Running head: TRAUMATIC BEREAVEMENT INTERVENTIONS

Investigating the Effects of Interventions in Traumatically Bereaved Individuals Sarah Penny University of Calgary

TRAUMATIC BEREAVEMENT INTERVENTIONS Investigating the Effects of Interventions in Traumatically Bereaved Individuals

Traumatic bereavement can have profound effects such as depression, anxiety, physical health concerns, and even increased mortality rates (Kato & Mann, 1999; Johannesson et al. 2009). It is commonly accepted by bereavement researchers that a sudden, unexpected or violent loss of a loved one is one of the most common life events leading to post-traumatic stress disorder (Kristensen, Weisaeth & Heir, 2012, p.77). Although there have been many studies conducted on the coping ability of bereaved individuals who have lost a loved one to an expected death, there is a lack of research on the how traumatically bereaved individuals cope, particularly over the long term (Tuck, Baliko, Schubert & Anderson, 2012). Therefore, the goal of this study is to address how traumatically bereaved individuals cope one year after their loss. Rationale It has been reported that at least half of the population can expect to experience a severe life stressor, or traumatic event in their lifetime (Drescher & Foy, 2010). Besides the aforementioned psychological issues that accompany a loved ones traumatic death, other issues that may arise for the survivors include self-blame and guilt, witnessing the death, waiting for confirmation of the death, and dealing with intrusive members of the media (Kristensen et al., 2012). In addition, a sudden loss can make it difficult for a family member to accept the reality that their relative has died. The suddenness may also prevent family members from saying goodbye, or having the ability to carry out the final wishes of the deceased (Kristensen et al., 2012). These factors are unique to traumatic deaths, and they emphasize the importance for continued research on bereavement and support interventions. Furthermore, it has been found that bereaved individuals who do not address their pain and grief are at risk for developing psychological disorders such as depression, anxiety and alcohol

TRAUMATIC BEREAVEMENT INTERVENTIONS abuse (Oliver, Sturtevant, Scheetz & Fallat, 2001). It has been found that bereavement counselling is an effective intervention for traumatic bereavement (Bonnano & Kaltman, 1999;

Neimeyer, 2000; Stroebe & Stroebe, 1987), thus the focus of this study will be on traumatically bereaved individuals who have received counselling, in order to examine the effects counselling has had. A major purpose for conducting this study is to outline the importance of researching mental health in the traumatically bereaved, and to address their needs in order to maintain psychological health. It is the hope of the researcher that this study will be used to help design counselling intervention programs aimed at helping traumatically bereaved individuals cope with their unique issues and to prevent psychological health issues from developing. Literature Review The following section discusses the literature related to this study. In the first section, recent research on interventions for the traumatically bereaved is presented and analyzed. In the second section, the effects of traumatic bereavement counselling are discussed. Rando (1996) reported that the sudden loss of a family member may be followed by a particularly difficult course of grief. However, it has been acknowledged that research on this topic is lacking, and further research would be helpful in developing coherent models of counselling that specifically target those who have lost a loved one in a sudden, violent death (Neimeyer, 2000). In a review of the related literature in the database psycINFO, a small number (8) of empirical studies have been conducted on interventions for the traumatically bereaved. For the purpose of space restrictions, the following section will present four of those studies. The first example of the research comes from a recent pilot study for family survivors of homicide, conducted by Tuck, Baliko, Schubert and Anderson (2012). This study included eight

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family members who participated in a two day retreat. The theoretical framework the retreat was based upon is holism, which emphasizes the interconnection of the mind, body and spirit. Spirituality, an important component in holism, has been found to be helpful in allowing the bereaved to make meaning of their loss, something that can be particularly difficult after a traumatic death (Park & Wortmann, 2009) Activities during the retreat included therapeutic interventions such as drumming, group counselling, symbolic memorial services and guided imagery. To examine the effectiveness of the retreat, participants completed surveys at five different intervals over the span of 30 months. Although the researchers acknowledge that the sample size is small, the outcomes of the surveys from the family members were overwhelmingly positive (p.766). Participants reported that experiences such as being listened to, having the opportunity to talk openly and feeling that they are not alone (p.780) were positive outcomes of the retreat. Furthermore, they reported that active, symbolic rituals, such as the drumming circle and the memorial services were useful in helping them to cope with the trauma they experienced through the sudden death of their loved one. All eight participants indicated that they would participate in another retreat, and expressed a wish for ongoing support beyond the weekend retreat. The recently developed RECOVER program at the Wendt Centre for Loss and Healing in Washington, D.C., provides crisis support and early intervention bereavement counselling for individuals who arrive at the morgue to identify family members who have died unexpectedly (Sklarew, Handel & Ley, 2012). Although this program mostly involves short-term counselling for the traumatically bereaved, it has provided valuable information about traumatic grief, including how to best support families through difficult phases following a traumatic death, such as autopsies, funeral planning and notifying friends and other family members. The program

TRAUMATIC BEREAVEMENT INTERVENTIONS does provide a follow-up service, which involves a phone call from a staff member, one month

after the family has used the service. The authors acknowledge that there is a need for long term, in-person grief counselling, yet because of financial restrictions, the RECOVER program is not able to offer it at this time. Muma and Jokinen (2008) reviewed a crisis intervention model for the traumatically bereaved in Finland. Located in the centre of the city of Vantaa, the Crisis Centre is open 24 hours, and responds to the mental, physical and social needs of individuals involved in a crisis situation. After a sudden death has occurred, the police give family members the contact information for the centre, as well as notify the centre that a traumatic death has occurred. Once initial contact is made, an appointment is set up between the family and a crisis worker within 72 hours. Crisis support provided by the centre involves debriefing the incident, assisting the family with funeral planning, and accompanying the family to identify the deceased. Having a centre fully devoted to supporting families experiencing traumatic bereavement is a relatively new approach to crisis intervention, and two audits of the centre in Vantaa yielded positive results. Drawbacks, however, include lack of funding for such a program, as well as the need for further follow-up with families. As with most crisis intervention models for the traumatically bereaved, the focus of the centres program is on short term reactions to a traumatic death. There is a need for further follow up and support in the long term (Muma & Jokinen, 2008). Finally, Oliver et al. (2001) proposed a model for supporting parents whose children died a traumatic death. Researchers contacted subjects through a pediatric trauma centre, and provided 59 bereaved families with an in-home visit one month after the death, an educational meeting with the parents and 15 extended family members and friends within two months after the death, and a final follow-up interview ten years later, to assess the effectiveness of the model. Results

TRAUMATIC BEREAVEMENT INTERVENTIONS showed that 82% of respondents viewed the intervention favorably. However, respondents

indicated the desire for further, long term support, and the researchers acknowledged the need for further research on the effectiveness of long term counselling approaches for the traumatically bereaved. Aside from crisis-intervention models, research on the effectiveness of counselling for traumatic bereavement has generally shown positive results (Neimeyer, Harris, Winokuer & Thorton, 2011). Stroebe, Schut and Stroebe, (2005) reported that individuals who suffered from traumatic bereavement benefitted from counselling. The researchers found that this was because traumatically bereaved individuals had trouble making sense of their loss, and found counselling to be helpful with this process. Furthermore, the authors examined the impact of expressing and sharing emotions across four domains: social support, emotional disclosure experimentally induced emotional disclosure and grief intervention. Results showed that disclosure in all four areas was not helpful for those experiencing normal, non-traumatic bereavement, but there was an improvement found in traumatically bereaved individuals. Kristensen et al. (2012) reported on the effects of bereavement counselling after a sudden and violent loss. The researchers found that long term counselling is most effective when clients show symptoms of post-traumatic stress disorder (PTSD), as counselling helps to alleviate the symptoms of PTSD. Furthermore, the authors found that a family therapy approach proved to be helpful when working with bereaved parents. In a meta-analysis study of treatment outcomes, Parkes and Prigerson (2010) reported that the more complicated the grief process, the better the chances are of intervention leading to positive results. Finally, a number of studies (Cohen & Wills, 1985; Stroebe, 2008; Stroebe, Zech, Stroebe & Abakoumin, 2005) have found group therapy to be an effective intervention for

TRAUMATIC BEREAVEMENT INTERVENTIONS traumatic bereavement, as social connections have been found to lessen the isolation of bereavement. Overall, the research seems to indicate that those who are suffering from traumatic bereavement do gain benefit from bereavement counselling interventions. Although there is

promising research on interventions with specific target groups, they mostly focus on short term interventions, and there is clearly a need for long-term outcome research. Methodology In order to examine the effects of counselling interventions in traumatically bereaved individuals, a focus group will be conducted to explore their level of coping one year after experiencing the traumatic death of a loved one. This study will take a qualitative approach because it is largely exploratory in nature. Sample After preliminary research, it was found that subjects could not be recruited through Bereaved Families of Ontario as initially planned, due to privacy laws. Therefore, in an attempt to reach individuals who have lost a loved on to a traumatic death, subjects will be recruited through ads placed in the local newspaper, notices handed out in various churches, in veteran affairs offices and notices pinned in the offices of bereavement psychologists (see Appendix A). The requirements of participants include having experienced the loss of a loved one due to a traumatic death no less than eight months to one year ago, and no more than one and a half years ago, to ensure a measure of consistency within the sample (Leedy & Ormrod, 2013). Furthermore, the participants must have received a counselling intervention since the death. Participants must be over the age of 18 and able to speak English fluently. Ideally, six to eight participants will be recruited, to allow for a variety of perspectives. Furthermore, six to eight

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members still allows for a small enough group to allow each participant to answer the questions, without feeling rushed because of time constraints. Instrumentation A set of qualitative interview questions will be used to measure participants level of coping (see Appendix B). These questions were designed to assess the participants current level of coping, compared to their level of coping at the time of their loved ones death, and to reflect on changes resulting from counselling interventions. Procedure The focus group will meet in a private space in the researchers office at the University of Calgary. At the beginning of the focus group, the researcher will outline the purpose of the study, as well as ask the participants to sign a consent form. Once the focus group begins, the researcher will pose the questions to participants, one at a time, and allow everyone to answer (or not answer if they so choose). Several open-ended questions will be utilized to allow participants to express their answers in their own preferred manner. The answers will be audiorecorded, with consent from participants. After the interview is complete, the researcher will offer time for participants to debrief the experience. Contact information for a psychologist specializing in grief counselling will be made available to participants before they leave, to provide extra support if needed. Finally, participants will be invited to view the results of the completed data, once it has been transcribed. Data collection and interpretation After the focus group, the audio recording of the session will be transcribed, and common themes throughout the answers will be extracted. The results will be analyzed using content analysis and open coding (Leedy & Ormrod, 2013). For example, certain answers will be

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compared between participants, such as question four: How are you coping now. Code words will act as themes, such as terrible, okay and good. Themes will be used to determine if participants perceive that counselling has helped them cope with the death, and to provide an overall idea of how participants are coping one year after the death. Implications Ethical Considerations Due to the sensitive nature of this study, many ethical considerations are necessary. When working with human subjects in research, there are a number of factors to consider, including confidentiality, consent, and protection for vulnerable persons, in order to ensure the study is ethical (Canadian Psychological Association, 2001). Permission for research with human subjects will be sought through the University of Calgarys Conjoint Faculties Research Ethics Board. The purpose of the study will be made clear to participants, as well as the fact that their participation is fully voluntary, and that they may withdraw at any point, without penalty. They will also have the chance to preview the focus group questions (via email) before deciding to participate. Before the focus group begins, they will be informed of the nature of the study, how it will be conducted, and what they will be asked to do. They will be assured that no identifying information will be collected, and that their identity will remain anonymous. Furthermore, after the audiotape of the focus group is transcribed, the tape will be deleted. The transcribed notes from the focus group will be kept in a locked cabinet in the researchers office, for a period of seven years, after which point, the notes will be destroyed. Finally, given the sensitive nature of the topic of this study, it is of utmost importance that participants are not harmed. There is a risk that participants may become upset by the questions in this study, especially when asked to

TRAUMATIC BEREAVEMENT INTERVENTIONS reflect upon how they are coping. It is the researchers intention to ensure that participants are fully aware of this risk before beginning the study, therefore, they are allowed to preview the questions. Also, they will be provided with a grief counsellors contact information, if they require further support. Benefits

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One main reason this research is important is because in terms of traumatic bereavement, the need for and the benefits of professional help from the public health care system are not clear (Kristensen et al., 2012, p.77). There exists a gap in the literature for the effectiveness of long term care for traumatically bereaved individuals. Groups that are at risk for experiencing psychological health problems resulting from traumatic bereavement include war veterans (Papa, Neria, & Litz, 2008), parents who have lost a child to illness or an accident (Oliver et al., 2001), family members who have lost a loved one to violence, including homicide (Tuck et al., 2012), and survivors of major disasters (Johannesson, et al., 2009). When a traumatic death occurs, it has been hypothesized that at least five relatives or loved ones are deeply affected (Tuck et al., 2012). It is important that these individuals have in place a comprehensive intervention program to aide them in the healing process. Presently, few studies have been conducted on the effects of interventions on [traumatically bereaved] individuals well-being and quality of life (Tuck et al., 2012, p.769). Therefore, there is a need for studies such as the present one, to better understand the grieving process, and to be used in subsequent research to assist in developing long term intervention models for traumatically bereaved individuals.

TRAUMATIC BEREAVEMENT INTERVENTIONS References Bonnano, G.A. & Kaltman, S. (1999). Towards an integrative perspective on bereavement. Psychological Bulletin, 125(6), 760-776. doi:10.1037//0033-2909.125.6.760.

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Canadian Psychological Association (2001). Canadian code of ethics for psychologists (3rd ed.). In C. Sinclair & J. Pettifor (Eds.), Companion manual to the Canadian code of ethics for psychologists (3rd ed., pp. 29-96). Ottawa, ON: Canadian Psychological Association. Cohen, S. & Wills, T.A. (1985). Stress, social support and the buffering hypothesis. Psychological Bulletin, 98, 310-357. doi:10.1037/0033-2909.98.2.310 Drescher, K. & Foy, D. (2010). When horror and loss intersect: Traumatic experiences and traumatic bereavement. Pastoral Psychology, 59, 147-158. doi: 10.1007/s11089-0090262-2. Johannesson, K.B., Lundin, T, Hultman, C.M., Lindam, A., Dyster-Aas, J., Arnberg, F., & Olof, M. (2009). The effect of traumatic bereavement on tsunami-exposed survivors. Journal of Traumatic Stress, 22(6), 497-504. doi.org/10.1002/jts.20467. Kato, P.M. & Mann, T. (1999). A synthesis of psychological interventions for the bereaved. Clinical Psychology Review, 19(3), 275-296. doi:10.1016/S0272-7358(98)00064-6. Kristensen, P, Weisaeth, L. & Heir, T. (2012). Bereavement and mental health after sudden and violent losses: A review. Psychiatry, 75(1). doi: doi:10.1521/psyc.2012.75.1.76. Leedy, P. D., & Ormrod, J. E. (2013). Practical research: Planning and design (10th ed.). Upper Saddle River, NJ: Pearson. Muma, P. & Jokinen, A. (2009). Crisis intervention in Finland. Bereavement Care, 27(1), 10-12. doi.org/10.1080/02682620808657709. Neimeyer, R.A. (2000). Searching for the meaning of meaning: Grief therapy and the process of reconstruction. Death Studies, 24(6), 541-558. doi.org/10.1080/07481180050121480.

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Neimeyer, R.A., Harris, D.L., Winokuer, H.R. & Thorton, G.F. (2011). Grief and bereavement in contemporary society: Bridging research and practice. New York, NY: Routledge Oliver, R.C., Sturtevant, J.P., Scheetz, J.P. & Fallat, M.E. (2001). Beneficial effects of a hospital bereavement intervention after traumatic childhood death. Journal of Trauma, Injury, Infection and Critical Care, 50, 440-448. doi.org/10.1097/00005373-200103000-00007. Papa, A., Neria, Y. & Litz, B. (2008), Traumatic bereavement in war veterans. Psychiatric Annals, 38(10), 686-691. doi.org/10.3928/00485713-20081001-07. Park, C. L & Wortmann, J.H. (2009). Religion/spirituality and change in meaning after bereavement: Qualitative evidence for the meaning making model. Journal of Loss and Trauma, 14(1), 17-34. doi:10.1080/15325020802173876. Parkes, C.M. & Prigerson, H.G. (2010). Bereavement: Studies of Grief in Adult Life (4th ed.). New York, NY: International Universities Press. Rando, T. A. (1996) Complications in mourning traumatic death. In K.J Doka (Ed. ). Living with grief after sudden loss (pp. 139-160). Washington, DC: Taylor & Francis. Sklarew, B.H., Handel, S. & Ley, S. (2012). The analyst at the morgue: Helping families deal with traumatic bereavement. Psychoanalytic Inquiry, 23, 147-157. doi: 10.1080/07351690.2011.592741. Stroebe, W. (2008). Does social support help with marital bereavement? Bereavement Care, 27(1), 3-6. doi:10.1080/02682620808657706 Stroebe, W., Schut, H., & Stroebe, M. (2005). Grief work, disclosure and counselling: Do they help the bereaved? Clinical Psychology Review, 25, 395-414. doi:10.1016/j.cpr.2005.01.004

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Stroebe, W. & Stroebe, M.S. (1987). Bereavement and Health: The psychological and physical consequences of partner loss. New York: Cambridge University Press. Stroebe, W., Zech, E., Stroebe, M.S. and Abakoumkin, G. (2005). Does social support help in bereavement? Journal of Social and Clinical Psychology, 24(7), 1030-1050. doi:10.1080/02682620808657706 Tuck, I., Baliko, B., Schubert, C.M. and Anderson (2012). A pilot study of a weekend retreat intervention for family survivors of homicide. Western Journal of Nursing Research, 34(6), 766-794. doi:10.1177/0193945912443011.

TRAUMATIC BEREAVEMENT INTERVENTIONS Appendix A

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Have you experienced the traumatic death of a loved one?

Have you also received bereavement counselling? A student researcher from the University of Calgary is conducting a study on interventions for traumatically bereaved individuals, one year after the loss. If you would like to participant in a small group interview, and share your experiences, please contact Sarah Penny, spenny@ucalgary.ca for more information.

TRAUMATIC BEREAVEMENT INTERVENTIONS Appendix B 1. How long has it been since your loved one died? 2. What type of counselling did you receive after the death? 3. How did you cope immediately after your loved one died? 4. How are you coping now, one year later? 5. What have you found to be the most helpful with coping since the death? Least helpful?

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