The Traumatization of Grief? A Conceptual Framework for Understanding the Trauma-Bereavement Interface
Stroebe, Margaret, Schut, Henk, Finkenauer, Catrin, The Israel Journal of Psychiatry and Related Sciences
Abstract: Scientific opinion differs on whether pathological (or complicated, traumatic)) grief is an entity distinct from post-traumatic stress disorder. Some argue that it is different, and for the creation of a new category of pathological grief for the DSM system, while others consider bereavement and associated grief reactions to fall within the category of traumatic life events, for which the existing system would offer adequate classification. Although investigators have begun to explore similarities and differences in the trauma and bereavement domains, there is still confusion and lack of consensus about definitions and basic concepts. A conceptual framework, suggested here, may help bring clarity to the area. Our analysis shows that the lack of consensus about the nature of reactions and disorders of bereavement is due to concentration on different parts of the framework. Furthermore, the lack of differentiation between traumatic and non-traumatic bereavement has caused neglect of the unique features of non-- traumatic grief reactions. These components need further exploration, especially since extension of DSM classification is currently under consideration.
It is important to establish how the two research fields of bereavement and trauma should be defined and conceptualized in relationship to each other. Should the phenomena be considered as separate entities, or should bereavement, being an extremely stressful life event, be included and analyzed among the broader range of devastating experiences that make up the category of traumatic life events? The decision taken on this issue has important consequences. For one thing, it affects judgements about the nature and categorization of pathological responses to trauma or bereavement. It also affects such matters as operationalization and selection of appropriate measurement instruments. Not least, the viewpoint taken will influence the choice of theoretical approach. Conversely, as it happens, the theoretical viewpoint taken by the researcher influences opinion whether bereavement phenomena should be considered as a separate, subsumed, or overlapping category, in relationship to those of trauma.
In fact, examination of research on bereavement and trauma across the decades shows systematic shifts in scientific thinking on this issue. The earliest work of bereavement failed to consider trauma. To trace this briefly: although Freud was interested in the impact of traumatic events on psychological functioning, this was not the subject of discussion in his classic article on bereavement, "Mourning and melancholia" (1). Rather, in this paper, which was to become the major landmark in the early history of scientific understanding of bereavement, he addressed the distinction between normal grief (translated as "mourning," see 2) and clinical depression ("melancholia"). Quite separately (although also of interest to Freud) attempts to understand traumatic experience were conducted in the context of the First World War, with cases of "shell shock" providing psychiatrists with good reason for scientific investigation. This early lack of direct comparison between the phenomena of trauma and bereavement continued through the 1940s with Lindemann's (3) similarly influential contribution "Symptomatology and management of acute grief." Many of Lindemann's respondents were survivors of a nightclub fire, which claimed lives. Although Lindemann described reactions as acute grief, it is evident that some survivors were traumatized as well as bereaved (cf. 4, discussed in 5) - and yet, no differentiation of these two influences on symptomatology was made by Lindemann.
The research fields developed along fairly separate lines throughout much of the Twentieth Century. Within the bereavement field, momentum grew with the work of Parkes (6) describing the specific consequences of loss of a loved one in adult life, while work on trauma fell within the more general study of psychosocial stress (7-9). …