david trickey

10/3/14

© David Trickey, Consultant Clinical Psychologist www.davidtrickey.com 1

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

David Trickey Consultant Clinical Psychologist

Trauma Specialist 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)

Meaning Memory

Maintenance

Symptoms of PTSD

EffecJve intervenJons Risk factors

Ehlers & Clark, 2000 Brewin et al., 2010

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

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Maintenance cycle of avoidance

Intrusions (e.g. memories, images,

dreams, thoughts)

Memory or thought suppressed and avoided

Original fear, horror, helplessness

Memory not processed

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

0

5

10

15

20

25

30

35

40

Assessment

2nd Session

3rd Session

4th Session

5th Session

Discharge

Intrusions Avoidance TOTAL

Total score PTSD Threshold

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

Beliefs

Meaning

Normal event Percep,on

Other people

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Meaning: Trauma1c events literally break the rules

Beliefs

Trauma4c event

Other people

Belief – Threat – Behaviour – Belief

Beliefs World is unsafe

Adults are dangerous (especially those that are supposed to care

for you), I am unlovable, uncontainable

Placement disrupJon

Others reminiscing

Thoughts They’re only being nice to me to get

close to me, then they’ll hurt me

Emo1ons Fear

Physiology Hyper-‐arousal

Behaviour Rejects carers, lashes out

Father takes his own life

Emo1on Fear

Thoughts If I go out, I will be

in danger

Physiological Various

symptoms

Belief – Threat – Avoidance

Beliefs World is unsafe Others are evil I am vulnerable

OpportuniJes to go out

Behaviour Avoid going out

System (actively encouraged avoidance)

Friend murdered

Emo1on Fear

Thoughts I must be on my

guard

Physiological Hypervigilence

Belief – Threat – Hypervigilence

Beliefs The world is dangerous

Other people are harmful

Behaviour Look for (and see) poten4al danger

System

Loved one killed

Emo1on Anger, sadness

Thoughts It was my fault, I deserved it

Physiological Various

symptoms

Belief – Guilt – Avoidance

Beliefs The world is

ordered and just I am a bad person

Reminders

Behaviour Avoid thinking it through

and correc4ng mis-‐percep4ons

System

Family homicide

Cycle of vicarious avoidance

ADULTS: Not menJoned

CHILD: Maybe they can’t bear to

have a conversaJon about it

ADULTS: Talking about it might

upset him and may even make him worse

CHILD: Not menJoned

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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

Average

0

5

10

15

20

25

30

0 20 40 60 80 100 120 140 160 180

CRIES

Days

Resilient 57%

Recovery 33%

Chronic 10%

0

5

10

15

20

25

30

0 20 40 60 80 100 120 140 160 180

CRIES

Days

Resilient 57%

Recovery 33%

0

5

10

15

20

25

30

0 20 40 60 80 100 120 140 160 180

CRIES

Days

Resilient 57% 0

5

10

15

20

25

30

0 20 40 60 80 100 120 140 160 180

CRIES

Days

Recovery following accidental injury (Le Brocque et al., 2010)

Meta Analysis of Risk Factors for PTSD in Adults (Brewin et al., 2002)

0.23

0.32

0.40

0.00 0.05 0.10 0.15 0.20 0.25 0.30 0.35 0.40 0.45

Trauma severity*

Subsequent life stress

Lack of social support

(sig variability)

Meta Analysis of Risk Factors for PTSD in CYP (Trickey et al., 2012)

0.03 0.15 0.15

0.21 0.29 0.29

0.33 0.36 0.36

0.46 0.47

0.64 0.70

0.00 0.10 0.20 0.30 0.40 0.50 0.60 0.70 0.80

Younger age (18) Prior psych probs (14)

Female (29) Pre-‐trauma life events (8)

Trauma severity* (41) Parental Psych Prob (25) Low Social support (4) Peri-‐traumaJc fear (3)

Perceived life threat (6) Poor family funcJoning (7)

DistracJon (2) PTSD (T1) (4)

Thought suppression (2)

(sig. variability)

(n.s.)

Trauma1c Bereavement: more than the sum of its parts

Impact of bereavement +

Impact of trauma +

Trauma impedes grieving

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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 •  Good aoachment & family relaJonships

•  Social support •  Meaning making •  ConJnuing bonds

Trauma,c nature of the death

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

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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

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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…

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…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)

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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

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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

Education