Family members may not quietly and peacefully accept what has happened...Family members have no choice--they must cooperate with the media, the police and sometimes the courts.
E.K. Rynearson, MD Virginia Mason Medial Center
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Meeting the Needs of Victim Survivors Following Violent Death
An Evidence and Theoretically Based Rationale By Connie Saindon, MA, LMFT
Below you will find some of the research that guides our thinking and work for the specialized services for folks who have suffered from violent loss. In order to guide participants towards appropriate levels of care, our assessment includes screening for Depression levels, Post Traumatic Stress (PTSD), Substance Abuse, Intrusive imagery and Traumatic Grief. Our comprehensive services include recommendations, referrals and partnerships with community resources
The impact of horrific loss is incomprehensible. The complexity and competing aspects of each loss can easily overwhelm the family, the community and service professionals who all work to regain a sense of safety, meaning and hope.
Trauma theory more accurately portrays the experiences following violent death of a loved one as proposed by Janoff-Bulman (1992). According to Bulman, trauma brings about the abrupt disintegration of one's view of the world as benevolent and meaningful and the self as worthy. Following an event, victims, see themselves as helpless and weak in a violent, meaningless world. The dominant emotional experience is fear and anxiety. The coping task is the creation of a new world consisting of personal and relational change. This task is difficult and lengthy because of the wrenching battle of emotion and thoughts.
Violent loss may result in disconnections within the family. Traumatic events breach the attachment of family, friendship, love and community. Traumatic events have primary effects on the individual but also impact the systems of attachment and meaning that link them to their community.
The existing literature of family survivors of criminal homicide victims consists of a modest collection of studies. The effects of homicide reach beyond the death of the victim to shatter the lives of family members. One study (Thompson, et. al., 1998) investigated the distress levels of 150 family members of homicide victims and found that levels were very high and that 26% reported clinical levels of distress. This study compared the homicide sample with two comparable groups of non-homicide trauma victims. Homicide survivors were found to be significantly more distressed than either group.
Another study (Murphy et. al., 1999) examined the prevalence of PTSD among parents bereaved by the violent deaths of their 12-28 year old children. A sample of 171 bereaved mother and fathers from the Medical Examiners records and followed for 2 years. Four important findings emerged: 35% of these parents still met case criteria for PTSD 2 years after the deaths.
Two studies provide direct evidence for the association of violent deaths with trauma symptoms by Zisook, Chentsova-Dutton and Shuchter (1998). The criterion for PTSD was met by about 10% of participants whose spouses died from natural causes. In contrast, one third of participants whose spouses had died from violent deaths met the PTSD criteria.
Most of the evidence linking violent death bereavement with PTSD is found following deaths by homicide. Rynearson (1984) was among the first to note intrusive and repetitive images, nightmares and intense self-protection among family members. Subsequent studies have corroborated Rynearson's findings. In addition to trauma symptoms, homicidal death bereavement responses include rage, revenge toward the killer, and frustration with the criminal justice system.
Parents describe the death of a child as "devastating," "a pain like no other," an event that has incomprehensible, lasting changes on the family (Cook, 1983; Lehman, Lang, Wortman, & Sorenson, 1989: Rinear, 1998.). One of the most difficult tasks for parents is to find meaning in their child's death (Cook, 1983; Frankl, 1978).
Both clinical and empirical reports have identified numerous negative outcomes in all domains of personal and social functioning, including grief, guilt, anxiety states, panic syndromes, anger and revenge, depression, trauma symptoms, insufficient support, and frustration with the criminal justice system.
There are unique responses to violent death. Following suicidal death, parents experience guilt, and symptoms similar to other violent losses such as difficulty sleeping, intrusive thoughts, diminished interest in previously enjoyed activities, and estrangement from others.
Traumatic losses involve more than depression (Prigerson et. al., 1995). Current studies by leaders in the field identify a unique stress response comprised of some symptoms associated with PTSD as well as symptoms of attachment distress (e.g., yearning, searching) There is strong agreement that the separation (attachment) distress symptoms are the most pervasive among those with traumatic grief.
A study to confirm the author's (Prigerson et. al, 1997) previous work consisted of interviews of 150 future widows and widowers at the time of spouse's admission in the hospital and at 6, 13 and 25-month intervals. The results suggest that it may not be the stress of bereavement, per se, that puts individuals at risk for long-term mental and physical health impairments and adverse health behaviors. Rather, it appears that psychiatric sequelae such as traumatic grief are of critical importance in determining which bereaved individuals will be at risk for long-term dysfunction. Those suffering with traumatic grief are those with current distress and are increased risk of suffering death, disability or an important loss of freedom.
No systemic study has focused on psychotherapy of bereavement after homicide. The few anecdotal studies that have mentioned treatment results have involved short-term individual psychotherapy or support groups. In a preliminary model of unnatural dying, E.K. Rynearson, MD (1994) suggests three V's (violence, violation and volition) that differentiate these losses. These responses include 1) posttraumatic stress disorder (PTSD; experiences of intrusive reenactment and avoidance), 2) victimization (rage and a sense of defilement), and 3) compulsive inquiry (a social and psychological need for investigation and punishment of the murderer).
Whereas PTSD and victimization are familiar symptoms, compulsive inquiry is more specifically associated with the trauma of unnatural dying. There is an inordinate need to understand how and why this dying happened. This commonly occurs when there is little or no external investigation and judicial inquiry (as is the case with some homicides and with suicide or accidental death). In the case of homicide, this may continue long after the crime has been solved and the perpetrator has been punished.
In one study (Masters, Friedman, & Getzel, 1988) 12,000 random calls were made to adults who were asked if they experienced any type of homicide in their lifetime as of 1988. According to a sample of 12,500, 2.8% had lost an immediate family member to criminal homicide, 1.6% to alcohol-related homicide. Another 6.5% had lost other relatives or close friends.
The data showed that 23.3% of all immediate family survivors or more than 1 in 5 developed homicide-related PTSD at some point in their lifetime following the homicide. Those survivors suffering from PTSD were at greater risk for suicidal ideation.
One striking implication of the results is that an individual does not have to be a direct victim of a trauma, or even witness the trauma to develop PTSD. Only 6% of the criminal homicide and 11% of the vehicular homicide victims witnessed the homicide, yet 19% and 27% of these two groups, respectively, developed homicide-related PTSD.
These results confirm the need for specialized mental health care for survivors of homicidal victims. Clinicians are in an important position for providing much-need education and support to survivors. Be learning to predict and cope with the exacerbation's of symptoms by anniversaries, reminders of their lost loved one, and very typically by ongoing criminal justice proceedings, survivors regain a sense of self-efficacy and security.
Although no treatment-outcome studies have been done, our clinical impression is that a treatment package combining education, support, and development of specific coping skills is most effective
A study by Hernon and Forst (1984) found that greater symptom severity was associated with greater dissatisfaction with the criminal justice system.
Lack of predictability and controllability are the central issues for the development and maintenance of PTSD. The combination of intrusive and numbing symptoms has been consistently noted over the past century (e.g. Janet, 1904; Kardiner, 1941), and forms the basis of our understanding of the nature of PTSD. A way to deal with the intense emotions after a traumatic event is to look for who can be held responsible. Often that leads to the victim or others blaming them for their failure to prevent what has happened. This has been called the "second injury" (Symonds, 1982).
In a chapter called the Black Hole of Trauma, authors van der Kolk and McFarlane discuss studies that report studies that show compulsive reexposure to the trauma can be seen in a wide range of traumatized populations. For example, combat soldiers work in criminal justice, abused adults may be attracted to abusers, and molested children may grow up and work in illegal sexual activities. In this reenactment trauma, an individual can be either a victimizer or victim.
Numerous studies have documented that many violent criminals were physically or sexually abused as children. (e.g.,Groth, 1979:Seghorn,Boucher, & Prentky, 1987). Studies consistently find a highly significant relationship between childhood sexual abuse and various forms of self-harm later in life, particularly suicide attempts, cutting and self-starving. (e.g., van der Kolk, Perry & Herman, 1991).
Terrifying experiences that rupture people's sense of predictability and invulnerability can profoundly alter the ways that they subsequently deal with their emotions and with their environment.
Several studies in recent years have shown that Post Traumatic Stress Disorder (PTSD) is among the most common of psychiatric disorders. The National Vietnam Veterans Readjustment Study (Kulka et al, 1990) found that approximately twenty years after the end of the Vietnam War 15.2% of Vietnam theater veterans continued to suffer from PTSD.
PTSD is associated with high levels of chronicity, co-morbidity and functional impairment; the general level of functioning varies a great deal between affected individuals.
What distinguishes people who develop PTSD from people who are merely temporarily overwhelmed is that people who develop PTSD become "stuck" on the trauma, keep re-living it in thoughts, feelings, or images.
Evidence during the past decade supports the notion it is the intrusive reliving, rather than the traumatic event itself that is responsible for the complex biobehavioral change that we call PTSD (McFarlane, 1988). Once they become dominated by intrusions of the trauma, traumatized individuals begin organizing their lives around avoiding having them (van der Kolk & Ducey, 1984). Avoidance may take many different forms: keeping away from reminders, ingesting drugs or alcohol that numb awareness of distressing emotional states, or utilizing dissociation to keep unpleasant experiences from conscious awareness. The helplessness, conditioned hyperarousal, and other trauma-related changes may permanently change how a person deals with stress, alter his/her self-concept and interfere with the view of the world as a basically safe and predictable place. A relative sense of safety and predictability are preconditions for effective planning and personal action.
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