TREATING TRAUMA AND GRIEF: A HIERARCHY OF NEEDS

John was referred to me for counseling after his wife was killed by a drunk driver in a head-on collision witnessed by John.  Mary came to see me for grief counseling after her husband died a painful and horrific death from cancer.  Louise is seeing me to deal with intrusive memories of her brothers’ emotional abuse when she was caring for her dying father.

These three situations are different in many ways – different relationships, different coping mechanisms, different types of deaths.  However, each of these individuals is experiencing traumatic grief.  It might be more accurate to say that they are experiencing the effects of trauma that are preventing them from processing their grief in a healthy way.

Through my work with many clients experiencing traumatic grief, I have come to understand that trauma must be processed before the loss of a loved one can be processed in a healthy way.  This truth brings to mind “Maslow’s Hierarchy of Needs.”

Abraham Maslow was a psychologist who posited that basic physiological needs, such as food and shelter, and then safety and security, must be attended to before one can accomplish “higher” needs, such as a sense of belonging, and ultimately, self-actualization and the achievement of one’s potential.  The classic diagram for Maslow’s Hierarchy of Needs is a pyramid, with fundamental physical needs at the broad base of the pyramid, and self-actualization at its pinnacle.

In describing self-actualization, Maslow (1943) said:

“[S]elf-actualization… refers to the desire for self-fulfillment.  This tendency might be phrased as the desire to become more and more what one is, to become everything that one is capable of becoming.”

The prioritization of needs to be attended to in the work of healing trauma and grief strikingly parallels Maslow’s hierarchy of needs.  This hierarchy is reflected in trauma therapies like EMDR, which works first on the physical realm, then the behavioral, cognitive, emotional and ultimately the spiritual realm of existence.

The physical effects of trauma can be tremendous.  Many traumatized individuals have difficulty sleeping due to intrusive images and thoughts.  They are often hyper-vigilant, leading to imbalances in the adrenal and other bodily systems. These physical effects can lead to other dire effects, such as deep depression and suicidality. It is thus critical to treat these physical effects of trauma as the first priority.  Moreover, if one is experiencing the physical effects of trauma, it is virtually impossible to process the loss of a loved one in a healthy way.

Moving up the pyramid, once physical symptoms are managed, it is necessary to deal with the behavioral dysfunctions that often result from trauma.  For example, a person trying to cope with trauma may turn to drugs or alcohol in a vain attempt to ease the pain.  He or she may also self-isolate and cut off sources of social support.  Finding healthy ways to cope and and cultivating support are important in healing trauma and grief.

Cognitive work can be seen as the next priority in processing trauma.  Negative self-beliefs go hand-in-hand with trauma.  For example, the surviving partner of a sudden or violent death may believe “it’s all my fault.” An individual dealing with an abusive relationship may believe “I don’t deserve love.”  Cognitive therapeutic work is thus necessary to let go of the power of such erroneous thoughts.

Once the grip of erroneous negative self-beliefs is loosened, and those beliefs are replaced with positive and healthy beliefs, one can then go about the work of healing grief.  The intense emotions and unpredictability of grief can be navigated successfully on the broad base of physical well-being, healthy ways of coping, and positive beliefs.

The healing of grief, like working to achieve the stages of Maslow’s Hierarchy of Needs, is a process of transformation and spiritual growth, i.e., self-actualization. The fruition of this process includes a sense of acceptance and realism, self-compassion and compassion for others, independence and interdependence, and an appreciation of life in all of its impermanence and imperfection.

References:

Maslow, A. H. (1943). A Theory of Human Motivation, Psychological Review 50, 370-96.

Maslow, A.H. (1943). Motivation and personality. New York: Harper.

 

 

Grief After Suicide: A Personal and Professional Perspective

My best friend Cassie committed suicide five years ago, and I sometimes still reel from the loss. Naturally, my initial reaction to Cassie’s sudden death was shock. I was unprepared for her death. In the months following Cassie’s suicide, I experienced a myriad of intense emotions: Of course, I was sad to lose my best friend. I had a bit of guilt, but primarily feelings of helplessness that there was nothing I could have done to prevent her self-destruction. I also felt a sense of shame, and was afraid people would condemn me somehow for allowing a friend to take her own life, despite the fact that I knew I had no control over her death. Perhaps the most intense feeling I experienced was anger. My feelings of anger would hit unpredictably, often when I was driving. I would smash my hand against the steering wheel and wail in anger and anguish — How dare Cassie leave me without saying goodbye? I hope no one saw me – they would surely have tried to have me committed!!

And yet, despite the seeming insanity of my profound grief, I knew, as a grief counselor, that my reactions were normal and that in fact my anger was healthy — better to extend my feelings of anger outward rather than turn my negative energy inward in a way that can fester in negative self-thoughts and depression.

Five years later, my grief can hit unpredictably — while listening to a piece of music that I associate with Cassie, when I have accomplished a goal she would have been happy to share in with me or other times. I have learned, both personally and through my professional work, to prepare for the more predictable moments of grief, such as Cassie’s birthday or the anniversary of her death. I have always told my bereavement clients that those anniversaries and important days stay in our bodies — sometimes our bodies know it before we do. In fact, I found myself walking around feeling particularly irritable and out of sorts about two years after Cassie’s death, only to realize later that it was in fact her birthday! My body knew it before my mind did. So, I practice what I preach and prepare for those important days and create rituals around those days. For example, I light a candle on the anniversary of Cassie’s death each year.

As I discussed in a prior article, suicide can be a form of “disenfranchised grief”, i.e., a grief that is not accepted by society, in this case, because of the nature of the death — Thus my feelings of shame. It was difficult for me to share my grief, other than with those who knew Cassie or had experienced a similar loss, out of fear of judgment or invalidation. As a result, I was often left feeling isolated and alone in my grief.

As a grief counselor, I tell my clients that we do not “get over” the death of someone close to us. Rather, we need to go through the pain of our grief. That process can be profoundly healing and transformative. We can find a place for our loved one in our life and in our heart. I know that Cassie is still there for me as a guardian angel, and I still ask her for guidance and support.

Suicide grief is understandably difficult, and it is important for those left behind to get support — whether through friends, family, spiritual community or a professional grief counselor, psychotherapist or grief/suicide support group. It is important to take care of ourselves — eat well, get exercise, sleep — because grief is exhausting and stressful. Journaling and other forms of expression can be immensely helpful for getting out the myriad of swirling emotions and thoughts. As someone who not only “talks the talk” but has “walked the walk,” I know how important it is to allow ourselves to go through the pain of our sudden loss and get support in the process in order to heal and grow.

EMDR as a Healing Tool in Transforming Traumatic Grief

The intense and painful experiences of grief are generally considered “normal.”  However, when those experiences are extremely distressing, unduly interfere with day-to-day functioning or do not subside to a manageable level over time, the bereaved may be experiencing complicated or traumatic grief.  Complicated grief has been proposed as a new diagnostic category in the Diagnostic and Statistical Manual of Mental Disorders (DSM), and suggested components of the diagnosis include (1) that sufferers experience bereavement by death; (2) that their reactions include intrusive and distressing symptoms, including yearning, longing and searching for the deceased; and (3) that the bereaved exhibit at least four marked and persistent trauma reactions, which may include:  “avoidance of reminders of the deceased,  purposelessness, feelings of futility, difficulty imagining a life without the deceased, numbness, detachment, feeling stunned, dazed or shocked, feeling that life is empty or meaningless, feeling a part of oneself has died, disbelief, excessive anger or bitterness related to the death, and identification symptoms or harmful behaviors resembling those suffered by the deceased” (Mitchell et al, 2004, p. 13).

Even in cases that do not fit the criteria for complicated grief as described above, the events surrounding the death may be sufficiently traumatic to interfere with daily functioning or result in unrelenting distress.  As a psychotherapist specializing in grief and loss, I have found EMDR (Eye Movement Desensitization and Reprocessing) to be an effective tool for alleviating trauma in grief.  As in grief, trauma affects the whole person — body, mind and spirit, and on a hierarchy of needs, trauma must be dealt with in order for the healing process of grief to proceed in a healthy, and healing, fashion.

What is EMDR?

In brief, EMDR was developed by psychologist Francine Shapiro after making a chance discovery that the lateral movement of her eyes reduced the intensity of disturbing material she was dealing with in her life (Shapiro, 1995, p. 2).  Dr. Shapiro spent several years scientifically studying this phenomenon, and found that bilateral stimulation, i.e., stimulation on both sides of the body — whether in the form of eye movements, tapping, sound or other forms — released traumatic material from the brain in a way that made the material workable. Trauma that is locked in the brain leads to the “fight, flight or freeze” response, and EMDR helps transform traumatic images into memories that no longer have a deleterious hold on the individual.

In addition to this physiological response to trauma, the traumatized individual often develops negative beliefs about him or herself (such as “I do not deserve love, “I was at fault” etc).  The beauty of EMDR is that it works on a cognitive level as well as the physiological level, not only facilitating the transformation of traumatic images in the brain, but also allowing the individual to replace negative cognitions about him or herself with positive ones (such as “I deserve love”, “I did the best I could”, etc.).  EMDR also works on a somatic level, with the therapist guiding the client to feel the traumatic images and negative beliefs in the body, thus further facilitating the transformation of the images into non-intrusive memories, and also transforming the negative beliefs into positive, useful ones. Therapists need to be trained to practice EMDR, and follow a standardized protocol in EMDR work with clients.

Case Studies

Two cases in my practice are illustrative of the effectiveness of EMDR in resolving traumatic grief.  “Carol”, the mother of two small children, came to see me complaining of ongoing distress after the death of her husband nine months before.  “Bill” was in a motorcycle accident, sustaining a broken leg. After being admitted to the hospital, Bill suffered a stroke and brain swelling, and died after being taken off life support two days later.  Carol was concerned about her irritability, particularly toward her children, and her anger toward Bill for dying and leaving her with two small children to raise alone. She also expressed guilt regarding her anger toward Bill, which I spent time validating and normalizing, since anger is often exhibited as a normal grief response.   Carol spent much time telling her story — a useful healing tool for making meaning of a seemingly senseless situation (White, 1995).  She did not exhibit signs of trauma for the first few months that we worked together.  However, as the anniversary of Bill’s death approached, Carol found it difficult to sleep, being awakened by intrusive images of Bill lying in the hospital bed and her shock when she learned of his condition.  We explored Carol’s negative cognitions around these images and Bill’s sudden death. The negative belief that that most impacted Carol was her belief that Bill’s death was her fault because she had a premonition that he would be in an accident, and she did nothing to prevent it.   In describing the images of Bill lying in the ICU and her belief that it was her fault, Carol felt tightness in her chest and had difficulty breathing. After two 90-minute EMDR sessions, Carol was able to replace her negative belief “I was at fault” with the positive belief “I did the best I could.”  She reported that she still, of course, experienced memories of Bill’s death, and reported she was very pleased that that she could feel sadness without guilt.  Carol was thus finally able to process her grief and loss in a healthy way.

My work with “Mary” was deeply profound and moving.  Mary’s husband “Don” suffered with Lou Gehrig’s disease (ALS) for three years, and Mary witnessed the horrible, inexorable ravaging of Don’s body while his mind stayed strong.  Mary’s expressed purpose for coming to see me was that she was unable to feel Don’s presence in her life.  Mary described Don as her soul mate, and I assured her that because of the strength of their bond, she would find a place for Don in her heart and feel his presence as a support in order to move forward. However, it was clear that she would first have to deal with the traumatic images that prevented her from fulfilling this step in her grief process.  The most disturbing image, and target for our EMDR work, was finding Don lying in a pool of blood on the bathroom floor after falling out of his wheelchair.  I taught Mary the “butterfly” technique, in which the client crosses his or her arms across the chest in a hug and taps alternately below each shoulder, simulating the bilateral stimulation used in formal EMDR sessions. I instructed Mary to use this technique at home as a resource when traumatic images arose.  After two sessions, with Mary working at home with the butterfly hug when disturbing images and emotions arose, Mary reported that those images had receded as mere memories that were no longer unduly disturbing.

Mary came into our next session glowing, and reported that she had felt a tug at the back of her shirt while sitting quietly one day and “knew it was Don, back in my life.”  She reported that she subsequently felt Don’s presence coming to her every night before she fell asleep.  Our trauma work was done, and Mary was well on the way to healing her grief.

Conclusion

My work with both Carol and Mary, as well as many others, has enhanced my confidence in my therapeutic skills in identifying and working with traumatic grief, and has increased my trust and faith in the effectiveness of EMDR as a healing tool in grief.

References

A. Mitchell, Y. Kim, H.G. Prigerson, M.K. Mortimer-Stephens. (2004). Complicated Grief in Survivors of Suicide. Crisis 25(1), 12-18.

F. Shapiro. (1995). Eye Movement Desensitization and Reprocessing:  Basic Principles, Protocols and Procedures. New York:  Guilford Press.

M. White. (1995). Re-authoring lives. Adelaide:  Dulwich Center Publications.