This document summarizes a presentation on how traumatic bereavement affects children and young people, and what can be done to help them. It discusses how trauma impacts memory and meaning-making, and how this can obstruct the grieving process. It then outlines risk factors for PTSD and reviews cognitive models of trauma. Finally, it discusses interventions that can help repair safety, support social support networks, and straighten the path of grief for those experiencing traumatic bereavement.

1. 10/3/14
David
Trickey
Consultant
Clinical
Psychologist
Trauma
Specialist
Too
Scared
to
be
Sad:
How
trauma1c
bereavement
affects
children
and
young
people
and
what
can
be
done
to
help
them
The
Irish
Child
Bereavement
Network
Conference
4th
October
2014
Dublin
Castle
Overview
• How
trauma
impacts
on
children
and
young
people
• How
the
traumaJc
nature
of
the
event
of
the
death
can
obstruct
the
grieving
process
• What
can
be
done
to
help
Cogni1ve
Model
of
PTSD
in
CYP
(Meiser-­‐Stedman,
2002)
Ehlers
&
Clark,
2000
Brewin
et
al.,
2010
Memory
Meaning
Maintenance
Symptoms
of
PTSD
EffecJve
Risk
factors
intervenJons
Normal
event
memories
Contextualised
representa4ons
(C-­‐reps)
Memory
store
Unconscious
Conscious
Normal
event
Trauma1c
event
memories
Sensory-­‐bound
representa4ons
(S-­‐reps)
• Memories
for
traumaJc
events
are
different:
– Raw
sensory
data
rather
than
words,
stories
and
meaning
– AutomaJcally
triggered
rather
than
recalled
on
purpose
– “Here
and
now”
rather
than
“there
and
then”
– StaJc
and
frozen
rather
than
fluid
and
updateable
– Fragmented
incoherent
rather
than
organised
flowing
narraJve
Trauma1c
event
memories
Sensory-­‐bound
representa4ons
(S-­‐Reps)
Memory
store
Unconscious
Conscious
Normal
event
TraumaJc
event
©
David
Trickey,
Consultant
Clinical
Psychologist
www.davidtrickey.com
1

2. 10/3/14
Maintenance
cycle
of
avoidance
Intrusions
Memory
not
processed
(e.g.
memories,
images,
dreams,
thoughts)
Memory
or
thought
suppressed
and
avoided
Original
fear,
horror,
helplessness
Pierre
Janet
(1889,
1906)
• “Fixed
ideas”
or
traumaJc
events,
rather
than
proper
memories
• VicJms
are
“unable
to
make
the
recital
which
we
call
narraJve
memory
and
yet
they
remain
confronted
by
the
difficult
situaJon”
• ConJnue
to
make
efforts
at
adaptaJon
S-­‐Reps
and
brain
ac1vity
–
PET
scans
(Rauch
et
al.,
1996)
N.B.
Neuropsychology
is
never
quite
a
simple
as
people
would
like
it
to
be
More
acJve
(compared
to
C-­‐Reps)
Less
acJve
(compared
to
C-­‐Reps)
Session
by
session
CRIES
scores
40
35
30
25
20
15
10
5
0
Assessment
Session
2nd
Session
3rd
Session
4th
Total
score
PTSD
Threshold
Session
5th
Discharge
Intrusions
Avoidance
TOTAL
Meaning:
Core
Beliefs
• People
act
as
if
their
assumpJons
were
truths
rather
than
constantly
re-­‐examine
them
• Domains:
– Self
(worthy,
loveable)
– World
(benevolent,
makes
sense,
safe
enough)
– Others
(trustworthy,
worth
relaJng
to)
• Usually
unconscious,
unarJculated,
taken
for
granted
• Evident
from
people’s
acJons
more
than
thoughts
Other
people
Beliefs
Meaning
Normal
event
Percep,on
©
David
Trickey,
Consultant
Clinical
Psychologist
www.davidtrickey.com
2

3. 10/3/14
Meaning:
Trauma1c
events
literally
break
the
rules
Other
people
Beliefs
Trauma4c
event
Belief
–
Threat
–
Behaviour
–
Belief
Beliefs
Father
takes
his
own
life
World
is
unsafe
Adults
are
dangerous
(especially
those
that
are
supposed
to
care
for
you),
I
am
unlovable,
uncontainable
Thoughts
They’re
only
being
nice
to
me
to
get
close
to
me,
then
they’ll
hurt
me
Placement
disrupJon
Others
reminiscing
Emo1ons
Fear
Physiology
Hyper-­‐arousal
Behaviour
Rejects
carers,
lashes
out
System (actively encouraged avoidance)
Emo1on
Fear
Belief
–
Threat
–
Avoidance
Thoughts
If
I
go
out,
I
will
be
in
danger
Physiological
Various
symptoms
Beliefs
World
is
unsafe
Others
are
evil
I
am
vulnerable
Friend
murdered
OpportuniJes
to
go
out
Behaviour
Avoid
going
out
Belief
–
Threat
–
Hypervigilence
Emo1on
Fear
System
Thoughts
I
must
be
on
my
guard
Physiological
Hypervigilence
Loved
one killed
Beliefs
The
world
is
dangerous
Other
people
are
harmful
Behaviour
Look
for
(and
see)
poten4al
danger
Emo1on
Anger,
sadness
Belief
–
Guilt
–
Avoidance
System
Thoughts
It
was
my
fault,
I
deserved
it
Physiological
Various
symptoms
Family
homicide
Beliefs
The
world
is
ordered
and
just
I
am
a
bad
person
Reminders
Behaviour
Avoid
thinking
it
through
and
correc4ng
mis-­‐
percep4ons
Cycle
of
vicarious
avoidance
ADULTS:
Not
menJoned
ADULTS:
Talking
about
it
might
upset
him
and
may
even
make
him
worse
CHILD:
Maybe
they
can’t
bear
to
have
a
conversaJon
about
it
CHILD:
Not
menJoned
©
David
Trickey,
Consultant
Clinical
Psychologist
www.davidtrickey.com
3

4. 10/3/14
What
makes
an
event
trauma1c?
Avoidance
• Problems
are
maintained
by
avoidance
• The
event
is
distressing
to
recall
so
people
try
hard
not
to
think
or
talk
about
it
• So
they
do
not
“process”
the
memory,
which
means:
– The
memory
remains
in
its
traumaJc
form
– It
is
difficult
to
make
useful
sense
of
Diagnos1c
Criteria
PTSD
(DSM-­‐5,
2013)
A.
Exposure
B.
Intrusions
C.
Avoidance
D.
Changes
in
cogni1ons
and
mood
E.
Arousal
&
reac1vity
F.
DuraJon
G.
Distress
H.
Due
to
event,
and
not
substance
or
medical
condiJon
Recovery
following
accidental
injury
(Le
Brocque
et
al.,
2010)
Chronic
10%
Recovery
33%
Average
30
25
20
15
10
5
0
Resilient
57%
0
20
40
60
80
100
120
140
160
180
CRIES
Days
Meta
Analysis
of
Risk
Factors
for
PTSD
in
Adults
(Brewin
et
al.,
2002)
0.23
0.32
0.40
(sig
variability)
0.00
0.05
0.10
0.15
0.20
0.25
0.30
0.35
0.40
0.45
Lack
of
social
support
Subsequent
life
stress
Trauma
severity*
Meta
Analysis
of
Risk
Factors
for
PTSD
in
CYP
(Trickey
et
al.,
2012)
(sig.
variability)
0.03
0.15
0.15
0.21
0.36
0.36
0.33
0.29
0.29
0.47
0.46
0.64
0.70
(n.s.)
0.00
0.10
0.20
0.30
0.40
0.50
0.60
0.70
0.80
Thought
suppression
(2)
PTSD
(T1)
(4)
DistracJon
(2)
Poor
family
funcJoning
(7)
Perceived
life
threat
(6)
Peri-­‐traumaJc
fear
(3)
Low
Social
support
(4)
Parental
Psych
Prob
(25)
Trauma
severity*
(41)
Pre-­‐trauma
life
events
(8)
Female
(29)
Prior
psych
probs
(14)
Younger
age
(18)
Trauma1c
Bereavement:
more
than
the
sum
of
its
parts
Impact
of
bereavement
+
Impact
of
trauma
+
Trauma
impedes
grieving
©
David
Trickey,
Consultant
Clinical
Psychologist
www.davidtrickey.com
4

5. 10/3/14
Straightening
the
path:
What
helps?
Bereavement
Grief
Adjustment
• Saying
goodbye
• Safety
&
stability
• Knowledge
&
informaJon
• Expressing
grief
&
emoJons
• Good
aoachment
&
family
relaJonships
• Social
support
• Meaning
making
• ConJnuing
bonds
What
helps
straighten
the
path?
Bereavement
Grief
Adjustment
• Saying
goodbye
• Safety
&
stability
• Knowledge
&
informaJon
• Expressing
grief
&
emoJons
Trauma,c
nature
of
the
death
• Good
aoachment
&
family
relaJonships
• Social
support
• Meaning
making
• ConJnuing
bonds
Trauma1c
inhibitors
to
grief
• Much
of
what
helps
with
grief
involves
bringing
the
deceased
to
mind,
thinking
about
their
life,
and
being
sad
about
the
loss
• But
those
trauma4cally
bereaved
may
feel:
– Too
scared
-­‐
images
of
the
event
of
the
death
take
precedence
over
memories
of
the
person
who
died
– Too
guilty
-­‐
feelings
of
guilt
take
precedence
over
sadness,
or
the
bereavedperson
thinks
that
they
deserve
to
feel
this
way
– Too
angry
-­‐
feelings
of
anger,
and
plans
for
revenge
occupy
the
person
at
the
expense
of
grief
Limited
goodbyes
• Children
bereaved
unexpectedly
do
not
have
the
opportunity
to
say
goodbye
• They
may
deny
or
not
understand
the
death,
and
therefore
not
see
the
need
to
say
goodbye
• Body
may
be
disfigured,
withheld
by
authoriJes,
or
missing;
further
denying
a
chance
to
say
goodbye
Making
the
best
goodbye
possible
• Viewing
the
body
can
help:
– Provides
“proof”
of
the
death
– Aides
understanding
of
death
– Offers
opportunity
to
say
goodbye
• Support
families
to
make
well-­‐informed
decisions
• Manage
expectaJons
• Make
use
of
rituals
(e.g.
Memorial
services,
school
assemblies,
balloons,
headstones
etc)
Sense
of
safety
and
stability
undermined
• Bereavement
may
undermine
view
of
the
world
as
safe-­‐enough;
traumaJc
bereavement
may
shaoer
that
view
• The
world
usually
seems
safe
enough
because
of
secure
aoachment,
predictable
rouJnes
and
familiarity:
– The
aoachment
figure
may
be
“unavailable”
– Subsequent
changes
may
remove
sense
of
predictability
– Familiar
things
and
places
may
be
unavailable
©
David
Trickey,
Consultant
Clinical
Psychologist
www.davidtrickey.com
5

6. 10/3/14
Repairing
sense
of
safety
and
stability
• Basic
needs
must
be
met
first
• Help
carers
to
re-­‐establish
rouJnes
• Help
carers
to
mobilise
their
own
support
systems
• Teach
emoJonal
regulaJon
skills
(e.g.
RelaxaJon)
• Provide
lots
of
“ordinary”,
even
though
it
seems
like
they
need
lots
of
“special”
Lack
of
helpful
social
support
• Friends
may
not
know
what
to
say
and
may
avoid
• Peers
may
say
apparently
cruel
things
• Bereaved
young
people
may
feel
different
to
their
peers,
and
so
isolate
themselves
• Bereaved
young
people
may
try
to
protect
others
by
not
talking
about
it,
or
not
gerng
upset
Presence
of
unhelpful
social
support
• Secondary
wounds
of
media
– SensaJonal
may
be
more
important
than
accurate
– May
approach
families
at
their
most
vulnerable
• Such
events
someJmes
aoract
“helpers”
who
may
not
actually
be
that
helpful
• Media,
“helpers”,
and
police
may
all
move
on
just
when
family
needs
stability
Enhancing
Social
Support
• Media
intrusion:
– Warn
and
prepare
family
– Use
Police
to
limit
intrusions
– Help
children
to
understand
the
role
of
media
• Short-­‐term
helpers:
– Ensure
they
are
in
it
for
the
long
haul
– Help
family
to
be
fussy
about
whom
they
let
into
their
lives
– Sign
post
longer
term
help
to
family
• Friends
and
family:
– Support
adults
with
their
grief
– Encourage
open
and
honest
communicaJon
– Help
parents
to
understand
and
help
their
children
– Signpost
alternaJve
sources
of
support
(e.g.
Bereavement
group)
Groups
• Many
services
offer
their
intervenJon
in
groups
• Universality;
normalises
experiences
and
reacJons
• Altruism
• Credibility
of
peers
as
counsellors
• SomeJmes,
you
really
do
have
to
have
been
there
(or
somewhere
similar)
• Reduces
sJgma
of
receiving
support
• Gives
“permission”
to
grieve
• Social
support
more
accessible
If
perpetrator
is
a
family
member
• Possible
ambivalent
feelings
towards
perpetrator
• Divided
loyalJes
to
each
side
of
the
family
• One
part
of
the
family
may
struggle
with
child’s
loyalty
to
another
part
• VisiJng
perpetrator
in
prison
can
be
problemaJc,
but
for
some
has
therapeuJc
potenJal
©
David
Trickey,
Consultant
Clinical
Psychologist
www.davidtrickey.com
6

7. 10/3/14
Grief
and
emo1ons
inhibited
• InhibiJon
–
may
try
to
protect
others
by
not
showing
distress
• Different
family
members
may
be
feeling
different
things
at
different
Jmes
• Too
scared
by
the
death,
to
be
sad
about
the
loss
Facilita1ng
emo1onal
expression
• Permission
and
normalisaJon
• AcJviJes
(e.g.
crat
or
exercise)
• Family
may
need
help
to
tolerate
different
emoJons,
at
different
Jmes
by
different
people
• May
need
to
“process”
the
event
of
the
death,
before
they
can
grieve
the
loss
Con1nuing
bonds
hampered
• Carers
may
be
avoidant
• Some
family
members
may
exaggerate
negaJve
stories
of
deceased
• Keepsakes
may
be
damaged
or
unavailable
• Vivid
sharp
frightening
traumaJc
memories
or
images
of
the
death,
may
take
precedence
over
other
soter,
sadder
memories
of
the
person’s
life.
Developing
con1nuing
bonds
• Enable
processing
of
the
event
of
the
death,
to
allow
access
to
memories
of
the
person
• Reminiscing:
– Listening
to
and
telling
stories
– Adding
new
ones
– ToleraJng
good
and
bad
stories
– ToleraJng
strong
emoJons
– Concrete
aide
memoires
(e.g.
salt
sculptures
memory
boxes,
story
telling,
memorial
visits,
leoer
wriJng)
to
keep
memories
fresh
Meaning
making
difficult
• Firng
any
loss
into
a
helpful
view
of
the
world
can
be
hard
enough
• But
accommodaJng
and
assimilaJng
the
event
of
a
trauma4c
death
is
more
than
doubly
difficult
• Meaning
making
requires
bringing
the
death
to
mind
and
so
is
hampered
by
reluctance
and
avoidance
• Children
rely
on
those
around
them
to
make
sense
of
the
world
and
events
Informa1on
may
be
witheld
• What
and
how
have
to
come
before
why
or
why
me,
so
an
adequate
account
is
needed
to
enable
some
sort
of
meaning-­‐making
• TraumaJc
nature
of
death
may
mean
that
informaJon
is
delayed,
uncertain
or
absent
• In
an
understandable
aoempt
to
protect
them
from
further
distress,
children
are
oten
not
told
the
whole
truth…
©
David
Trickey,
Consultant
Clinical
Psychologist
www.davidtrickey.com
7

8. 10/3/14
…but
what
if
• What
they
are
told
does
not
tally
with
what
they
saw
or
overhear
• They
fill
in
the
gaps
with
a
fantasy
that
is
worse
than
the
reality
• They
find
out
the
truth
in
an
unhelpful
way
(e.g.
playground,
t.v.,
30
years
later)
• Media
presents
a
different
version
• They
ask
“awkward”
quesJons
• Different
adults
have
different
views
on
what
should
be
said
• It
gets
harder
not
easier
to
tell
them
the
truth
Criminal
aspects
may
also
impede
meaning
making
• Trial
may
be
delayed,
keeping
everyone
hanging
on
• Perpetrator
may
plead
innocent,
causing
confusion
and
/
or
anger
• Trial
may
be
unsuccessful
or
result
in
a
short
sentence,
leading
to
disappointment
or
fear
• Therapy
may
conflict
with
giving
evidence
• Trial
can
be
re-­‐traumaJsing
• Defence
may
be
“provocaJon”
leading
to
very
shaming
accounts
of
vicJm
during
trial
Criminal
aspects
may
also
impede
meaning
making
• Trial
may
be
delayed,
keeping
everyone
waiJng
• Defendant
may
plead
not
guilty
(or
actually
be
not
guilty)
causing
confusion
or
anger
for
children
• Trial
may
be
unsuccessful
or
result
in
a
short
sentence,
leading
to
disappointment
or
fear
• Therapy
may
conflict
with
giving
evidence
• Trial
can
be
re-­‐traumaJsing
• Defence
may
be
“provocaJon”
leading
to
very
shaming
accounts
of
vicJm
during
trial
Processing
of
trauma1c
memories
(Developing
a
descripJon
and
useful
explanaJon)
• Overcome
avoidance
and
bring
the
traumaJc
event
to
mind
– (i.e.
“think”
about
it)
• Develop
a
coherent
narraJve
– (i.e.
“wrap
up”
the
sensory
informaJon
with
words)
• Make
realisJc
and
helpful
meaning
e.g.
– Realise
how
safe
the
world
is,
rather
than
just
how
dangerous
it
is
– Be
more
appreciaJve
of
others
Processing
of
trauma1c
memories
• Requires:
safety,
support,
informaJon,
all
of
which
may
be
lacking
• OpportuniJes
to
talk
or
think
it
through
may
also
be
lacking
because
of
– SJgma
– Not
knowing
what
to
say
– Fear
of
the
bereaved
person’s
distress
– Fear
of
their
own
distress
– Not
wanJng
their
helpful
assumpJons
to
be
challenged
• But
whilst
something
is
unmenJonable,
it’s
likely
to
remain
unmanageable
Enabling
processing
• Many
children
make
use
of
their
pre-­‐exisJng
relaJonships
(e.g.
family,
school,
pets)
which
enable
processing
by:
– Making
the
death
talkable-­‐about,
and
thinkable-­‐about
– Helping
re-­‐appraisals
&
correcJng
mis-­‐percepJons
– Providing
support
to
avoid
avoidance
• Professionals
can
explore
any
resistance
(in
child
and
those
around
them)
to
talking
about
it
(e.g.
protecJon,
guilt)
and
offer
support
where
appropriate
• Young
person
and
those
around
them
may
need
to
understand
how
thinking
about
it
might
help
(e.g.
Wardrobes,
chocolate
factories
and
waste
paper
bins)
©
David
Trickey,
Consultant
Clinical
Psychologist
www.davidtrickey.com
8

9. 10/3/14
Formal
interven1ons
• Standard
intervenJons
for
uncomplicated
grief
may
not
work
– IntervenJon
may
trigger
traumaJc
memories
– Young
person
may
drop
out
because
of
their
avoidance
Trauma-­‐focussed
sessions
(Cohen
et
al.
2004)
• PsychoeducaJon
• Feeling
idenJficaJon,
affecJve
modulaJon,
relaxaJon
• CogniJve
triad
(Thoughts
–
Feelings
–
Behaviour)
• RaJonale
for
creaJng
trauma
narraJve
• CreaJon
of
trauma
narraJve
and
cogniJve
restructuring
My
life
before
The
worst
part
of
it
My
life
since
My
hopes
for
my
future
Grief-­‐focussed
sessions
• Grief
psycho-­‐educaJon
• CreaJng
and
preserving
memories
of
the
deceased
• ConverJng
relaJonship
from
interacJon
to
memory
• Recommirng
to
current
relaJonships
• Making
meaning
of
the
loss
Endings
• Predict
&
prepare
• GraduaJon
Evidence
(1
of
2)
• Layne
et
al
2001
– 55
x
15-­‐19
yr
olds,
from
Bosnia
– Decrease
in
symptoms
of
depression,
PTSD
and
CTG
• Saltzman
et
al
2001
– 26
x
11-­‐14
yr
olds
with
PTSD
symptoms
following
community
violence,
7
had
been
bereaved
of
a
loved
one
– Decrease
in
symptoms
of
PTSD
and
CTG
©
David
Trickey,
Consultant
Clinical
Psychologist
www.davidtrickey.com
9

10. 10/3/14
Evidence
(2
of
2)
• Cohen
et
al
2006
– 39
x
6-­‐17
yr
olds
with
CTG
– Parents
included
in
parallel
sessions
– Decrease
in:
• Children’s
PTSD
(only
during
trauma
focussed
module)
• Children’s
depression
• Children’s
anxiety
• Children’s
behavioural
problems
• CTG
• Parental
PTSD
In
summary
• When
a
child
is
bereaved,
there
are
various
things
that
oten
help
that
child
to
grieve
the
loss
and
adjust
• But
if
the
bereavement
is
“traumaJc”
then
many
of
those
things
are
compromised
or
missing
• Such
that
the
traumaJc
nature
of
the
death
prevents
the
child
from
grieving
• There
are
things
that
can
be
done
to
support
traumaJcally
bereaved
children
to
process
the
event
of
the
death,
and
then
they
can
begin
to
grieve
their
loss
©
David
Trickey,
Consultant
Clinical
Psychologist
www.davidtrickey.com
10