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Meet the expert: PTSD following sudden bereavement

Wednesday 7 March 2012, London

Dr Stephen Regel, Principal Cognitive Behavioural Psychotherapist
The Centre for Trauma Resilience and Growth


Sudden bereavement is a type of trauma. Although it affects everyone differently there are common factors that influence a person’s reaction:
• Whether or not the person was present at their loved one’s death
• If they were present, were they also injured or at threat of an injury
• Whether they were present but unconscious; if someone is present but unconscious for more than 15 minutes of the incident they are significantly less likely to develop PTSD than if they were present and conscious

It is of course possible for someone to develop PTSD as the result of witnessing the death of a stranger; it is not just those who are bereaved that are affected. It is also possible for a sudden bereavement to affect a whole community, or even a country as in the case of the 2011 Norwegian shootings.

Sudden bereavement often results in psychological and emotional problems including but not limited to PTSD. When someone is seen from very early on after a trauma they are less likely to develop long term problems; when someone’s access to support is delayed until a while after the incident they normally require treatment over a much longer period of time.

However it can be very difficult to access support from the National Health Service (NHS) following a sudden bereavement because bereavement itself isn’t an illness, it is a cause. The Centre for Trauma Resilience and Growth sees victims on average three to four years after the traumatic incident because a lot of people are too scared to ask for help or don’t realise they need it. Those that do seek support find it very difficult to get an NHS referral. People bereaved in a high profile case (e.g. the 2004 tsunami) that attracts the attention of politics or the media are far more likely to receive support.

[Dr Regel then presented a series of case studies illustrating the difficulties of getting bereavement support through the NHS.]

NICE guidelines

The National Institute for Health and Clinical Excellence is a special health authority within the English NHS produces guidance on clinical best practice and the treatments and care available and appropriate for different illnesses.

Key points raised in the NICE guidelines:
• Eye Movement Desensitization and Reprocessing (EMDR) is recognised as an effective technique, but not a treatment in itself.
• Trauma focussed Cognitive Behavioural Therapy (CBT) is recommended.
• ‘Safe practice’ should be exercised; you should not expose a patient to something until they are ready.
• ‘Watchful waiting’ is the practice of observing the patient’s progress without intervening; the NICE guidelines do not recommend early interventions.

PTSD treatments

Psychological debriefing is a controversial early intervention in which a trauma sufferer is asked to talk about their experience shortly after the incident occurs. The technique is advised against by the NICE guidelines, as two studies have suggested it exacerbates trauma and can even retraumatise the patient.

However, psychological debriefing is intended to be used with high risk groups exposed to trauma regularly such as emergency services or army personnel and to be done as a group exercise; this is not reflected in the two studies that question the technique.

Also, when supporting a patient and giving them guidance it is important that you treat them in the context of their individual problem and therefore it is necessary to know as much as possible about their problem to enable proper support.

Trauma Risk Management (TRiM) is a technique often used by the armed forces to overcome the problem of soldiers preferring to talk to their peers after a trauma rather than trained professionals. In each unit at least one soldier undergoes TRiM training; if soldiers from their unit are then involved in a trauma they are invited to speak informally with their TRiM trained peer, who assesses how they are coping and identifies individuals at risk of developing problems.

The TRiM technique is now being used outside the armed forces; a good source of free TRiM training resources is www.ifrc.org.

Peer support groups - regular, informal support groups can help patients to normalise their experience and express themselves. This is not the same as a therapy group; it is just a forum in which patients can talk to others with similar experiences.

Imaginal exposure - when someone experiences a trauma the brain tries to pack the memories away. Therapy is the process of unpacking and repacking the trauma; it is unhealthy to leaved trauma packed away and untouched forever (avoidance) but it is equally unhealthy for trauma to be unpacked all the time as this prevents people moving on. They need to have access to their trauma but also learn to be in control of it so it can’t spill out all the time.

Imaginal exposure can help PTSD sufferers to unpack and repack- to process their feelings. The patient is asked to recount their trauma in the present tense first person into a video camera and then to watch back their testimony.

This is a type of exposure tactic; through exposure to things that trigger their trauma the patient is able to come to terms with the triggers and not slip into avoidance behaviours. This is like ‘emotional physiotherapy’; it is painful at first but gets easier and is necessary in making progress.

Common responses to bereavement

Avoidance behaviours - in most severe traumas avoidance occurs, in the immediate aftermath of the incident this is understandable but if it continues beyond three weeks there is potentially a problem. If avoidance continues beyond three months it is a strong indication that the individual will develop severe PTSD further down the line. People can become adept at engineering their whole life to avoid anything that might trigger their trauma; the longer they successfully do this for, the more they suffer when something eventually does trigger the trauma. The sooner after an incident a patient is seen the better as they can be treated before avoidance behaviours take hold. The key to preventing long term avoidance is maintaining routine and structure in daily life; this is the best source of long term stability.

Women are more proactive in seeking help, men tend more to avoid and deny issues.

Guilt is a very common response when someone is suddenly and traumatically. Guilt takes two main forms:

• Survivors’ guilt- someone is guilty that they live on when their loved one is gone
-‘it should have been me’
• Guilt of omission/ permission- someone feels that their actions are the cause of their loved one’s death
-‘if only I had/ hadn’t done…’

In the first three months after an incident, the following reactions are common:
• Sorrow
• Anger
• Helplessness
• Guilt
• Numbness
• Tension
• Restlessness
• Fear
• Anxiety
• Inability to sleep
• Inability to concentrate
• Mental avoidance of the incident

In the initial stages of grief these reactions are natural, they are only an issue if they become debilitating. If these responses continue beyond three months it is an indication of deeper problems. For patients who don’t receive treatment until three or four years after an incident, the problems are very entrenched.

The trajectory of a victim’s recovery is influenced by:
1. Pre-trauma risk factors- if stressors and psychological problems predate a trauma, long term problems are more likely. Also, acute or accumulative stressors, substance misuse, severity of event, and subjective life threat.
2. Support mechanisms in place at the time of the incident- whether or not someone has an existing social support network (close family etc) in place is a key factor in whether or not they suffer long term problems
3. Post-trauma risk factors- physical injury, bereavement, perceived lack of justice, financial considerations, context and scale of event, accumulative trauma, litigation and role of media.

Although there are guidelines for how quickly a victim’s recovery will progress, nothing is predictable and each case must be treated individually. Patients seen at the Trauma Centre within six months of the event tend to need an average of 15 sessions; the sooner someone is seen the easier it is to predict the trajectory of their grief.

Other factors affecting recovery
- Proximity to the event
- Pre trauma risk factors
- Size of event
- Role of media (NB this is strongly linked to the size of the event; the larger it is the more media interest it generates)
- Whether or not someone knows the perpetrator/ person responsible for the loss of the loved one can hugely effect their grief (this is quite particular to road death and homicide)

Peri-traumatic risk factors
- Peri traumatic risk factors are the responses/ circumstances evident at the time of the traumatic event.
- Peritraumatic risk factors are the circumstances at the time of the trauma.

Non-peri-traumatic risk factors
- The presence of non-peri-traumatic risk factors indicates an individual is more likely to develop severe problems further down the line.

The most significant risk factor affecting the victim’s grief is structured social support, something that the therapist professional help cannot provide. When the bereaved victim doesn’t have close a safety net of close family and friends and a supportive community they are at higher risk of developing PTSD.

The role of the therapist

When seeing a new patient it is important to develop a clear picture of their pre and post trauma risk factors as soon as possible; this will give a good idea of the treatment required. Discuss common responses to trauma early on in a patient’s treatment to normalise their feelings and reassure them that their reaction is not unusual and they shouldn’t be ashamed or scared.

The therapist’s role is to liberate the patient to speak and to put the patient’s feelings and experiences into context; this normalisation helps people to process their grief and attendant grief.

Patients are vulnerable and they need their therapist to be supportive; the therapist’s reaction to a patient’s testimony should not ask anything of the patient emotionally. The therapist’s office should be a space where the victim feels comfortable

The therapist’s reaction to a patient’s testimony can inhibit the patient’s progress. If the therapist appears shocked or upset this can make the patient feel upset or guilty and discourage them from sharing their story for fear of making other people feel bad. Alternatively, if a therapist appears disinterested or uncaring the patient may feel they’re uncaring and be discouraged from opening up.

A therapist should develop a good connection with their patient and be sensitive and empathetic whilst remaining objective and professional. However, sensitivity should not extend to avoiding discussion of difficult topics.

It is also important to provide patients with the rationale for their treatment. Don’t just treat the patient but explain why you’re treating them in a sort of way; the problem you’re addressing and how the treatment will help to overcome it. For example in the case of exposure tactics, explain the danger of avoidance behaviours becoming habit and how exposure to triggers combats this danger.

The therapist’s office should be a space in which the victim can express themself without guilt or apology.