grief would include meditation, exercise, art and music therapy, and a variety of self-help techniques. However, caution needs to be exercised. These therapies can actually perpetuate a grief response if not correctly matched to the individual's needs.

Q. How do children express grief? How can they be helped?

A. One of the challenges following 9/11 is to discern which children need help. Children under the age of 5 tend to follow their parents' lead, adopting their attitudes. These children typically have reactions including fear of parental separation as well as crying, screaming, immobility, trembling and excessive clinging. Such children may also manifest behavioral regression, such as bedwetting. Older children, those between 5 and 12, may not display overt grief about the tragedy itself. Instead, they may manifest conduct disturbances such as aggression or deterioration in schoolwork. They may also show extreme withdrawal, lack of emotional expression, inability to pay attention and irrational fears. They may have medical complaints, such as stomach aches as well. Play therapy is also effective up to the age of 12 years. Adolescents typically respond more like adults and may show substance abuse, problems with peers and anti-social behavior as well as academic decline. They also may be more prone to harbor revenge fantasies against the perpetrators of the events like September 11, as are many adults. Lack of family support is a risk for maldaptation, and family therapy is an important way to help grieving children. The school also may need to be involved.

Q. What are the most important developments in treating grief over the past 100 years?

A. The emphasis is not so much on new treatments as on a shift in attitudes, including for example, the acknowledgment that social support is key to achieving normal function. We now know that grief can be manifested by trauma-related distress, such as recurrent and intrusive thoughts of or nightmares about the deceased, intense reactions to or the avoidance of any reminders of the deceased, increased arousal or irritability, hyper-vigilance, decreased concentration, emotional numbness, feeling detached or estranged and the sense of having a foreshortened future.

New therapies include our team's development of a bereavement support group technique related to our theoretical stressor-support-coping model. This involves treating loss in the same way as other life stressors and combining grief work with stress management techniques in a support-group setting.

Identifying and Diagnosing Complicated Grief

The death of a spouse, or the irrevocable ending of any significant relationship, occurs at least once in most lifetimes. Grief is a natural response to such bereavement. After six months to a year, about 80 percent of grieving survivors have worked through their loss and are able to move on.1 But for some survivors, the grief develops into a persistent, chronic condition that makes it impossible to function normally. This is known as "complicated grief."

In recent years, mental health experts have developed criteria for identifying complicated grief and distinguishing it from the normal process of grieving. Holly G. Prigerson, Ph.D., a professor of psychiatry, epidemiology and public health at the Yale University School of Medicine, says the unique elements of complicated grief are clearly defined.

"Both depression and normal grief can take place in the context of bereavement," she says, "but excessive yearning, pining and searching for the deceased partner, emptiness, a feeling that a part of yourself died along with the deceased are symptoms of separation anxiety and are unique to complicated grief."

Individuals who are extremely closely attached to one another are more likely to experience complicated grief and poor health in the year following the death of their partner. Sleep and appetite disturbances, alcohol dependence, heightened blood pressure, a greater risk of cardiac problems and even a small increase in cancer risk can accompany complicated grief. It can also heighten the risk of suicide, especially among adolescents and the elderly.

A definitive set of criteria for complicated grief is being refined in field trials to create a distinct clinical entity in the profession's standard reference, the Diagnostic and Statistical Manual. Meanwhile, the taboos surrounding death in the United States and other developed nations can make the grieving process more difficult. Prigerson believes there is excessive pressure from employers and many family members, friends and acquaintances to have survivors "recover" or "get over their grief" and "get back to normal" quickly. While this may serve the needs and wishes of the survivor's employer, friends and family to see the survivor recover their daily functional capacity and productivity, it is insensitive to the needs of the bereaved person.

"Physicians often fail to advise family and friends on how to cope with the impending death of a loved one," says Prigerson. "Additionally, healthcare providers who may have been consulted almost daily during the final illness of the deceased often move on as soon as the patient dies, creating another gap in interaction and support for the family."

With important data still emerging, there is no universal agreement on intervention strategies for prolonged, complicated grief. However, promising new directions include cognitive behavior therapy that helps patients restructure the meaning of losing a loved one. Prigerson stresses that treatment is not intended to help patients get over their loss, but to help them gain a renewed sense of identify and self-worth in the absence of their loved one, to improve their functional capacity and enjoyment of activities and to increase their general sense of well-being.

New Research Creates More Comprehensive Picture of Grief and Bereavement

In 1984, the National Academy of Sciences' Institute of Medicine released the results of a study on the effect of bereavement on general and mental health. Bereavement: Reactions, Consequences and Care was an important first step in defining the domain of grief research and treatment. Today, the Center for the Advancement of Health is working with scientists from a number of disciplines to survey recent advances in the field and identify ways to strengthen grief research as it relates to the provision of grief-related services within health care settings. This work is being conducted with a grant from the Project on Death in America of the Soros Foundation's Open Society Institute.

"The Grief Research Project will review existing research and identify gaps in our understanding of grief and how it affects health," says Janice Genevro, Ph.D., senior scientific consultant to the Grief Research Project. "Rather than carrying out its own research, the Center's aim is to build connections between various stakeholders and ensure that the research is translated into effective practice, particularly in the health care setting."10

Genevro says that over the past decade, one trend in research has been to balance and combine quantitative research with more qualitative methods. "For example, some researchers are using subjects' responses to interviews to obtain more subtle and unique information than can be obtained through standardized questionnaires." In other studies, for example, facial expressions of emotion have been assessed and used with other types of information to determine the level of grief and predict outcomes for improved functioning.12

Increasingly, biological and psychological factors and social interaction during grief are being included in studies to help create more effective interventions for individual needs. Genevro acknowledges a gap between what researchers study and what providers need to do their work, although the gap is gradually closing.

Genevro says that future directions for research include evaluating the use of music, art and other expressive therapies to help grieving individuals. She also cites the need for more large-scale, long-term studies of the general population, assessing how age, gender and culture differences affect grieving. And in a time of widespread trauma and unexpected loss following the events of Sept. 11, 2001, there is intense interest in researching how people understand and create meaning from bereavement.

The Research

1. Prigerson, H.G., Massachusetts Medical Society. (2002). Better bereavement. Coping with the death of a spouse. HealthNews consumer newsletter.

2.Stroebe., et al (2001). Concepts and issues in contemporary research on bereavement. Handbook of bereavement research: Consequences, coping and care. (pp. 4-22). Washington, DC: American Psychological Association.

3.Centers for Disease Control and Prevention, National Center for Health Statistics (2000). Deaths: Preliminary data for 2000. Vol. 49. No. 12. 40pp. (PHS) 2001-1120. Available www.cdc.gov

4. Centers for Disease Control and Prevention, National Center for Health Statistics. (2001). 2001 Fact sheet: Deaths: final data for 1999. NVSR volume 49, No. 8. 114pp. (PHS) 2001-1120. Available www.cdc.gov

5. Centers for Disease Control and Prevention, National Center for Health Statistics (2001). Vital and Health Statistics Series 13, No. 143. Available: www.cdc.gov

6. National Center for Health Statistics. Health, United States, (1991). Hyattsville, MD: U.S. Department of Health and Human Services, Public Health Service, CDC, 1992.

7. National Center for Health Statistics. Mortality data tapes. Hyattsville, MD: U.S. Department of Health and Human Services, Public Health Service, CDC, 1993.

8. National Center for Injury Prevention and Control. (2001). Fact Book. Available: www.cdc.gov

9. American Cancer Society (2001). National Smoking Survey. www.cancer.org

10. PDIA Newsletter (2000). Project on death in America. Available: www.soros.org

11. Stroebe., et al (2001). Concepts and issues in contemporary research on bereavement. Handbook of bereavement research: Consequences, coping and care. (pp. 4-22). Washington, DC: American Psychological Association.

12. Bonanno, G.A., (2001). Grief and emotion: a social-functional perspective. Handbook of bereavement research: Consequences, coping and care. (pp. 493-515). Washington, DC: American Psychological Association.

13. Hall, M., & Irwin, M., (2001). Physiological indices of functioning in bereavement. Handbook of bereavement research: Consequences, coping and care. (pp. 473-492). Washington, DC: American Psychological Association.

14. Stewart, A.E. (1999). Complicated bereavement and postraumatic stress disorder following fatal car crashes: Recommendations for death notification practice. Death Studies 23(4), 289-321.

15. Zisook, S., Chentsova-Dutton, Y., & Shuchter, S.R., (1998). PTSD following bereavement. Annals of Clinical Psychiatry 10(4), 157-163.

16. Dyregrov, A. & Dyregrov, K. (1999) Long-term impact of sudden death: A 12- to 15-year follow-up. Death Studies 23(7), 635-661.

17. Dowdney, L. (2000). Childhood bereavement following parental death. Journal of Child Psychology and Psychiatry, and Allied Disciplines 41(7), 819-830.

18. Burns, E.A., House, J.D. & Ankenbauer, M.R. (1986) Sibling grief in reaction to sudden infant death syndrome. Pediatrics 78(3), 485-487.

19. Goodkin, K., Feaster, D.J., Asthana, D., Blaney, N.T., Kumar, M., Baldewicz, T., Tuttle, R.S., Maher, K.J., Baum, M.K., Shapshak, P., & Fletcher, M.A. (1998). A bereavement support group intervention is longitudinally associated with salutary effects on the CD4 cell count and number of physician visits. Clinical and Diagnostic Laboratory Immunology 5(3), 382-391

The Center for the Advancement of Health is an independent nonprofit organization that promotes greater recognition of how psychological, social, behavioral, economic and environmental factors influence health and illness. The Center advocates the highest quality research and communicates it to the medical community and the public. The fundamental aim of the Center is to translate into policy and practice the growing body of evidence that can lead to the improvement and maintenance of the health of individuals and the public. The Center was founded by the John D. and Catherine T. MacArthur Foundation and the Nathan Cummings Foundation, which continue to provide core funding. Funding for this series was provided by the Robert Wood Johnson Foundation.

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