Family Recovery From Terror, Grief and Trauma

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Recovery Over Time

Traumatic events usually lead to a variety of internal changes in the family. Such changes include changes in outlook on life and expectations about the future, there may be a development of subtle posttraumatic reactions that continue to influence a person’s life, i.e. at anniversaries, or for some years of continued longing and searching for the lost person. Over time, however, most families, even those who lost a loved one, are able to establish new continuity, and live on with both happy and sad memories. The long and tiresome task of establishing new meanings and verifying old may go on for years. In the following I will focus on some of the challenges for families in dealing with the event, with ensuring that adults and children continue to communicate in ways that benefit them in the long run.

The changes and problems that occur in families do not necessarily lead to dysfunction at work or in school, but continue to influence the family. For many, the loss of a loved one means that some life spheres never will be as before, while others will normalize over time. Some survivors are able to return to normal fairly soon, while others struggle for a long time.

While much is known about the factors that influence individual recovery, less is known about the factors that influence family adaptation to trauma and grief over time. Family recovery will be determined by the interplay of factors such as: the nature of the disaster and one’s exposure to it, the family’s prior history of trauma and loss, the prior and current functioning of the family, family coping resources, and availability of help and support. In the following some aspects of family functioning will be given particular attention, and some suggestions to help foster adaptive coping outlined.

FAMILY DYNAMITE - INTERNAL DYNAMICS

When a traumatic situation strikes a family member or the whole family, the entire family experiences the aftermath. Traumatic events have the capacity to disturb vital functions within the family such as parenting functions including emotional nurturing, education, and protection. Children may be particularly at risk when trauma occurs in the family, as traumatized parents often reduce physical contact and try to shield their offspring from facts. Communication, intimacy, expressiveness and role-distribution may be affected, resulting in a reduced capacity to cope with internal and external demands. Single parents may be at special risk. Parents and other adults that are aware of their tendency to overlook children in this period can try to balance their absorption with what happened with nurturing their children’s need for more presence and physical comfort.

Internal Dynamics - Fact Sharing

From more than twenty years of experience from working with grief and trauma, I have realized that the first and following days following a traumatic event often are extremely important in how individuals and families can cope and recover over time. Not only is this related to the traumatic impact of this day, but also to the resulting cognition regarding one’s own and other’s reactions, and the secondary trauma that family members may experience in their meetings with responding organizations and other members of their family or social network. These problems are very often related to the provision of facts to the family or to communicating these facts within the family. The immediate handling of information to and within the family can influence communication patterns, cohesion, and the internal dynamics of the family and their long-term recovery. It cannot be emphasized strong enough how important it is to try to foster a climate where facts and information can float freely within the family, and where difficult facts and issues are dealt with in an open and direct manner. Parents and other adults are role models for how their offspring with deal with difficult situations later in life.

At the same time experience shows us that traumatic events often become the starting point for the formation of family secrets. Secrets are a minefield in families, especially between parents and children. After the death of a father one mother held back from her two boys, twelve and sixteen years old, the fact that he had a child with another woman. At the funeral this now pre-adolescent girl turned up, to the surprise of the two boys. In a family session following this, where this and some other secrets were dissolved, the twelve year old said: "Are there more secrets now?"

Family secrets can create walls of silence within the family, walls that are difficult to tear down when solidified over time. When facts about a trauma are hidden from parts of the family system, this can greatly affect the trust and stability in the system over time. Sometimes it is a partner that keeps back information in relation to a trauma or loss from the other partner with reduced trust or continued suspicion that other facts also are held back as the result. For children it is important that parents continue to speak openly and directly about facts of the disaster that become known over time.

Internal Dynamics - Handling of Traumatic Reminders

Family members may hold very different views on what to do with the personal belongings of a loved one, on how to deal with anniversaries and rituals, and on how to approach or avoid symbolic places like the scene of the event. An example will illustrate this. Following the death of a young adult son, his parents gave his fiancé a shirt that he always used to wear. This created strong tension between the parents and their daughter, as she felt that they disregarded her need to keep that shirt when they gave it away. The sister felt she was higher in the grief hierarchy than the fiancé. Not only did this create a tension within the family, but the sister also started to feel anger towards the fiancé who also was her good friend. Dispute over personal belongings can take many forms, but are often related to different needs in different family members regarding when to take away, clean or organize all the belongings that are left from the dead loved one. One family member may be ready to put the belongings away while the other needs them present for a long time. A mother who lost an adult son demanded that the crumbles from his bread should be left on the kitchen table and she commanded her partner to let some of his favorite food be left in the fringe. Imagine the strain upon her partner, not the father of the boy, when this order still was in effect more than a year after the boy’s death. Be careful to include children in discussions about what to do with personal belongings – they will very often have opinions that should be listened to.

Internal Dynamics - Lack of Synchronism in Reactions

When working with families it is obvious that while the immediate reactions often are similar, involving shock reactions characterized by unreality etc., reactions over time differ greatly due to differences in personality, previous experience, age and interactions with the wider social network. If reactions are asynchronous this can cause problems and conflicts in the family, i.e., lack of understanding from parents regarding absence of strong emotional reactions in children, or inability of members to support each other. These aspects are also tied to different gender reactions in grief and trauma. Women tend to experience more intense emotional reactions that last over a longer time. They also tend to use confrontational coping styles where they want to talk about and share feelings around what happens, while men use more avoidance strategies where they work through the event alone, in a more private manner, often through activities and rituals. This lack of synchronism can lead to blaming for not reacting enough, for dwelling on the thoughts about the lost one, or for lack of understanding of one’s partner’s reactions. Based on different reactions, the members of the family can have different expectations for how they perceive that other people should react and what kind of caring and comfort they want from a family member. When individual members of the family have been traumatized, there may be large differences in the recovery time needed. This is difficult as the different members may be at different stages in the recovery process.

Children grieve differently than adults, although the types of reactions are similar. They are able to distract themselves and be absorbed in other activities, while in the next moment being very aware, even overwhelmed, by the thoughts of what has happened. Children’s emotional span is shorter than adults, they usually are not very sad for long periods of time, and may shock adults with their questions and behavior. Do not put pressure on them to behave or grieve in a certain fashion. Many children use time before they are able to confront the loss, and may be unwilling to talk about what has happened (this is especially so for boys). If the child is doing okay in school, does not withdraw from friends, and does not evidence major personality changes, have patience, but use natural opportunities to start a conversation about what has happened.

Internal Dynamics - Sub-Level Conflict

A trauma shatters the illusion of invulnerability and makes the parents and children very prone to expect the worst. In parents this often leads to a need to control, restrict and limit the child in a way that sometimes preclude them from developing autonomy and independence, or make them prone to develop into more anxious children. This overprotection can limit the child’s development and make them more anxious. However, anxiety in children can develop as a consequence of misperception and fantasies on their behalf as well. Only by being interested in and asking about their perceptions can adults understand what goes on inside children’s heads.

Both following non-death trauma, but especially following bereavement, roles within the family may be transformed. A traumatized parent may be unable to fulfill his or her role obligations, both regarding practical tasks in the family, but also in providing the emotional support that children may need. While the effects of depression in parents on small children are well researched, less is known about what effects trauma in parents has on children. Parental trauma may sometimes result in too much pressure on children:

Following the accidental death of her father, a teenage girl, an only child, had to make dinner for her mother every day as the mother became dysfunctional at home, returning exhausted from her workday. In a joint session with her mother, about one and a half months following her father’s death, she exploded and accused her mother bitterly of ruining her life. She complained that she had no time for friends, no time for her school lessons, and she got no comfort from her mother at all. "I feel like your mother."

If possible a constructive discussion on what has happened to the role functions that the deceased took care of, and in what ways other needs of various family members are cared for in the present situation could be talked about in the family, maybe with the assistance of someone with experience in leading such family discussions.

Family Dynamite - Social Network Problems

Family recovery does not take place in vacuum. How successfully the family can deal with trauma and grief is partly dependent on the interaction with their social network. Although much of the grief and trauma literature specifies the importance of the social network, there are reports from both the trauma and the grief area that have pointed out some problems that can arise between traumatized family members and their social network. Too easily we tend to think that most families are met by understanding from their friends and family, a network that will help them talk about the event and provide support and understanding. As a clinician I repeatedly hear how difficult this interaction with the social network can be. Although there usually is an immediate outpour of concern and an increase of social attention immediately following a trauma or loss, many traumatized family members soon perceive a lack of deeper understanding of their reactions, both regarding type, intensity and duration. Many describe how, sometimes already after some weeks, there is a pressure to conform to a norm of rapid recovery where members of their social network wants to hear that things are going better and everything is returning to normal. With a disaster of this magnitude, there will be more acknowledgement of the depth of the tragedy and continued social support. However, an inadequately understood social psychological process is at work, where it seems that many people doesn’t want to be reminded of the fact that horrible things can happen to everyone. Those who have experienced a trauma or a recent loss become a reminder of our own vulnerability. Therefore people often refrain from making contact over time, or actively avoid traumatized people when they see them, leaving the traumatized person and family in a social vacuum. This vacuum can be reinforced by family member’s own perception of not being understood that leads to a withdrawal from the social network on their part.

As traumatic events often lead to a revaluation of values in life, it is not uncommon that a different rate of maturation and growth occurs in the family, compared to their former social network. Often this leads the family to seek the company of other families with a similar experience, i.e., through grief groups or survivor groups, and to a gradual reduction in contact with their previous network members or to a renewal of their network over time. Traumatized people can find conversing with their old friends shallow, as they sense that they are concerned with the trivialities of life instead of more "real" issues.

Social network problems can also lead to blaming between the family and their social network. The traumatized family members can blame their network for lack of understanding, for not making enough contact, for forgetting them, or for not helping enough. The social network can find the family demanding; blame them for being to preoccupied or for nurturing the loss or trauma, or for being to sensitive and moody. Sometimes this can have a dramatic impact on close relationships.

This is a phenomenon that adolescents often experience as well. They can find their friends and their friends activities less interesting before and may gradually withdraw from what they find are "empty" activities. As adults we may have to explain to them why they experience this, i.e., that the disaster has triggered a maturational "spurt" and that they should keep up their social contacts even though they for a time find them more "shallow".

Intervention to Promote Family Recovery

Immediately after a trauma, the family continues to be in a situation where everything they experience is experienced with more intensity than normal. This means that the caring climate around them has the potential to be felt as very caring and helpful, or distant, cold and unhelpful. This makes it extremely important that the family is met by a good system for immediate help. Because of the heightened sensitivity to all aspects of their environment, a high emphasis must be placed on establishing a caring climate. Parents and siblings can years after an event return to this situation, either with a positive focus: "The doctor had tears in his eyes. Can you imagine that he cared so much for us that he cried", or with strong, negative intrusive memories: "I will never forget how we were left waiting and waiting with no information at all."

Psycho-Educational Intervention

It is very important to receive information about normal psychological reactions that may be experienced by family members over time. Almost every family return to the value of the information they received about various reactions (thoughts, feelings, behavior) that are common after a trauma. Being mentally prepared for what is to be expected helps identify, sort out and accept reactions as part of a normal reaction, and helps in understanding what happens within themselves and in their relationship. Parents should make sure that children and adolescents get the same information. Many adolescents can be frightened by the intensity of the emotions they experience, and may fear they are turning crazy, others are amazed that their friends and teachers so soon forget what they have been through.

Handling Traumatic Reminders

Finding acceptable ways of handling traumatic reminders within the family is very important. How are the family members able to deal with the reminders, i.e. viewing the television coverage of the disaster and the investigation? In what way are they able to modulate the strong affect triggered by the reminders? Talking about the reminders, identifying what triggers reactions, and learning ways to gradually approach difficult reminders are crucial for regulating emotions, and can determine how this is done for the rest of a person’s life. Handling reminders often involve returning to places, meeting persons, or confronting activities that involve the presence of emotional pain resulting in avoidance. After family trauma, we have found that a confrontational approach to such situations benefits family members, adults or children alike. Family members or individuals should be properly prepared for entering the situation, be accompanied by others, and have control over the tempo of approach, and be followed up afterwards.

Besides helping the family members with both their emotional and cognitive work-through of the traumatic event helpers must focus on the sensory impressions and intrusive recollections that result from the disaster. Unfortunately, many families receive inadequate help in working through their traumatic moments in a second by second, detailed fashion. There is a need for professional competence in this area, as it is not enough simply to tell one’s story. If that is done, both important thoughts and sensory impressions are often left out. Without proper help in this regard, there is an increased chance of sensory impressions turning into long-term traumatic recollections. Lately, I have added what I find to be an important aspect to the follow-up information I give to families within the two first weeks following a sudden, traumatic event. The family members who have been exposed to strong sensory impressions are given advice on what they can do to take control of the intrusive memories. I tell them to imagine that they see the image (or film) on a television-screen. They are then instructed to imagine that they have a remote control in their hand, and to turn the image off. Alternatively, they are asked to see the haunting image in front of them, and then to move it further and further away from them, until it finally reaches the wall, or to change the image from color into black and white, etc. Such simple methods have been reported as very helpful for those who struggle with memories they have no control over. There is a variety of such "control methods" that can help family members take control over intrusive images.

Family Dynamics Intervention

Early on in the intervention, preferably within the first two weeks of the event, but not in the first shock phase, partners must receive information concerning usual gender differences. This may prevent undue blaming between the partners, lessen potential conflicts, and increase their sense of control. The information should be verbal and written. The following themes should be discussed to secure more understanding between partners and within the family:

a) speed of recovery, intensity of reactions, anticipation of conflicts

b) interpretation of partner-behavior, i.e., when men contain their emotions to protect women from further hurt

c) discussion of how to publicly display their reactions

d) information on possible grief competition and grief ownership

e) self-blame and blame of partner

f) differences in perception of appropriate reactions and grieving.

By giving such information and discussing these themes, men’s sense of incompetence at formulating own reactions into words may be reduced, and they may feel more at ease in participating in the follow-up, though they may not contribute as much as women in talking about emotions. By helping the family members exchange information, express emotions and listen to each other, intra-family cohesion is advanced.

Both from our empirical studies and my clinical experience I know that the care and concern following tragic losses often focus on females. This may stimulate men to disregard their reactions, leading to them pulling themselves together and be strong for their partner. Unfortunately such behavior can lead to more isolation and less emotional support for men. Our interventions must take such experience into account and make sure that the men’s reactions are accepted, not rejected. Men are not particularly good at asking for what they need, and maybe they are more unaware of their own emotional needs. Men have a different oral tradition than women. While women more directly talk and confide in each other about emotional matters, men more often tell stories. Men’s stories can be action oriented and are more seldom put in written form., i.e. in a diary.

Rolf (12 ½ years old) lost his brother in an accident. When asked if he had written about what had happened he looked at me as if I was from a different planet. It was obvious that writing a diary was something girls did. But when I persisted asking if he in some way had written about his brother, he said: "Do you mean on the PC?" When I asked what he had written there he said he had written about things that he and his brother had done together. He read this when he missed his brother and it lessened the pain.

Another noticeable difference between men and women are that men tend to give more advice; while women are less action oriented and listen more. Men are usually less able to read non-verbal cues than women are. In follow-up sessions it thus can be helpful to use some time explaining and exemplifying non-verbal communication, helping men to become more active in both seeing their partner's needs, and in expressing their own needs. Low-conflict couples have been found to use non-verbal communication and code words and signals to let each other know how they feel.

Improving family communication and cohesion is not an easy task. By making the discussion of communication, role distribution, emotional gratification, conflict, etc., part of the follow-up sessions, it is possible to work directly to establish a favorable climate for recovery from trauma. In a similar manner we can help families understand social network reactions and give them practical suggestions for how they can activate their social resources.

In an article published earlier this year I summed up the knowledge we have about communicating with children about traumatic events (Dyregrov, A. (2001). Telling the truth or hiding the facts. An evaluation of current strategies for assisting children following adverse events. Association for Child Psychology and Psychiatry Occasional papers nr. 17, 25-38.)

Based on this the following recommendations can be made for long-term caring for children:

1. Adults need to continue to communicate openly and directly with children. Trauma and loss reactions take time, and thus they have a potential need to talk about the disaster or its consequences long after it happened. It is, however, not enough to point out the need for open and honest communication, families need practical suggestions and role models for how they can communicate about traumatic events, and the family changes that can originate following such events.

Early intervention in families who experience trauma should include helping families to develop constructive ways of communicating openly and honestly about what happened and it’s effects on the family. By providing a model for emphatic listening, ways of asking questions, clarifying affects, allowing children to have their say, providing feedback, etc., a caring, supportive climate within the family can be established. By making the discussion of communication, role distribution, emotional gratification, conflict, etc., part of the follow-up sessions, it is possible to work directly to establish a favorable climate for recovery from loss or trauma. By regularly having family meetings, at increasingly spaced intervals over an extended period of time, this supportive communication climate can be sustained.

2. We need to educate adults on children’s need to make sense of events, by creating or constructing a narrative or total picture of what happened, even when children are quite small. For children more directly exposed (or having problems as a consequence of the extensive media coverage), they should be allowed a chance to describe what happened, the thoughts related to what happened, understanding what caused the disaster and what they did to survive it, as well as giving words or another form of expression (i.e., drawing) to the different sensory impressions experienced during the disaster (or media exposure), and the reactions that ensued. This is recommendable to prevent the event from having unnecessary consequences. If parents and children or adolescents experienced the disaster together, this detailed review should be done with all persons involved present, as this increases the chance of getting a full picture of what happened.
3. We need to talk to children directly about traumatic events. This is the only way to ensure that we understand what children have experienced, how they have understood their experience and the facts they are missing to be able to construct a full narrative from what happened. We also need to make sure that children are asked, or that we listen carefully, about their understanding of "why" something happened. Cause and meaning are important aspects of the reality construction that takes place following adverse events, and this construction have an important impact on the development of basic assumptions throughout childhood.
4. When telling the truth we do not need to hit the child over the head with facts. While the focus is on open, truthful and direct information, we need not give them all details, i.e., about parental disputes that preceded a death, etc. If children ask about details, however, I suggest we tell the truth without deliberating on the grotesque or scary details. Telling the truth is a good strategy also when it comes to more advanced explanations for the background of a tragic event, i.e. why persons can commit such atrocities.
5. Trauma will oftentimes affect the family system in different ways, and thorough family intervention will need to explain family dynamics to children and adults alike in addition to providing information on common trauma reactions. The therapeutic tasks of preparation, explanation, interpretation and teaching are activities that help foster the intra-family environment and can prevent the development of blocks to recovery.
6. While there is a wealth of studies documenting the importance of preparing children and adults for surgery, there is little written about the importance of providing children and adolescents with a map of the terrain they are going to walk in following the experience of traumatic events. Good quality trauma intervention must be specific in providing children and adolescents with advice on how to handle the after-effects of traumatic events. This information will have to be provided both verbally and written.
7. We need to reconsider how we include children in rituals. Although clinical experience and empirical research support including children in such activities, we do need to put more emphasis on preparing for and helping children through such activities.

Conclusion

Following a trauma it is hard to face the future, one dwell on what has been (past), and the present is so painful. As helpers, friends or family our role is to help the family to live in the present, not being overwhelmed by the past, and build up positive expectations for the future. Most people underestimate the time course for trauma and loss reactions. Regardless of the time it may take to establish new meaning in life, most families can learn to live with what has happened in a way that ensures the continued health of all family members. If the disaster is dealt with openly and directly within the family, and children and adolescents’ needs are acknowledged and met, they can go on with the tasks of development in a constructive manner. As adults we can help children maintain and develop the inner representations or images of their loved ones, not embedded by the anger resulting from the tragedy, but as good memories they can continue to experience in fantasy.

International Critical Incident Stress Foundation, Inc.
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