Approximately one in three Americans have a loved one die in a sudden violent manner in their lifetime. Moreover, in the year following a violent death, survivors are at increased risk for perpetrating violent acts against others, dying by their own hands, or dying in an apparent violent accident. The impact from violent death often remains hidden because of social norms that stigmatize the bereaved and silence their pain. Social work has a unique role to play in recognizing these survivors, intervening on the obstacles to their grieving, and using the tragedy of violent death as a catalyst for new growth.
The three leading causes of death for persons ages 15-24 are fatal accidents (51.8%), homicide (21.3%), and suicide (16.3%). Of the fatal accidents, motor vehicle traffic deaths account for 47% of the total, which makes motor vehicle fatalities the leading cause of violent death. In actual numbers, motor vehicle accidents annually claim 42,000 lives, suicide takes 30,000 lives, and homicide is responsible for the loss of 20,000 lives.
Although violent death knows no socioeconomic boundaries and shows no respect for age, race, or gender, there are clear disparities between different groups. The highest rates of violent death occur among non-white adolescent males. Although Hispanic and black male teenagers travel fewer vehicle miles than Caucasians, they are nearly twice as likely to die in a motor vehicle crash.
These figures are sizable. Yet, the magnitude of relatives, friends, and co-workers affected by the deaths of teens as well as people in other age groups is substantially larger. Virginia Mason Medical Center contends that homicidal deaths produce between 120,000 and 240,000 new homicide survivors each year. Based on the estimate of 6 survivors for every suicide, the American Association of Suicidology calculates that there are now at least 4.5 million American suicide survivors. Using the same estimate, there would be approximately 252,000 new survivors of motor vehicle fatalities annually.
Grieving a violent death is different from ‘normal’ mourning behavior. One reason for the difference is that the death is caused by human intent or negligence rather than an internal disease, old age, or natural event, e.g. flood, tornado, fire. The body may have been mutilated and the deceased may have suffered unbearable pain or torture. Instead of being able to anticipate and understand the predictable course of a fatal illness, survivors of violent death are left with scraps of information about what may have happened. Consequently, the bereaved may obsessively feel the need to assign blame and responsibility, search for reasons, or dwell on the missing details in an attempt to have the senseless loss make sense. For survivors of violent death, negative or stigmatizing social attitudes received from others about how the death occurred are more common than expressions of concern and support. However, unlike natural dying, the story of this kind of death has no positive or redeeming resolution. Comments, which might otherwise soften the loss such as “He died peacefully “,” She lived a full life”, or “At least, she is no longer suffering” are irrelevant statements when applied to victims who died a violent death. Survivors experience the story about the death as a structural dead end defined by the killing. In addition, beliefs about the goodness of people, the natural order of events, or self-worthiness may be imploded as a result of the violent death leaving the survivor to revamp basic assumptions about the world and how it operates.
When compared to the grief that accompanies ‘natural’ dying, the intensity and duration of reactions to violent death appear to be atypical or even pathological. The extreme shock induces a wide array of both physical and emotional responses. These responses include significant sleep disturbance, exaggerated startle behavior, phobic anxiety, intense shame and feelings of rage, fear, horror and guilt. They interrupt the normal feelings of loss and sadness and disrupt the reflective and integrative processes that otherwise accompany grieving. The co-existence and interplay between the trauma reactions and the need to grieve create a synergy that delays recovery. “The disintegratory effects of traumatic imagery and avoidance on cognition, affect and behavior impair the more introspective and reflective demands of acknowledging and adjusting to the loss.” Likewise, the normal process of reflection and remembrance can trigger trauma reactions because remembering can transform the dying into something abhorrent. Hence, trauma can prolong bereavement and bereavement can prolong trauma.
Today, there is greater recognition of the co-occurrence of trauma and grief as a ‘normal’ response to violent death. The presence of both traumatic distress due to the mode of dying and separation distress due to the loss is referred to as traumatic grief. Traumatic grief includes cognitive, affective, physiological, and behavioral dimensions. The cognitive dimension includes rumination, intrusive thoughts, confusion, memory impairment, denial, and thoughts of revenge. The affective dimension includes emotional flooding due to overwhelming feelings of rage, terror, depression, and guilt. The physiological dimension includes increased arousal which in turn leads to an intensification of emotional reactions and trigger responses to somewhat benign stimuli. The behavioral dimension includes phobic avoidance of trauma-related events, increased self-protective behavior, and changes in the utilization of social support.
The concept of traumatic grief is an emerging diagnostic disorder with two symptom clusters: symptoms of separation distress (Cluster A) and symptoms of traumatic distress (Cluster B). Symptoms of separation distress are related to the motivation for attachment. Symptoms of traumatic distress are primarily related to the motivation for autonomy and self-protection. The occurrence of these symptoms is considered ‘normal’ for survivors of violent death. Individuals with marked and persistent symptoms, however, are considered to be distressed and ‘at risk’. Studies using independent bereavement samples demonstrate that the symptom criteria for traumatic grief are distinct from symptoms of depression and anxiety. Although there is some controversy about the duration of symptomatology necessary for assigning a clinical diagnosis, data from two separate samples suggest that a six-month assessment is superior to a two or three month evaluation in predicting numerous mental and physical health. Duration criteria are still being tested.
The Meaning of Resilience
For survivors of violent death, resilience refers to their ability to prevail over the forces of destruction that took their loved one’s life and forces that metaphorically threaten to take theirs too. Those threatening forces may include overwhelming rage, suicidal ideation, depression due to the physical limitations caused by vehicle-related injuries, or diminishment by the criminal justice system. To prevail means to become very strong, gain vigor or force, have or gain the advantage. Survivors who systematically and successfully overcome step by step the destructive potential in the myriad of challenges related to violent death discover, in hindsight, that they strengthen existing abilities, develop new skills, and grow the wisdom that allows them to triumph in the end.
Resilient survivors continue, therefore, to grow and even thrive in spite of and quite often because of their history.
Indeed, resilience or the ability to prevail in the face of horrific loss may be more common than is often believed and may be reached by a variety of different pathways. Tedeschi observes that for some survivors, the shock associated with violence can be a catalyst for personal and social transformation. “Those who are in greatest despair and have felt most out of control are prone to transformative experiences while persons who are open to experience, hopeful, extroverted and creative make the most out of trauma.” Tedeschi contends that the struggle with the new reality in the aftermath of the trauma determines the extent to which posttraumatic growth occurs. The struggle can increase self-reliance or self-efficacy as well as resilience for new trauma. The experiencing of strong emotions coupled with recognizing one’s vulnerability can be a kind of empathy training that allows survivors to be more intimate in relationships. In addition, the struggle can strengthen religious beliefs or lead to a spiritual quest that gives life deeper meaning. It can produce wisdom based, in part, on the ability to take a broader perspective of events.
Although these growth possibilities are encouraging, it is important to remember that survivors of the violent death of a loved one rarely view their journey as deliberate and intentional. Rather, they make choices based on individual circumstances, what comes at them, available resources, and their perceptions of the events around them. Since the goal is to help survivors of violent death prevail, social workers need to focus their attention on the obstacles that stop or otherwise impede movement These obstacles include unremitting reactions to the trauma, the impact from negative social responses, and the inability of survivors to make meaning of the death.
Types of Violent Death
Measures used in the past to detect differences in responses to natural and violent death mistakenly concluded that there are no differences in the mourning process. Likewise, studies frequently combine the three types of violent death based on the violence, the sense of being violated, and the preventability that they hold in common. Although there are similarities in the reactions to the three types of violent death, survivors of motor vehicle fatalities, suicide, and homicide have different experiences because they face different challenges within each of the obstacles to movement.
Motor Vehicle Fatalities
Death due to motor vehicle crashes is sudden. There are no warning signs. Crashes can be painful, violent, and mutilating in their effects prior to death occurring. Survivors may be left with haunting images of what happened and recurring questions about whether and how much the loved one suffered before death or was aware at time of death. Indeed, data from the Fatality Analysis Reporting System indicates that 44% of motor vehicle fatalities are instant or occur at the crash scene before victims can be rescued. For a majority, death is prolonged since 54.2% of victims die in route to the hospital or at the hospital within one month of the accident.
Vehicular crashes are considered the most unanticipated of deaths. Generally, the offender is not known to the victim nor does he actively choose the victim. Although homicide may also be unexpected, victim and offender often know each other and survivors, in retrospect, may point out signs that warned of the impending death. For survivors of motor vehicle fatalities, however, there is no forewarning or psychological preparation. Because of the suddenness, therefore, how the news of the death is delivered has lasting significance since the death notification itself often becomes the event that indents forever in the survivor’s psyche. A husband recalled the words of a neurosurgeon who first told him about his wife after he was summoned to the hospital. “I would like to tell you she’s hanging on by her fingernails – but it’s just one [fingernail] – I don’t think she’s gonna make it.” Brutal and insensitive statements can leave lasting scars and become the subject matter for long term trauma reactions. Family members report nightmares, flashbacks and exaggerated startle responses to things such as the sound of door bells or ringing phones that remind them of the notification.
Although many survivors first learn of the death from a police officer or medical official, they may suffer additional losses due to the medical conditions of other surviving victims from the accident. Moreover, survivors themselves may be victims of the crash too and have to manage the news of the violent death of the loved one as well as their own injuries and/or body mutilation. One survivor who had lost his son commented on the injuries of his daughter. “The bone ends were just hash – like breakin’ a stick. Her right arm was broken. Her pelvis was broken in four places. Her jaw was almost torn off. Her lower jaw was broken off and was two inches out of line. Her mouth stretched open further than a mouth can open. She had no teeth.” The potential for multiple losses is high in motor vehicle fatalities. Victims may never fully recover from their injuries or may remain comatose for years. The human costs of head injury, for example, which is one of the leading non-fatal medical consequences for victims of motor vehicle crashes can include significant long-term disability, impairment in basic bodily functions (e.g. vision, memory), and markedly decreased quality of life.
Trauma Reactions. Survivors of motor vehicle fatalities experience a myriad of trauma-based reactions that consist of physical symptoms of arousal, somatization, physical health consequences, phobias about travel, helplessness, and self-reproach and self-blame. Reports of the occurrence of a DSM-IV sanctioned post-traumatic stress disorder (PTSD) among survivors range from 26% to 62%. Physical symptoms of arousal are common such as trembling, psychomotor agitation, exaggerated startle response, hypervigilance, sleep and appetite disturbance, changes in immune system functioning and physiological re-experiencing of the trauma occasioned by seemingly benign stimuli. Rumination about death imagery including intrusive or disturbing images of the crash may prolong the trauma
Responses can also include concerns about the survivor’s physical wellbeing. Survivors suffer from multiple physical complaints and pain of unknown origin. In addition to other conditions, they report high blood pressure and the need for sleep medication or anti-anxiety drugs. Survivors also include children. In a fatal bus crash, child survivors had psychosomatic problems at the end of the first year with approximately 60% describing headaches and 20% to 40% describing sleep difficulties, tiredness, pain and appetite problems.
Indeed, an assessment of survivors of motor vehicle crashes with non-victims found that 27.5% of survivors rated their health as fair or poor compared with only 5.6% of the non-victim sample. In some instances, survivors have physical injuries and medical issues that result directly from the crash. Injuries can serve as a constant reminder of the loved one’s death which hinders emotional recovery particularly if recovery from the injuries is slow or survivors have to rely on others to perform many of the tasks they used to do.
In addition to physical manifestations of the trauma or physical conditions as a result of the crash, survivors also report greater psychopathology including obsessive compulsive behaviors, interpersonal sensitivity, depression, phobic anxiety, and psychotic symptoms four to seven years after the crash. Phobic anxiety about driving or travel is particularly common. In addition to acute anxiety and panic attacks, survivors feel a loss of pleasure related to travel, may avoid travel, or generalize anxiety about vehicles to other modes of transportation.
Survivors also experience intense feelings of vulnerability, insecurity and helplessness as a result of the crash which intensifies apprehension about bad things happening to themselves or others. Whether warranted or not, self-reproach and self-blame for their loved one’s death undermines their confidence in their ability to handle things well.
Negative Social Responses. Post event circumstances are often the most determinative of the grief process because the reactions of friends, family and institutions to the loss reflect the social meaning or significance accorded to the mode of death. If the significance is undervalued or stigmatized, survivors have additional obstacles such as isolation and shame to confront in mourning the death of their loved one. Survivors of motor vehicle fatalities have to contend with the fact that vehicular crashes are dealt with as random events, unintentional or truly accidental in their origin. So-called motor vehicle accidents are commonly prosecuted as negligent homicide or involuntary manslaughter and offenders can receive a minimal sentence, probated sentence, avoidance of jail or no sentence at all.
Although motor vehicle fatalities are generally considered beyond human control, 82% are deemed ‘due to negligence’ which indicates that they were preventable. Indeed, in 1999, 38% of motor vehicle accidents involved the use of alcohol or other drugs and 14% involved speeding and other reckless behaviors, e.g. running red lights or potentially negligent behaviors, e.g. eating and grooming while driving. In society’s view, the decision to drink and drive, however, still does not increase the intentionality of the fatality because alcohol or drug use is considered a disease over which the offender has little control.
In effect, the lack of assigned culpability leaves survivors feeling powerless and frustrated. The muted response of the criminal justice system to their loss creates anger, hopelessness, confusion, and despair. Without being able to hold someone legitimately responsible, survivors have few targets for the healthy and appropriate expression of anger. With no one to blame, it is harder to cope.
Social acceptance of drinking and driving and institutional minimization of the death create inequities in the interface between survivors and the criminal justice system that can be socially, emotionally and financially devastating. A father who lost his son in a drunk-driving collision described his experience with the criminal justice system. “The crash happened on the most dangerous road on the county. Officers patrol that road closely. But that day they were all in a meeting. What burned me the most, though, was that since the drunk driver that killed my son was on dialysis and not expected to live long, they decided not to prosecute the case. Now he’s dead and what am I left with? I’ll never be able to confront him about what he took from me and I’ll never get to see justice done. I’m left with nothing”. This kind of experience has potential physical and psychological implications for survivors. Dissatisfaction with the criminal justice system has been found to be associated with poorer self-rated health (r=-.18) and high levels of PTSD (r=-.47).
In addition to issues with the criminal justice system, survivors may be impacted by issues about their loved one’s body. Survivors, for example, may be prevented from seeing their loved one’s body until the coroner is finished with the autopsy and the body is sent to the funeral home. Awooner-Renner claims the following: “If a mother is not able to examine, hold, and nuzzle her dead child, she is being denied motherhood in its extreme.” Indeed, survivors who are not able to view the body are more likely to have death imagery because they fill in the vacuum with horrendous pictures from their imagination. Discounting the importance of the death can also be perpetuated by clergy and the faith community who counsel survivors to forgive and not be angry and by friends who comment to survivors, “You’re so lucky to be alive.”
Survivors of motor vehicle fatalities discover that others tend to respond to the mutilating death of their loved one with a tolerance for fault that diminishes the significance of their loss. Survivors, therefore, may feel that social support is limited or ambiguous given the magnitude of their suffering. Since research has shown that less psychological support was far more predictive of PTSD than severe injury, it is likely that social attitudes that fail to assign culpability or diminish the significance of the death may make it more difficult for survivors to feel supported in their need to sort through and express their reactions in ways they move them forward.
Meaning Making. The search for meaning after stressful events is a common and essential task. Meaning making is considered an activity that allows the bereaved to integrate the death of a loved one and move forward. Indeed, the attention given to meaning reconstruction is growing and is considered by some to be the central feature of grieving. Meaning making is usually done by either making sense of the death, i.e. finding reasons for why it happened, or by according some larger purpose or benefit to the death. Studies have shown that finding meaning occurs less often for persons dealing with violent death because they are not able to make sense out of a senseless death or find purpose in a death that seems pointless.
Indeed, many survivors of motor vehicle fatalities indicate that they are not able to find meaning in their loved one’s death. A study of survivors found that 64% were not able to make sense of or find any meaning in the death four to seven years after it occurred. Up to 80% of survivors described that they were still searching for meaning years later.
Difficulty with finding meaning is evidenced by the fact that distress is long lasting. Over 1400 survivors of motor vehicle fatalities indicated serious psychological symptoms 5 years after the death. Even 4 to 7 years after the loss, 62% of survivor spouses and 59% of survivor parents have current thoughts that the crash was unfair or that they were cheated by it. A study of survivor parents found that only 38% reported progress toward loss accommodation after 5 years. The passage of time does not appear to reduce the vividness of the event or its impact.
Meaning making is further impeded by the fact that survivors of motor vehicle fatalities have to incorporate not only the loss but the changes the loss makes in their lives. Survivors of motor vehicle fatalities, for example, are aware that they will never be the same person again. “I try to walk and can’t. I try to reach or lift something and can’t.” They lose a sense of security in the world because of the vivid realization that they have no way to safeguard themselves or their loved ones from the possibility of being victimized, for example, by a drunk driver. These realizations may impact faith in both negative and positive ways. A study of non-fatal accident survivors found that 60% reported their faith changed as result of the crashes. Although 9% said their faith was weakened or gone, 50% said their faith was strengthened. Research on changes in faith, however, has not been done with survivors of motor vehicle fatalities.
Self-death is incomprehensible. The horror it embodies creates lasting trauma as survivors struggle to grasp how the person could have done it and are consumed with guilt for having failed to save their loved one’s life. Indeed, the lasting legacy for suicide survivors is that the death of their loved one was preventable. This socially held belief implicitly makes those closest to the victim responsible for the death and for the conditions that generated their loved one’s wish to take life as a way out. At the same time, suicide is an fundamental betrayal and a profound form of desertion. Regardless of the victim’s state of mind, the act is an affront that leaves relationships forever unfinished and survivors to pick up the fragments of a shattered existence.
Although suicide is depicted as unanticipated, survivors report that suicide was often a consequence of prior conditions. Reed and Greenwald found that 79% of suicide victims gave suicidal warnings, threatened to commit suicide, and/or had previously attempted suicide. A wife described her husband’s premeditated ‘murder’. “First, he went to the north woods and tried to hang himself. But he said he didn’t have the courage. Then he drove around for months with cans of something to asphyxiate himself with while telling his psychiatrist about the methods he was considering.” Cerei, Fristad, Weller & Weller report that suicide families have high rates of marital separation prior to the death, poor parent child relationships with the suicide completer, and divorce. Psychiatric illness, physical illness, monetary trouble or legal trouble contributes to chronic family stress. Approximately 95-98% of suicide completers are suffering form a mental illness, most notably depression and/or substance abuse. Very few suicides, therefore, ever happen “out of the blue.” More likely, what appears to be the result of a sudden, momentary impulse usually is the culmination of a long history of crises and traumas within the victim’s life.
For centuries the act of suicide was met with punishment and ostracizing of the family. The victim’s property was forfeited to the state and the surviving family was left homeless and destitute. Families were socially branded and forced to move from their homes for relief. Even today, some ministers and priests deny burial in a church-approved cemetery since suicide is considered a mortal sin. A young child told her mother about being shunned by her best friend. “Suzie isn’t allowed to play with me anymore. Her mom’s a psychiatrist and says that something was wrong with Daddy because he committed suicide.” Whether explicitly voiced or implicitly inferred, the stigma associated with suicide creates shame which is internalized by survivors and colors the post suicide experience.
Survivors of suicide victims may find themselves haunted by gruesome death imagery based on their imagination of the way the person died or the reality of finding the victim dead. Survivors of suicidal death, however, are also traumatized by the profound rejection implicit in the act, presumably for something they did or did not do. In a letter written shortly before his death, a husband said, “I need more love than this world can give me and I’m taking the chance of finding it beyond.” Indeed, the activation of responsibility and attendant guilt and self-blame may be more prominent and important to recognize as trauma reactions than the shock or even death imagery commonly associated with unanticipated death. Miles and Demi found that 92% of parents of suicide victims felt guilt. Parent survivors also listed guilt as the most distressing factor in their experience. When compared to survivors of motor vehicle fatalities, suicide survivors have been found to be more depressed initially and to have greater feelings of shame. Feelings of anger also remain insular because anger tends to move between self-anger and anger at the victim.
The internalizing symptoms of depression, shame, perceived stigma, and guilt are kept alive by an obsessive search for why. Why did this happen? What did I do to cause this? Was it my fault? Although ruminating, in effect, may be an effort to relieve the guilt and reclaim a sense of control, the pursuit only unleashes more and more questions, doubt, and guilt. Survivors cannot ascertain the victim’s true thought processes. “It just remains a mystery that you can’t really let go of and that you can’t deal with because there’s nobody there to answer when you hit the right answer to the riddle.“
The tortured search for why is accompanied by concerns about who to tell and what to say. Indeed, many suicides give the appearance of accidents, e.g. motor vehicle accidents, drug overdoses, eating disorders. Jordan found that that 44% of suicide survivors lied about the cause of death. Nelson and Frantz argue that the secrecy established by some families about the suicide of a loved one and lack of open communication results in interminable mourning. Indeed, suicide is marked by its sleeper effects. Grief intensity increases rather than decreases over time. Somatic complaints are high. Survivors show compromised health patterns during the first 3 years and report that they were sick more often after the suicide than before. Alcohol intake, as a form of self-medication, has been found to rise. Survivors feel a declining faith in others and worry about the security of interpersonal relationships and the prospect of losing more people they care about.
Negative Social Responses. Inexorable guilt and the stigma of suicide force survivors into a privatized and individualized mode of grieving. Their isolation is, in part, a response to the judgments they expect and feel from others. Parent survivors, for example, have been portrayed as less likable, more blameworthy and less psychologically healthy than parents survivors of children who dies from natural causes. Spouse survivors have been viewed as more to blame as well. The media contributes to these perceptions by printing inaccurate accounts or not providing a full portrayal of who the victim was. Indeed headlines such as “It’s a Shock. It’s a Nice Town” suggest that suicide tarnishes the reputation of the entire town.
A survey of funeral directors found that 84% felt that members of the community react differently to suicide survivors including greater discomfort in talking to the surviving family at the funeral than to families of those who died in other ways. The lack of rites on how to deal with suicidal deaths and concern about what not to say or do may discourage interaction with the survivors.
Survivors themselves contribute to the distance. They tend not to seek assistance from institutions and agencies or informal help. They limit social contacts to avoid the why question and innuendos in the conversation. At the same time, their desperate search for answers and reassurance defines each social interaction and survivors often leave feeling insecure and abandoned. Dunn and Morrish-Vidners have suggested that the deep need for supportive responses coupled with a low level of expectation of support results in a skewed perception of the amount of support actually given. Moreover, suicide survivors are apt to draw heavily on a few close friends but otherwise withdraw and remain distant. Survivors, therefore, may withdraw out of shame which makes others pull away because they feel frustrated in their efforts to connect and feel rejected.
The lack of communication extends to survivor families. When compared to illness and accident survivors, suicide survivors reported that relationships with family members and friends became more distant after the suicide. Since many families had serious problems prior to the suicide, this additional shutdown can seal in depression, guilt, and anger and increase the isolation that marks the post suicide experience. Indeed, the seeming biological predisposition for survivor children to also commit suicide is more likely due to growing up with a heritage of anger, guilt and a sense of worthlessness.
Meaning Making. According to Janoff-Bulman, trauma such as suicide shatters the assumptive base that allows people to function effectively. The three beliefs that comprise the assumptive base are 1) the world is benevolent, 2) the world is predictable and has order, and 3) the self is worthy. Suicide survivors frequently refer to the fact that the suicide of a loved one forever alters who they were. There is no going back. This fundamental modification of their character reflects changes to these three basic beliefs. Specifically, the world may no longer seem kind. Things may make no sense. The sense of rejection and responsibility for the tragedy fits with the just world hypothesis that people get what they deserve and deserve what they get.
These changes do not help survivors find positive meaning or better understand what happened. Indeed, the ability to make sense or find significance is hampered by the meaninglessness of their loved one’s death. The perpetual need to search for both physical and psychological clues as to the true reason for the suicide leads nowhere. The loss of purpose and meaning in their own lives makes it difficult to see what the victim resolved through suicide other than ending the suffering. Murphy and colleagues’ recent study of survivor parents found that 61% were still unable to find meaning five years after their child’s suicide.
The inability to make meaning leaves survivors suspended in time. Parent survivors who could not find meaning reported higher levels of mental distress, lower levels of marital satisfaction and physical health than parents who reported finding meaning. Rynearson contends that it is not possible to find meaning in the meaningless void of violent dying and survivors need, instead, to disengage from the futile search for coherence in the story of the dying. For some survivors, however, letting go of the pursuit for answers equates to giving up. As a wife said, “By losing faith and abandoning hope I would be validating the suicide of my husband.”
The author is interested in comments and can be reached at:Marilyn Peterson Armour, Ph.D., MSW University of Texas at Austin
1925 San Jacinto Blvd
Austin, TX 78712 firstname.lastname@example.org