On April 17, 2007, one day after the Virginia Tech massacre of 32 students by another student, the Washington Post published an article entitled “Survivors of Shootings Grieve in Stages.” The author quotes an "educator" who counseled Columbine survivor families as describing specific, time-limited stages to occur in a particular order. The educator explained that in the first stage “the body shuts down in shock for seven days. It is a piercing grief; you stumble through what has to be done.”
The second stage, beginning at about six months, “is defined by intense sorrow. You go back to doing normal things but everything is colored steel-grey.” One of my bereavement support group members pointed out that, apparently, the survivors cease to exist from day eight until the beginning of the second stage. And since she herself was just a few days beyond the six-month anniversary of her young husband's sudden death and clearly able to perceive my fuchsia outfit while not seeing “steel-grey”, the group - facetiously - concluded that she must "not be grieving right."
According to the educator, the third stage, “about a year after the event, is sadness tempered with joy at getting on with your own life.” None of us, way past our first-year anniversary, recalled having jumped with “joy.” But there is hope: “You know that you’re there when it does not feel bad to feel good.” We are still waiting! Needless to say, the above meaningless language is easily picked up by a society which itself wants to “be done” with death and trauma and thus is reassured that there is an orderly course of grief within a limited time frame. And that, yes, you will actually “get over it.” But does this reassurance help the survivors?
Freud, in the late 19th century, created the term "grief work." The so-called "stages of grief" theory originated in the 1980s when Elizabeth Kubler-Ross had the audacity to put the subject of death, still considered rather taboo until then, on the national agenda. While she deserves much credit, it is now common knowledge among mental health experts that there is no particular sequence of "stages" as Kubler-Ross had initially postulated. Neither does a survivor experience all or necessarily even any one of them.
Kubler-Ross provided us with some early concepts of "grief responses" which were helpful to stimulate further research but are not necessarily useful descriptions of a person's emotional responses. Neither are they concepts upon which grief therapy should be based.
The impact on a person having experienced traumatic death or violence belongs on a much higher-order level - that of acute traumatic stress, occurring immediately after the event, followed by the post-traumatic stress syndrome if symptoms of trauma persist, as described in the DSM-IV. Whether someone is a shooting victim, sibling, spouse or parent of a victim, or a witness; a soldier or journalist returning from duty in Iraq after exposure to violence and destruction; or has lost a loved one through traumatic death (defined as untimely, sudden, violent – an accident, suicide, homicide - , or the witnessing of and/or participation in terminal care), is only the triggering experience when looked at from this point of view.
What does matter is the combination and severity of the symptoms of trauma such as memory impairment, difficulty concentrating, irritability and anger, flashbacks and frightening dreams, hyper-arousal, feeling that the world is not real (a dissociative symptom), insomnia, loss of interest in formerly pleasurable activities, and anxiety. Symptom combinations and severity depend on numerous individual factors, both situational and personal.
What matters in addition is the degree of interference with daily functioning. Traumatic stress debriefing, conducted shortly after the event in a professional and carefully structured fashion (International Critical Incident Stress Foundation, www.icisf.org), helps with trauma prevention. This may be followed by trauma therapy combining supportive counseling, cognitive-behavioral therapy, psycho-dynamic work, relaxation techniques, the retelling of the traumatic event, and the development of coping skills to manage the course of grief over time. EMDR and structured exposure therapy are not advisable.
The problem with postulating stages, time frames and a predictable end point is that survivors are traumatized even more when they do not see themselves able to live up to what their environment apparently considers to be "normal”: universal emotional states resolved within a pre-determined, fairly short period of time. Advice dispensed by the uninitiated adds to the trauma of the survivor now living in an unfamiliar and extremely distressing emotional dimension, unimaginable to those who have not been there themselves. Attempting to focus on others presumed to be “worse off” or on “all the good things in life” has no effect whatsoever and hence induces even greater distress in the survivor.
As a psychologist and traumatologist, I regularly hear the question, "Am I going crazy?" The proper response is that the unfamiliar feelings, thoughts and behaviors occurring under traumatic stress are natural reactions to an abnormal experience. And that there is no “one size fits all” approach to grief therapy leading to a uniform outcome within a predetermined period of time.
Traumatic stress produces neurophysiological and neurobiological changes. Imaging techniques such as fMRIs and PET scans have shown a hyper-activation of the amygdala while the medial pre-frontal cortex, modulating the intensity of emotions by inhibiting the amygdala, is under-activated. In addition, the hippocampus, contributing to memory functioning, shrinks in size and responds abnormally to memory tasks. So far, we have no studies indicating whether the original size is recovered after most symptoms of trauma have abated.
What we do know is that prior trauma such as childhood abuse or adult trauma create permanent neural pathways, easily triggered by another traumatic experience and often inducing more severe traumatic stress symptoms. Furthermore, we now can also demonstrate what we have known since Freud - that language is very powerful: whenever the language centers are activated, amygdala activation and consequently emotional intensity are reduced.
One last word of caution: there are numerous, often commercial organizations, promising “certification in grief counseling” in four days to teach “anyone to heal grief, from the break-up of a romantic relationship to death” (in one single sentence!). None of these organizations would receive continuing education accreditation by the American Psychological Association or the American Psychiatric Association.
Hopefully, the horrifying events at Virginia Tech will bring the country several steps closer to a better understanding of the burdens on the survivors of traumatic death and the highly specialized care by qualified, licensed mental health professionals needed to assist the survivors with managing their traumatic grief appropriately.