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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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