Clinical Intersections: Grief, Trauma, and Complex Trauma - 5 Questions & Answers for Social Workers
by Dr. Danna Bodenheimer, LCSW, author of Real World Clinical Social Work: Find Your Voice and Find Your Way and On Clinical Social Work: Meditations and Truths From the Field
There is such a heavy focus on trauma in social work treatment, and this focus is both essential and timely. There is trauma everywhere, whether in the foster care system or ongoing wars or simply the news. However, the more we use the word trauma to describe the sequelae from psychological stressors, the more we lose the nuance around the different ways that trauma can show up and make itself known. There is confusion around the distinction between trauma, complex trauma (otherwise known as C-PTSD, and grief. Below are some clarifying questions AND answers on how we can understand the differences between how trauma lives in one mind versus another.
Is it possible for people to have PTSD after an event that didn't threaten death, harm, or sexual violence? If so, would this fall under C-PTSD (Complex PTSD)?
The truth is that there is no simple answer to this question. The reason why is because the idea of an event threatening death or harm can be experienced subjectively, based on individual nervous symptoms, neurobiology, attachment histories, and past trauma. So, someone who has been in a nearly fatal car accident can get rear-ended several years later, and it can feel life-threatening because of how the original memory is stored in the brain.
The other confounding issue is that of neglect. While neglect does not threaten immediate death or harm, it does diminish one’s capacity to connect and relate to others. It also diminishes a person’s ability to respond to their own internal cues about what is and is not dangerous. The impact of neglect, though not an obviously acute trauma, often takes the shape of Complex PTSD.
Can someone have PTSD or C-PTSD after a significant loss or death of someone close to them?
A lot of people describe grief as a form of trauma. Sometimes grief does become trauma, and often it does not. To begin, we are all prepared for the fact that death is a part of life. We don’t want to lose people, but somehow we are wired to do so and to adapt to the reality of loss. There are occasions, however, when this adaptation becomes complicated and morphs into a trauma.
It is widely understood that a parent losing a child can result in trauma. This is because it feels out of the “natural” order of things. However, if that child had been sick for a while and there was a significant lead up to the loss, grief can remain as it is, a sad and upsetting state that does not result in traumatic or hypervigilant responses.
Further, if a loss occurs at the hands of violence, it is more likely that the loss will manifest itself in a type of trauma, whether that is PTSD or C-PTSD. If that violence is witnessed, the risk of developing a trauma diagnosis increases. Our ability to remain squarely in the realm of grief often rests on how much meaning we can make of the loss and how openly we are able to discuss and process it over a lengthy period of time.
The more underrepresented way that grief becomes PTSD is when something called a hagiography occurs. The word, though not commonly known, means to create a biography of someone (post mortem) that idealizes that figure. Upon someone’s passing, there is a strong pull to start to discuss and hold memories of the person in a strictly positive light. In 1917, Sigmund Freud wrote about the distinction between mourning (grief) and melancholia (trauma or depression). He hypothesized that we are more likely to experience grief if we can tell the truth about who we lost and not create a fiction or fantasy about that person. He went on to suggest that a traumatized or depressive state would ensue if we were forced into some sort of secret keeping over how we really felt about the person who died. The secret keeping would be ensured by largely held ethics around “not speaking ill of the dead” or “only thinking positive thoughts.”
Shame and trauma are closely linked, and secret keeping, which is often created by the need to preserve fiction and fantasy, creates shame. The link between idealization of the dead and trauma is one that has long been considered but has not been widely discussed.
In what ways is C-PTSD different from PTSD?
The central distinctions between C-PTSD and PTSD are the length of time that the symptoms persist and the persistence and duration of the precipitating trauma. While PTSD can, itself, last years, C-PTSD is much more elusive to treat. It often becomes fused with the personality, making it harder to pinpoint and target the symptoms. Complex PTSD takes a more substantial toll on one’s sense of self, leaving one’s psyche in a nearly constant state of doubt and distrust. The feelings of doubt and distrust can be turned inward, creating extreme feelings of self-hatred and disgust. They can also be turned outward, leading someone to act with extreme aggression or violent behaviors.
PTSD is typically evoked by an event, sudden or unpredictable, that happens outside of our familiar ecosystem. It can be at the hands of something that happened in the military, a robbery, a sexual assault. While all of these possibilities take a heavy psychological toll, they don’t necessarily destroy one’s ability to attach and take comfort from familiar loved ones and other resources, such as our own homes or spiritual lives.
C-PTSD typically arises from childhood trauma. It is made all the more likely when that childhood trauma has occurred at the hands of an attachment figure. C-PTSD makes our ability to form secure attachments nearly impossible and leaves us with the inability to regulate our affect states, the tendency toward dissociation, poor impulse control, and difficulty making decisions or experiencing mastery over our own thought processes. Because of the nature of C-PTSD symptoms, normal development is typically thwarted in at least one way, if not more. Simple learning processes can become difficult, as can our inner knowing about how to feed and care for ourselves properly.
What would you recommend to someone who is dealing with PTSD (or at least very similar symptoms) after a significant loss or death? How can someone cope in this situation?
The first thing I would recommend to anyone who is dealing with PTSD is to talk about it - and in talking about it, to allow one’s thoughts and emotions to truly flow. The more that is discharged, psychologically, the less likely it is that the event will reside in the mind in a traumatizing way. I often think of traumatic events or loss as similar to a large build-up of plaque. The more we attend to it, the less likely the build-up is to occur. So, we really ought to brush and floss, as many times a day as necessary, or the residue gains in its own potency.
There also needs to be an enhanced focus and attention to something called ADLs. These are the activities of daily living - getting dressed, taking a shower, eating, tying one’s shoelaces, doing laundry. Because of the psychological and physical toll that trauma takes upon the body, these tasks become far more laborious. From a purely physiological standpoint, the body responds to trauma by drowning the system in the stress hormone: cortisol. Recovering from this chemical bath, basically, takes significant time and patience. It can almost feel flu-like to move through the world post-trauma.
There can never be any rush placed on the processing that is required to metabolize a trauma. It simply takes the time it takes, but the mind and body can and will process it if someone can make use of their relationships as tools by which they can share some of the psychological burden that is being shouldered.
Finally, the use of spirituality, routine, exercise, journaling, and sleep can all add to the possibility of trauma being resolved. These are all activities that are based on routine and predictability, the central things that trauma is not. The more that we experience routine and predictability, the less our hypervigilance can reign supreme.
Are there factors that make it more likely an event will cause PTSD or symptoms that occur in PTSD, or will be traumatic to the person experiencing it?
When soldiers returned from Vietnam, the number who suffered from PTSD was alarming. In fact, the number is around 31%, far more than soldiers who returned from Afghanistan (11%) or Iraq (10%). The underlying hypothesis around this is that the soldiers returned to a country that felt both ambivalence and shame around the war itself. Furthermore, many of the soldiers who were in Vietnam were drafted and there on a less than consensual basis.
These are two significant issues that thwarted the soldiers’ ability to make meaning of their time in Vietnam: there was very little meaning to be made of the war, and the wish to be a part of it was not autonomously made - thereby making being there, at all, feel empty and meaningless. Very simply put, the meaning making process is kryptonite to trauma. The more that someone is able to discuss, string together a narrative, and tell a story about their own experience, the less likely that the mind is to become haunted by the symptoms of PTSD.
The other underlying risk factors that predispose someone to developing PTSD are attachment history and previous traumas. If someone was raised in a relatively predictable and secure environment, they are less likely to develop PTSD. And, if someone has already experienced a trauma, particularly an unresolved one, the capacities that would have helped them to negotiate that trauma are likely diminished and unavailable.
Dr. Danna Bodenheimer, LCSW, is the founder of Walnut Psychotherapy Center, and the executive director of the Walnut Wellness Fund. She is the author of Real World Clinical Social Work: Find Your Voice and Find Your Way and On Clinical Social Work: Meditations and Truths From the Field (The New Social Worker Press).