After a traumatic bereavement, people often feel intense rage mixed with guilt and shame. Every area of their life tends to be affected by such a sudden loss. But how this kind of experience can be treated has not been so clear.

In a practice-oriented evidence review, Nicole Barlé and her colleagues recommend a comprehensive treatment approach specifically developed for traumatic loss. For as well as feelings of sadness and emptiness, “…the impact of a sudden traumatic loss is so devastating, it frequently results in symptoms of posttraumatic stress disorder (PTSD), such as flashbacks, sleep difficulties, and concentration problems”, particularly if survivors have experienced childhood abuse and neglect. Alongside distress, depression and anxiety, difficulties at work or with partners exacerbate feelings of inadequacy or failure to cope. This, say the researchers, is not so strange, as traumatic death can shatter survivors’ assumptions about the world and fragment religious or spiritual beliefs.

In fact, the researchers have identified that survivors habitually feel guilty even if they are not to blame. Remorse often focuses on whether their loved one suffered. As one father explained; “I have nightmares about how my son struggled with his killer”. Family relationships can become strained, as partners feel shut out, and surviving parents can be left financially and emotionally devastated with concerns about raising children alone.

Work sometimes provides much needed routine, but equally physiological changes associated with PTSD such as hyperarousal and headaches, can affect attendance and work rate. Equally, at home, recreational activities bring painful reminders of a loved one’s absence. When people struggle to know how to respond compassionately to survivors of traumatic bereavement, disappointment and anger set in.

Few of us consider our response to accidental death. In a disaster, however, survivors’ intense rage towards those seen as responsible, may intensify in the face of media coverage; the 9/11 terrorist attacks were repeatedly shown on the media, re-opening the wounds from grief. Suicide can evoke feelings of shame and resentment that loved ones were not protected, while homicide can cause confusion, dread and high levels of PTSD and grief symptoms.

Data from the literature showed Barlè and her team that “It is essential to help clients build the coping resources for the difficult work of processing the traumatic elements of their loss”. Therapists helping clients to manage painful demands, through breathing retraining and self-care strategies, should determine how much support clients have, and whether they are gradually withdrawing from that care. Clients, on the other hand, benefit from understanding which situations trigger overwhelming emotion. Either way, each needs to understand that strong reactions to traumatic bereavement are part of the mourning process and likely to be accompanied by a search to find meaning in the loss of a loved one.

Discussion around practical questions, “How did my loved one die?” to relational questions, “Who am I, now that I am no longer a spouse?”, or even existential questions, “Why did God allow this to happen?” can help survivors regain a sense of purpose, “and mourn secondary losses such as the loss of a co-parent”. Suggested treatment approaches for cognitively and emotionally processing trauma include Cognitive-Behavioural Therapy, Emotional Processing, Prolonged Exposure, and Cognitive Processing Therapy. Exposure treatment, however, is controversial as people have been re-traumatised by the treatment. Interpersonal Therapy which focuses on the client’s interpersonal relationships is offered as an effective alternative.

Trauma processing, claims Barlè and her team, can “pave the way for healthy mourning”, and broadly falls into the following stages. Survivors must Recognise the loss before being able to React to the separation. Only then can the mourner Relinquish old attachments to the loved one and Readjust their identity to honour the past relationship but accept “the new reality”, before acknowledging the need to Reinvest in a future without the deceased.

Admittedly, this research doesn’t fully resolve the long-standing questions about which therapeutic approach might be more useful when working with clients who have been traumatically bereaved, but it does recognise that clients “benefit considerably if they are helped to understand that their reactions to such situations are typical and not indicative of coping failure-and that they need not last forever”.

Barlè, N., Wortman, C.B., & Latack, J.A. (2017). Traumatic bereavement: Basic research and clinical implications. Journal of Psychotherapy Integration, 27(2), 127-139. doi:10.1037/int0000013