What is traumatic bereavement?

Traumatic bereavement guide for practitioners

This page is part of a traumatic bereavement clinical guide, which supports practitioners working therapeutically with traumatically bereaved children and young people.

Download the complete guide here.

Overview of the definition and the impact on children and young people

This chapter explores more fully what traumatic bereavement is and how it might lead to the development of mental health difficulties. It compares traumatic bereavement to other ways in which people struggle to adjust to their loss. It uses several models of grief to help explain how traumatic bereavement might disrupt the grieving process. Finally, it outlines some ways that children and young people with traumatic bereavement might be helped.

Key messages

• Traumatic bereavement describes how the trauma of the death disrupts the grieving process.
• Traumatic bereavement can lead to the development of mental health difficulties for children and young people.
• Exploring models of grief can help us understand how traumatic bereavement might pose challenges in supporting children and young people using common bereavement support interventions.

What is traumatic bereavement?

Traumatic bereavement is when the natural grieving process is disrupted as a result of the trauma of the death of a friend or family member, leading to lasting negative impact on wellbeing and everyday functioning.

Thinking about traumatic bereavement requires us to consider both trauma and bereavement. Trauma describes the way that some distressing events are so extreme or intense that they overwhelm a person’s ability to cope, resulting in lasting negative impact. Bereavement describes the experience of the death of someone significant.

When a child or young person experiences a traumatic bereavement, they face having to cope with both the trauma of the death and the grief following their loss. This can result in a higher incidence of trauma symptoms than when a young person experiences trauma without death [1]. The traumatic nature of the death can inhibit the grieving. This has important implications when seeking to offer help and support.

It is sometimes suggested that all bereavement is traumatic. Research indicates that although bereavement can be stressful, painful, and hard to manage, many children and young people go on to adjust without longer term problems [2]. Traumatic bereavement is not a diagnosable condition and does not have a formal clinical threshold that clearly differentiates it from a typical grieving process. It can help to imagine a continuum with typical grief at one end and traumatic bereavement at the other [3]. Children and young people might be positioned in different places along the continuum to reflect the severity of their difficulties. Identifying children and young people who have experienced a traumatic bereavement is nuanced rather than clear-cut.

Although not a formal diagnostic term, Childhood Traumatic Grief (CTG) [4] (widely used in the USA) is similar to traumatic bereavement as it shares the same core principles of the trauma disrupting the grieving process but is classified by the inclusion of PTSD symptoms. Children and young people who are experiencing CTG benefit from support for their grief as well as their PTSD symptoms. Traumatic bereavement encompasses a broader range of responses to the trauma of the death, including low mood and anxiety, rather than exclusively PTSD [5].

What traumatic bereavement looks like

In a typical grief response, a child or young person may experience a broad range of emotions, often intense and at times difficult to manage, but largely within their capacity to cope. You could describe the child or young person as stepping in and out of their ‘puddles of grief’ and you would usually see the intensity and frequency of these emotions diminish over time. In traumatic bereavement, strong emotional reactions of fear, anxiety, guilt, anger or shame arise from the trauma of the death and have a negative impact on the child or young person, effectively blocking their ability to grieve and adapt to their loss. They might be described as stuck in a puddle, or even a well, of grief.

The impact of traumatic bereavement might lead to or co-exist with diagnosable mental health problems including PTSD, anxiety, depression, conduct disorders, or any combination of these. There has been a great deal of focus on PTSD as a reaction to trauma. In fact, research has indicated that other difficulties are almost as common as PTSD, with depression likely to be a more common presentation [6]. Even when traumatic bereavement does not lead to a formal mental health diagnosis, trying to manage trauma and loss may be extremely difficult.

Post-traumatic stress disorder (PTSD)

Some children and young people develop PTSD as a result of the trauma of the death. It is possible to have a diagnosis of PTSD without traumatic bereavement or to have a traumatic bereavement without PTSD. Traumatically bereaved children and young people might experience some or many symptoms of PTSD, even if they do not meet the criteria for a full diagnosis. These might typically include:

• Struggling with unwanted thoughts and memories of the trauma during the day or as nightmares.
• Avoiding thinking or talking about what happened, avoiding any reminders of the death or of the traumatic meaning made of the death.
• Experiencing heightened emotions of anger, anxiety, guilt, fear, and distress.
• Presenting in a hypervigilant state, on edge, fearful and/or irritable.

What traumatic bereavement is not

Traumatic bereavement is not a clinical diagnosis with a prescribed set of symptoms. It is a way to describe the difficulties that can arise after a child or young person experiences a bereavement as traumatic. There are many other terms used to describe how some people’s struggle with grief results in poorer outcomes. Our literature search identified: complicated grief, complex grief, Prolonged Grief Disorder, Persistent Complex Bereavement Disorder, child maladjusted grief, unresolved grief, traumatic loss, delayed grief, and disenfranchised grief. Whilst these might share some common features with traumatic bereavement, they do not appear to be exactly the same.

Prolonged Grief Disorder (PGD) is a diagnostic label that describes difficulties following a bereavement. (It replaces Persistent Complex Bereavement Disorder). Although a PGD diagnosis does not preclude the existence of post-traumatic symptoms it describes specific difficulties including yearning for and pre-occupation with the person who died. PGD is different in character to traumatic bereavement, where the trauma of the death and its meaning are central to the difficulties experienced but may well co-occur with it. Research about PGD has largely been on adult populations and may not yet reflect the specific needs of children and young people [7].

Why traumatic bereavement matters

Complexities that can arise from traumatic bereavement impact on the child or young person’s everyday life in multiple areas including personal, social, and educational. Without effective and appropriate support, traumatically bereaved children are at increased risk of developing diagnosable mental health difficulties and long-term poor outcomes [8].

Why traumatic bereavement occurs

Traumatic bereavement is determined by the meaning the death has for the child or young person, rather than the objective circumstances of the death. This meaning might result from the child or young person’s perception or understanding of what happened, what it means to them, or it may arise from inaccurate information about the death [9]. It is
about the way the death has ‘coloured’ how the child or young person now sees themselves, others, and the world around them. The way that we see ourselves, other people, and the world in general is based on our experiences and also how things are seen by those around us. Once we have an idea of the way that things are ‘supposed’ to be, that view of things colours the way that we see everything. If something doesn’t fit with our expectations, we might colour it so that it does fit. For example, if you think that a particular area of London is violent, then you may start to notice any news reports that confirm your view, and you may even ignore reports that don’t fit.

It can be helpful to show children and young people how the death might have coloured the way that they see things: the way that they see themselves, other people, and the world in general. They may start to believe that they are the sort of person who deserves to have bad things happen to them, or they may start to see the world as generally dangerous. In one of our fictional case studies, Shabana’s Baba (dad) was stabbed to death in front of her. This profoundly changed how Shabana saw the world:

Models of bereavement seek to help us understand grief and how it might be navigated. These are widely used to underpin many interventions for bereaved children and young people. Exploring several commonly used models, can help us better understand how trauma might disrupt the grieving process for children and young people and interfere with their ability to adapt to their loss. These might help you identify when a child or young person is traumatically bereaved and help you to support them with suitable activities.

Worden’s Tasks of Mourning

Worden’s Tasks of Mourning [10] are commonly used as a model to explain the grieving process and to foster effective coping by supporting bereaved people to:

• Accept the reality of the loss
• Process the pain of the loss
• Adjust to living without the person who died
• Maintain a bond with the person who died whilst reinvesting in life without them

When a child or young person embarks on these tasks, there are several ways in which experiencing a traumatic bereavement might make it harder. A key response to trauma is to avoid processing the difficult memories as a protective measure against the overwhelming emotions they may trigger. This potentially makes it difficult to work on any task of grieving. Exploring each task in more detail allows you to consider how these might be more of a struggle for a traumatically bereaved child or young person.

Accepting the reality of the loss will require the child or young person to confront the reality of the death and to believe that what happened is real. This might be very difficult if what happened is so horrific to them that bringing it to mind becomes distressing, or if the death is so shocking that they simply struggle to believe it. They may, understandably, want to avoid thinking about it. The circumstances of the death may also make this hard if they break social and moral codes or are surrounded by stigma. For example, it might be difficult for families to accept that a person took their own life, meaning that nobody mentions it, and they may not tell children and young people what actually happened.

Processing the pain of the loss may conflict with the child or young person’s attempts to push the feelings of fear, guilt, and horror of the death out of their mind. Instead of experiencing a range of grieving emotions, the child or young person may be consumed by several trauma-specific feelings such as persistent fear or anger.

Adjusting to life without the person who died will require the child or young person to accept the reality and permanence of what has happened, and then start to focus on life without them. They may find it impossible to stop going over and over the death, making it impossible to adjust. The child or young person might also be struggling with a post-bereavement environment filled with reminders of the trauma or with others who are affected by the trauma of the death. These factors could pose a barrier to their adjustment.

Maintaining a bond with the person who died whilst reinvesting in the future may present challenges, as this involves the child or young person purposefully processing the loss and being ready to consider the future. This could be tricky to accomplish, as the traumatic memories of the death might take precedence over memories of that person they might wish to hold onto.

Continuing bonds

The concept of developing and maintaining continuing bonds [11] might also present significant challenges for traumatically bereaved children and young people. In establishing and preserving a connection, the child or young person needs to be able to tolerate the memory of the person and their death. For those affected by trauma this might bring with it an avalanche of distress as described above.

The Dual Process Model of Grief

The Dual Process Model of Grief [12] helps us to understand effective coping through two modes of functioning: the loss oriented and the restoration oriented.

In the loss domain, bereaved children and young people would confront their loss, be reminded of it, and feel its intensity.

In the restoration domain, children and young people might avoid their grief, getting on with the business of rebuilding their lives.

Adaptive coping is achieved by being able to alternate between doing the work of grieving and getting on with life. This can be likened to the idea of stepping in and out of puddles of grief.

When a child or young person has experienced traumatic bereavement, they may struggle to alternate smoothly between the two domains, battling with extreme intrusions of the loss and avoidance of the trauma [13].

Other perspectives

You can also look to the concept of ‘growing around your grief,’ [14] often presented as an image of a stone in a jar. This shows that for many people time does not necessarily heal or reduce the pain of the death – the grief does not shrink. Instead, the concept proposes the role of restoration as the child or young person is supported to ‘grow their world’ by finding things to offset their pain and distress.

For bereaved children and young people, ‘growing your world’ might mean encouraging them to find things that bring comfort and to re-engage with activities. For those affected by traumatic bereavement, this can be particularly hard, as the trauma may trigger the development of a range of mental health needs. These might act as barriers to ‘growing your world’. For example, anxiety may have an impact on re-engagement, low mood may result in a lack of motivation and difficulty finding pleasure, and trauma symptoms may make the world frightening.

Understanding the way traumatic bereavement might have an impact on a more typical grieving process is useful in helping you identify children and young people who may be struggling. You can also use these models to help you think about what else a traumatically bereaved child or young person might need over and above more typical therapeutic interventions. The importance of working collaboratively with the system around the child or young person is even more critical.

What helps

By offering specifically tailored activities alongside your usual bereavement support, you can support children and young people who have experienced traumatic bereavement by helping address both their trauma and their loss.

Suggested activities for this are described in chapters 7-13 of the traumatic bereavement clinical guide available for download here.

However, some children and young people affected by traumatic bereavement will require specialist clinical support to help with their specific mental health needs. This might include evidence-based interventions for anxiety, depression, PTSD and conduct disorders. These interventions might not specifically help the child or young person with their grief. Trauma-Focused Cognitive Behaviour Therapy with grief component has an emerging evidence base to support the child or young person with both their trauma and their grief.

Chapters 5 and 6 in the traumatic bereavement clinical guide can help you identify and differentiate when specialist support is needed.

---

References

1. Brown, E.J. & Goodman, R.F. (2005). Childhood traumatic grief: an exploration of the construct in children bereaved on September 11. Journal of Clinical Child & Adolescent Psychology, 34(2):248–59.
2. Melhem, N.M., Porta, G., Shamseddeen, W., Walker Payne, M., & Brent, D.A. (2011). Grief in Children and Adolescents Bereaved by Sudden Parental Death. Archives of General Psychiatry, 68(9), 911-919.
3. Dyregrov, A., Salloum, A., Kristensen, P., & Dyregrov, K. (2015). Grief and Traumatic Grief in Children in the Context of Mass Trauma. Current Psychiatry Reports, 17(6), 1-8.
4. Cohen, J., Mannarino, A., & Deblinger, E. (2017). Treating trauma and traumatic grief in children and adolescents (Second ed.). Guildford Press.
5. Cohen, J.A., Mannarino, A.P., Greenberg, T., Padlo, S. & Shipley. C. (2002). Childhood Traumatic Grief: Concepts and Controversies. Trauma, Violence & Abuse, 3(4), 307-327.
6. Lewis, S.J., Arseneault, L., Caspi, A., Fisher, H.L., Matthews, T., Moffitt, T.E., Odgers, C., Stahl, D., Teng. J.Y. & Danese, A. (2019). The epidemiology of trauma and post-traumatic stress disorder in a representative cohort of young people in England and Wales.  Lancet Psychiatry, 6, 247–56.
7. Duffy, M. & Wild, J. (2017). A cognitive approach to persistent complex bereavement disorder (PCBD). Cognitive Behaviour Therapist, 10 (10).
8. Cohen, J.A., Mannarino, A.P., Greenberg, T., Padlo, S. & Shipley. C. (2002). Childhood Traumatic Grief: Concepts and Controversies. Trauma, Violence & Abuse, 3(4), 307-327.
9. Ehlers, A. & Clarke, D.M. (2000). A Cognitive model of posttraumatic stress disorder.  Behaviour Research and Therapy, 38, 319.
10. Worden, J. W. (2009). Grief Counseling and Grief Therapy: A Handbook for the Mental Health Practitioner (4th ed.). Springer.
11. Klass, D., Silverman, P.R., & Nickman, S.L. (1996). Continuing bonds: New understandings of grief. (Series in death education, aging, and health care). Taylor & Francis.
12. Stroebe, M. & Schut, H. (2010). The Dual Process Model of Coping with Bereavement: A Decade on. Omega: Journal of Death and Dying, 61(4), 273-89.
13. Stroebe, M., Schut, H., & Finkenauer, C. (2001). The traumatization of grief? A conceptual framework for understanding the trauma-bereavement interface. The Israel Journal of Psychiatry and Related Sciences, 38(3-4), 185–201.
14. Tonkin, L. (1996). Growing around grief – Another way of looking at grief and recovery. Bereavement Care, 15(1), 10.

---

Learn more

You can download the complete traumatic bereavement clinical guide and watch supplementary videos here.

Specific information and guidance for schools and colleges can be found on the traumatic bereavement for school communities page.