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Intersections Between Grief and Trauma:
Toward an Empirically Based Model for
Treating Traumatic Grief
Cheryl Regehr, PhD
Tamara Sussman, MSW
Two divergent areas of study have focused on the experiences of grief, i.e., bereavement,
and on trauma and its aftermath. The grief literature has its foundations in
psychodynamic and relational theories, and thus treatment modalities have focused on
resolving relationship issues through reminiscence and developing a new sense of the
relationship and of the self, independent of the lost loved one. The trauma literature,
while having some psychodynamic roots, has been founded primarily on biological and
cognitive formulations. Again, while many different treatments are discussed, cognitive-
behavioral approaches based on cognitive restructuring and symptom management
dominate the practice efficacy literature. But trauma and bereavement/loss are not
mutually exclusive, and when a practitioner is faced with a client suffering from both, it is
necessary to attempt to integrate these divergent theories and at times antithetical
treatment approaches. This paper therefore seeks to address the issue of treatment
efficacy in traumatic loss and develop guidelines for evidence-based approaches to
practice. [Brief Treatment and Crisis Intervention 4:289–309 (2004)]
KEY WORDS: traumatic grief, traumatic loss, posttraumatic stress disorder, evidence-
based practice.
Two parallel streams have emerged in the
professional and academic literature—these
regard grief, i.e., bereavement, loss of a loved
one, and trauma. The grief literature has
focused on the process of mourning. The theory
in this area has concentrated on relational
dimensions and bereavement accompanying
the experience of detaching from the deceased.
Treatments recommended involve remember-
ing the deceased, ‘‘working through’’ feelings,
and attaining a new relationship with the mis-
sing loved one. By contrast, the trauma
literature has examined responses to exposure
to horrifying and life-threatening events.
Theory and research in trauma have long
From the Centre for Applied Social Research and Faculty
of Social Work, University of Toronto.
Contact author: Cheryl Regehr, PhD, Centre for
Applied Social Research, University of Toronto, 246 Bloor
Street West, Toronto, Ontario, M5S 1A1. E-mail:
cheryl.regehr@utoronto.ca.
DOI: 10.1093/brief-treatment/mhh025
289
Brief Treatment and Crisis Intervention Vol. 4 No. 3, ªOxford University Press 2004; all rights reserved.
RESEARCH COMMENTARY
considered both the psychological and physi-
ological dimensions of terror and its aftermath.
Distressing memories and physiological reac-
tions are viewed as symptoms of a disorder.
Treatment is aimed primarily at symptom
management and eradicating intrusive images
of the traumatic event. Yet, trauma and grief are
often not mutually exclusive. People survive
accidents that their loved ones do not. Family
members are murdered. Children die suddenly.
Depending on the suddenness and violence and
the sense of justice associated with the loss, as
well as the nature of the relationship between
the deceased person and the survivor, people
may suffer trauma and grief simultaneously.
This requires that we develop and test inter-
vention strategies that deal with these com-
plex situations.
Despite the proliferation of theoretical and
clinical literature in the area of grief studies, the
empirical basis for theoretical constructs and
resulting treatment approaches in the area of
grief work is quite weak (Jordan & Neimeyer,
2003). In the area of trauma, outcome studies do
point to the efficacy of some approaches,
particularly those with cognitive-behavioral
foundations (Follette, Ruzek, & Abueg, 1998;
Harvey, Bryant, & Tarrier, 2003; Rothbaum &
Foa, 1996). However, there is evidence that the
application of certain approaches with clients
who possess certain vulnerabilities or charac-
teristics may in fact be iatrogenic (Regehr,
2001). Traumatic grief is an emerging construct,
and few treatment approaches specifically
address its issues, yet a growing body of
evidence exists upon close examination of
inclusion criteria for grief and trauma inter-
vention studies. This research literature can
form the foundation for an evidence-based
approach to clinical practice with individuals
suffering from traumatic grief.
Evidence-based practice is defined as the
conscientious, explicit, and judicious use of
the best available scientific evidence in profes-
sional decision making (Sackett, Richardson,
Rosenberg, & Haynes, 1997). More simply
defined, it is the use of treatments for which
there is sufficiently persuasive evidence to sup-
port their effectiveness in attaining the desired
outcomes (Rosen, Proctor, & Staudt, 2003) for
the particular problem and for clients with the
characteristics of those presently being
served (Roberts & Yeager, 2004). This paper
examines the intersection between trauma and
grief/bereavement and attempts to determine
empirically based approaches for treatment
interventions in the event of traumatic loss.
Considering the intensity of these tragic events
and the depths of despair that may be
experienced by individuals who encounter
traumatic loss, it is imperative that mental
health professionals respond with approaches
that do in fact assist to relieve suffering and do
not carry the risk of elevating symptoms.
Foundations of Grief Theory
Throughout the past century, grief work has
been the major theoretical construct to explain
how people cope with bereavement. Due to the
fact that virtually all humans can be expected to
experience significant loss at some time in their
lives, grief is viewed as a normal, albeit
distressing, process. High levels of emotion
are experienced but are viewed as having
a clearly defined goal, that is, helping the
bereaved abandon the commitment to the
relationship with the deceased (Freud, 1917).
Movement toward resolution is conceptualized
to occur in stages or phases during which
individuals complete a series of mourning tasks.
While the number of stages or tasks one passes
through differs in the various conceptual
modes, commonalities exist. In general, the
first stage is described as acute grief, which is
characterized by numbness, frequent yearning
for the deceased, and denial of the permanence
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290 Brief Treatment and Crisis Intervention / 4:3 Fall 2004
or reality of the loss. Although bereavement
theorists are hesitant to provide timelines for
normal grief patterns, this stage is thought to
typically last a number of weeks, generally 6 to
8 (Humphrey & Zimpfer, 1996; Worden, 1991).
Once the permanency of the loss becomes
a perceptual reality, the bereaved typically is
thought to experience an extended period of
disorganization and despair which can last
several months (Shuchter & Zisook, 1993).
Finally, as the intensity of loss-related emotion
begins to subside, the bereaved individual
enters a phase of reorganization in which he
or she must learn to function in an environment
without the deceased and come to a new sense
of the lost relationship (Bowlby, 1980; Parkes,
1996; Worden, 1991). This stage is still
accompanied by elevated emotions; however,
the frequency of yearning and crying and the
centrality of the loss in the bereaved individ-
ual’s life begin to diminish. According to many
grief theorists, the process of normal grieving is
expected to last between 1 and 2 years and
varies depending upon the nature of the
relationship between the deceased and the
bereaved and the circumstances surround-
ing the death (Humphrey & Zimpfer, 1996;
Worden, 1991).
A somewhat different interpretation of the
process of grief is proposed by Stroebe and
Schut (1999), who put forth a dualistic model of
bereavement which suggests that grieving is
a dynamic process that reflects both the
realization of the loss and the continued fight
against the reality of the loss. These theorists
propose that bereaved people have a tendency
to oscillate between confronting and avoiding
loss at every stage of the bereavement process.
Accordingly, people engage in both loss
orientation, which concentrates on dealing
with some aspects of the loss (e.g., yearning
for the deceased, looking at old photos, crying
about the death), and restoration orientation,
which concentrates on life changes (e.g., how to
deal with social loneliness). Unlike stage
theorists, Stroebe and Schut do not propose that
one orientation necessarily proceeds another,
but rather suggest that a balance between both
is normal and necessary during the course of
bereavement. What remains unclear is the ideal
balance between confrontation and avoidance.
These conceptual models for understanding
bereavement have contributed to a view that
people experiencing grief subsequent to loss
must confront and work through their reac-
tions. This notion that one has to process grief
can be traced back to Freud (1917), who
described the ‘‘work of mourning’’ as a process
wherein the bereaved reminisces and emotion-
ally experiences the memories and significance
of the deceased, as a step toward letting go of
involvement with him or her. Like Freud,
Stroebe (1992) defined working through as ‘‘a
cognitive process of confronting a loss, of going
over the events before and at the time of the
death, of focusing on memories and working
towards detachment from the deceased’’ (p. 20).
These definitions have been maintained by
others (Rando, 1992; Sanders, 1993; Worden,
1991). There are two assumptions articulated in
this conceptualization. One is that individuals
must express their emotions, particularly neg-
ative ones, in order to resolve their grief; and
the second is that this highly painful and
emotional process will help the bereaved to
detach from the deceased and achieve resolu-
tion. The first assumption has guided most
clinical grief interventions: The primary goal
for practitioners is often to help individuals
work through the process of grief by express-
ing both positive and negative emotions di-
rected toward themselves, the deceased, and
others. Failure to express these highly charged
emotions is assumed to put individuals at risk of
complicated grief, specifically delayed grief
reactions.
Thus, clinical theorists consistently promote
the need to confront grief-related emotions as
Intersections Between Grief and Trauma
Brief Treatment and Crisis Intervention / 4:3 Fall 2004 291
a means of achieving ‘‘grief resolution.’’
Clinicians offering grief therapy to individuals
evidencing both normal and pathological pat-
terns of bereavement are encouraged to facili-
tate the expression of grief-related emotion by
asking the bereaved to identify and experience
feelings such as what they do and don’t miss
about the deceased and what negative feelings
they have toward the deceased (Bowlby, 1980;
Humphrey & Zimpfer, 1996; Worden, 1991).
Expressing both positive and negative emo-
tions regarding the deceased is seen as impor-
tant in grief resolution, as this phase requires
the integration of a balanced and realistic
memory of the deceased rather than an
idealized or completely negative one (Hum-
phrey & Zimpfer, 1996; Worden, 1991). Fur-
ther, guided by these stages of grief, counselors
are advised to help individuals express their
numbness and yearning so that the reality of
the loss can be actualized; to identify and work
through their despair, including their feelings
regarding the lost relationship, so that the
intensity and frequency of grief-related emo-
tions can dissipate; and finally to focus on the
external world so that lost roles and self-
concepts can be re-formed. Although stages/
phases are not necessarily meant to be linear, it
is a clear assumption that one cannot experience
the stage of reorganization without having
verbalized and worked through the emotions
identified in the first stages of grief.
Foundations of Trauma Theory
The experience of psychological trauma in
response to exposure to horrific events is
a theme that can be found in the earliest of
literature. Achilles in Homer’s Iliad and Hot-
spur in Shakespeare’s Henry the IV are fre-
quently cited as excellent portrayals of what we
now understand to be traumatic stress reactions
secondary to involvement in combat. Psychia-
trist Pierre Janet is quoted as writing in 1919:
‘‘All famous moralists of olden days drew
attention to the ways in which certain happen-
ings would leave indelible and distressing
memories—memories to which the sufferer
was continually returning, and by which he
was tormented by day and by night’’ (quoted in
van der Kolk & van der Hart, 1989, p. 1530). In
the late 1800s and early 1900s many physicians
began describing reactions to traumatic events,
including both physical responses (such as
‘‘irritable heart’’ [DaCosta, 1871; Oppenheimer
& Rothschild, 1918]; posttraumatic spinal cord
injuries due to nervous shock and without
apparent lesions [Page, 1885]; and ‘‘neurasthe-
nia,’’ a physical disorder associated with fear
[Mott, 1918]) and psychological reactions such
as ‘‘war neurosis’’ (MacKenzie, 1916) and ‘‘shell
shock’’ (Southward, 1919).
Two main theories emerged out of this
literature. The first was proposed by Freud,
who suggested the concept of ‘‘anxiety neuro-
sis,’’ or ‘‘hysteria,’’ in which a horrific psycho-
logical event leads to physical consequences
(Turnbull, 1998). The second suggested that the
impact of physical forces on the central nervous
system experienced during a traumatic event
such as a rail disaster or combat resulted in
a temporary neurological dysfunction, which in
turn leads to symptoms (Turnbull, 1998).
However, this interest in the effects of psycho-
logical trauma on individuals subsided after
the end of the First World War and did not
resurface until the mid-1970s. At that time,
interest in the effects of war on Vietnam
veterans emerged, resulting in the concept of
‘‘posttraumatic stress,’’ and interest in the
effects of rape on victims emerged, resulting
in the concept of ‘‘rape trauma syndrome’’
(Burgess & Holstrum, 1974). Together, the
pressures arising from the needs of these two
highly divergent groups of sufferers resulted in
official recognition of posttraumatic stress
disorder (PTSD) in the Diagnostic and Statistical
REGEHR AND SUSSMAN
292 Brief Treatment and Crisis Intervention / 4:3 Fall 2004
Manual of Mental Disorders (DSM) (American
Psychiatric Association, 1980).
One aspect of trauma response is viewed as
neurophysiological. As a result of exposure to
an experience of fear or danger, individuals
undergo neurophysiological changes that en-
hance the capability for fight or flight. These
biological responses generally return to normal
levels within a period of hours. In individuals
suffering from posttraumatic stress, however,
several biological alterations remain, including
an enhanced startle response that does not
habituate, increased activation of the amygdala,
alterations in the hypothalamus, and decreased
cortisol levels (van der Kolk, 1997; Yehuda,
1998; Yehuda, 2002). Thus, autonomic hyper-
arousal mechanisms related to the event con-
tinually recur and are exacerbated by traumatic
memories and images. The sufferers thus find
themselves alternating between states of rela-
tive calm and states of intense anxiety,
agitation, and anger and hypervigilance (Rob-
erts, 2002). In part, the neurophysiological
influence is evidenced by the disorganization in
trauma memory and the difficulty in producing
a coherent narrative (Brewin, 2001). As indi-
viduals attempt to reconstruct events, they
discover gaps and experience spontaneous
flashbacks, which they attempt to control by
manipulating the probability of their being
triggered by stimuli (Brewin, 2001). Thus, in
order to cope with the symptoms, the in-
dividual frequently attempts to avoid exposure
to stimuli that are reminiscent of the event or to
shut out memories of the event. From this
perspective, treatment focuses on controlling
stimuli and on symptom management.
What is problematic about the biological
formulation, however, is that there is consider-
able evidence that not all people will have
traumatic stress reactions to a catastrophic
event. Several studies have shown that 50%
to 80% of men and women experience potential
traumatic events but that the majority do not
develop PTSD, which requires that the symp-
toms continue for more than 1 month. For
instance, a nationally representative study of
512 Israelis who had been directly exposed to
a terrorist attack and 191 who had family
members exposed demonstrated that while
76.7% had at least one symptom of traumatic
stress, only 9.4% met the criteria for PTSD
(Bleich, Gelkopf, & Solomon, 2003). In this
study, the majority of people expressed opti-
mism and self-efficacy regarding their ability to
function in a terrorist attack. Similarly, a study
of Latino primary care patients in the United
States revealed that of those who had experi-
enced political violence in their homeland, 18%
met the criteria for PTSD (Eisenman, Gelberg,
Liu, & Shapiro, 2003). The lifetime prevalence
of PTSD in the general population of the United
States is reported to be 5% for men and 10% for
women (Kessler, Sonnega, Bromet, Hughes, &
Nelson, 1995). This is not to say that individuals
are unaffected by the events, but rather that
they have symptoms of distress that for the
most part subside within a relatively short
period of time. These findings provoked Shalev
(2002) to suggest that traumatic events may be
more appropriately called potentially trauma-
tizing events. Thus, the evidence is that most
people are resilient and adaptive following
a traumatizing event.
It has been suggested that the ability to
contain disruption caused by trauma within
reasonable boundaries is associated with a clus-
ter of personal attributes, including mastery,
control, flexibility, and optimism. This un-
derstanding of trauma response is primarily
cognitive in nature. That is, a traumatic event
violates assumptions that individuals hold
about the world, such as, ‘‘If I drive safely, I
will not get into a horrific accident.’’ As a result
of this disjuncture between an individual’s
view of the world and the event that has
occurred, his or her normal adaptive mecha-
nisms fail to be activated. Sensory images of the
Intersections Between Grief and Trauma
Brief Treatment and Crisis Intervention / 4:3 Fall 2004 293
event are stored in active memory, where they
are repeatedly experienced. These intrusive
thoughts and images give rise to feelings of
anxiety, guilt, and fear (Horowitz, 1976). From
this perspective, an individual attempts to cope
with the traumatic imagery by (1) failing to
be sensitive to the discrepant information, (2)
interpreting the meaning of the information in
a way that is consistent with current beliefs, or
(3) altering existing beliefs to match the
experience (McCann, Sakheim, & Abrahamson,
1988). Those individuals who are able to main-
tain a sense of control and optimism regarding
the outcome of the event are thus expected to
fare better. Treatment therefore is aimed not
only at controlling symptoms, but in addition at
cognitive restructuring of the meaning of the
event and the degree of control that an
individual has over the outcome of the event.
These formulations, however, ignore other
factors that influence the individual and his or
her response to trauma, such as whether the
origin of the event is attributable to human
intention or to natural causes (Briere & Elliott,
2000) and the secondary losses or stressors
associated with the event (Brewin, Andrews, &
Valentine, 2000; Green, 2000; Hobfoll, 2001). In
addition, the degree of support in the environ-
ment is important, including the individual’s
personal network and the community response
to the event.
Intersections Between Grief
and Trauma
While grief theory and trauma theory have
differing perspectives on the etiology and out-
come of tragic events, clearly grief (bereave-
ment, loss) and trauma are not mutually
exclusive. Lindemann (1944), for instance,
conceptualized crisis and loss while following
the experiences of the survivors of a 1942 fire in
the Coconut Grove nightclub in Boston, in
which close to 500 people died. Lindemann
observed and documented the reactions of the
survivors, which included somatic responses,
behavioral changes, and emotional responses
such as grief and guilt. In describing the pro-
cess of their recovery, he noted the impor-
tance of grieving, adapting to the loss, and
developing new relationships. Undoubtedly
these individuals experienced the trauma of
near-death and witnessing death as well as grief
related to the loss of loved ones. Yet, despite the
overlap between trauma and grief (see Figure
1), the two experiences are conceptualized as
distinct by some theorists and indistinguish-
able by others. Raphael (1997) has considered
the differences between the experiences of
trauma and grief. For instance, she notes that
although both have intrusive thoughts or
memories, traumatic memories focus on specific
negative or horrifying aspects of the event,
while grief memories focus on the lost person
and can be either positive or negative in nature.
Anxiety in traumatized individuals tends to be
related to threat and fear rather than separation,
as it is in bereaved individuals. Further, while
traumatized people tend to be avoidant and
socially withdrawn, bereaved people often seek
out reminders and social support. Unresolved
trauma reactions are seen to lead to chronic
PTSD, while unresolved grief issues are more
associated with depression (American Psychi-
atric Association, 2002). Conversely, Brom and
Kleber (2000) suggest that ‘‘there is no need to
see the response to the loss of a close person as
essentially different than the response to other
traumatic events’’ (p. 48). In the case of a natural
death, the survivor may be preoccupied with
images of the deceased and feel longing, sad-
ness, and depression. If the bereaved witnessed
a death by force or calamity, the images may be
more violent and the emotional response one of
rage or helplessness. Nevertheless, in the
researchers’ view, the altered content does not
represent a distinct entity.
REGEHR AND SUSSMAN
294 Brief Treatment and Crisis Intervention / 4:3 Fall 2004
Recent theorists and researchers have dis-
cussed the conceptual links between grief and
trauma (Green, 2000; Pfefferbaum et al., 2001;
Stroebe, Schut, & Finkenauer, 2001). Others are
attempting to move beyond the distinctions
between grief and trauma and develop criteria
for a new category, that of traumatic grief.
Prigerson, Shear, and colleagues (1999) have
proposed consensus criteria for traumatic grief
based on PTSD criteria in the DSM, fourth
edition, revised (American Psychiatric Associ-
ation, 2002). In Prigerson et al.’s model,
Criterion A requires the death of a significant
other and a response to that death involving
intrusive, distressing preoccupation with the
deceased person, such as yearning, longing, or
searching. Criterion B requires a combination
of the following symptoms: efforts to avoid
FIGURE 1
The relationship between trauma and grief.
Intersections Between Grief and Trauma
Brief Treatment and Crisis Intervention / 4:3 Fall 2004 295
reminders of the deceased; feelings of purpose-
lessness and futility about the future; a sense of
numbness or detachment resulting from the
loss; feeling shocked, stunned, or dazed by the
loss; difficulty acknowledging the loss; feeling
that life is empty and unfulfilling without the
deceased; a fragmented sense of trust, security,
and control; and anger over the loss. Thus, while
the symptoms parallel traumatic stress, there is
no discussion about the nature of the death as
a specific criterion. Horowitz and colleagues
(1997) have similarly proposed a new diagnostic
category of complicated grief disorder, which
includes such symptoms as intense intrusive
thoughts, severe pangs of emotion, denial of
implications of the loss to self, feelings of
exceptional aloneness and emptiness, excessive
avoidance of tasks reminiscent of the deceased,
sleep disturbances, and neglect of necessary
adaptive activities at work or at home—lasting
more than 1 year postbereavement. Again, the
nature of the loss is not specified. Based on
conceptualizations of traumatic grief, Boelen,
van den Bout, and de Keijser (2003) have devel-
oped the Inventory of Traumatic Grief, which
differentiates between traumatic grief and
bereavement-related depression and anxiety.
Empirical evidence confirms that when
trauma and grief occur together, subsequent
reactions are more prolonged and distressing.
Traumatic grief has been associated with a five-
fold increase in the likelihood of suicidal
ideation in young adults (Prigerson, Bridge, et
al., 1999). When compared with those who
experienced a traumatic event in the form of an
assault, a sample of young women who had
experienced traumatic loss had higher rates of
intrusive symptoms, reexperiencing symptoms,
and impaired school performance (Green et al.,
2001). It is important to attempt to distinguish
which factors differentiate grief over loss from
traumatic grief. Stroebe, Schut, and Finkenauer
(2001) suggest that traumatic grief can be
distinguished from grief/loss responses based
on the enormity of the event and from trauma
responses based on the fact that the enormity
includes a consideration of the intensity of the
relationship with the deceased. Green and
colleagues, in studying the survivors of the
Beverly Hills Supper Club Fire, which killed
165 people (Green, Grace, & Gleser, 1985), and
the survivors of a dam collapse at Buffalo Creek
(Gleser, Green, & Winget, 1981), found that the
closeness of the relationship with people lost in
the disaster predicted similar or higher levels of
distress as that of personal life threat. Other
researchers suggest that the quality of the
bond, ambivalence related to the relationship,
or unhealthy attachments are important pre-
dictors (Field, Nichols, Holen, & Horowitz,
1999; Worden, 1991). Similarly, when death is
violent, such as due to accident or homicide,
bereavement has been found to be more
complicated in terms of prolonged symptoms
of PTSD and depression (Kaltman & Bonanno,
2003; Thompson, Norris, & Ruback, 1998).
Factors which contribute to traumatic grief in
individuals who have lost a loved one to
murder include not only shock and disbelief,
but also a sense of injustice regarding commu-
nity and legal response to the event (Armour,
2002; Rock, 1998). In addition to the cause of
death, factors related to perceptions of justice
include the age of the deceased, whether or not
the death was expected, and the co-occurrence
of other losses or stressors. Death of a child is
uniformly associated with prolonged and com-
plicated grief in parents (Finkbeiner, 1996;
Weiss, 2001). In the case of death during dis-
aster, other concurrent losses and disruptions
add to the experiences of loss and trauma
(Najarian, Goenjian, Pelcovitz, Mandel, &
Najarian, 2001; Norris, Friedman, & Watson,
2002).
Thus, there is a movement to consider
traumatic grief as a distinct entity that encom-
passes elements of bereavement and trauma,
yet acknowledges that in combination these
REGEHR AND SUSSMAN
296 Brief Treatment and Crisis Intervention / 4:3 Fall 2004
experiences result in higher levels of distress.
This requires that we consider what treatment
approaches might be of greatest benefit to those
suffering from traumatic grief, as approaches to
trauma treatment and grief treatment are highly
divergent from one another.
Empirical Evidence for Bereavement
Interventions
As stated above, the central theme of grief
treatment is the notion of working through the
mourning through reminiscing and emotionally
experiencing memories of the deceased. At
best, however, the efficacy of working through
the emotions of grief appears equivocal in
empirical research. Some studies have demon-
strated that the expression of grief-related
emotion during the initial stage of bereavement
does lead to lower symptomatology over time.
For example, Stroebe and Stroebe (1993) found
that widowers who confronted their grief
during the first 4 to 7 months following their
loss suffered fewer depressive and somatic
symptoms after 2 years. Further, Lepore and
colleagues (1996) found that parents who had
lost a child to sudden infant death syndrome
and who focused on disclosure of feelings
showed lower depression rates than those who
did not, if their social environment was
perceived as supportive of such disclosures.
Conversely, however, prospective longitudinal
studies have found no associations between
negative emotional expression during the first 6
months of a loss and grief symptoms 5 years
later, suggesting that failure to do ‘‘grief work’’
in the initial stages of bereavement does not
necessarily lead to prolonged or delayed grief
(Bonanno & Field, 2001; Middleton, Burnett,
Raphael, & Martinek, 1996). Other prospective
studies confirm that grief work is no more
efficacious than avoidant strategies (Archer,
1999; Stroebe & Stroebe, 1991).
There are four recent reviews of the bereave-
ment intervention literature (Kato & Mann,
1999; Litterer Allumbaugh & Hoyt, 1999;
Neimeyer, 2000; Schut, Stroebe, van den Bout,
& Terheggen, 2001). Kato and Mann (1999)
conducted a qualitative and quantitative re-
view of 13 randomized controlled bereavement
studies, separating their analyses by interven-
tion type (individual, family, or group). Ac-
cording to their review, the 3 studies offering
an individual intervention for grief found small
but inconsistent improvement in the physical
health of the bereaved as measured by per-
ceived health (Gerber, Wiener, Battin, & Arkin,
1975; Raphael, 1977; Vachon, Lyall, Rogers,
Freedman-Letofsky, & Freeman, 1980). Vachon
and colleagues (1980) demonstrated improve-
ment in perceived health on the general health
questionnaire (GHQ) for bereaved women who
were paired with other widows trained in
supportive counseling and whose grief was
considered resolved. The widows who were
particularly distressed at the onset benefited
the most from the intervention. Kato and Mann
(1999) caution, however, that the difference
between groups on perceived level of social
support prior to the intervention may have
accounted for some of the differences noted in
the study. Gerber and colleagues (1975) and
Raphael (1977) studied interventions for acutely
bereaved individuals receiving individual
counseling from a professional counselor.
Participants in the Gerber et al. study received
a 6-month intervention which focused on both
emotional resolution and practical advice.
While the control group had more visits to
their doctor immediately after the intervention,
there was no difference upon long-term follow-
up 8–15 months after the loss. Further,
individuals participating in the intervention
did not differ from nontreatment controls in
their medication use and reported health
during, immediately after, or 6 months after
treatment. In the Raphael study, widows
Intersections Between Grief and Trauma
Brief Treatment and Crisis Intervention / 4:3 Fall 2004 297
receiving a 3-month intervention were consid-
ered at high risk because they either had an
unsupportive social network, the death had
been untimely or unexpected, they had had
a highly ambivalent marital relationship, or
they had a concurrent life crisis. Individuals
receiving the intervention were offered ego
support and encouraged to express their grief
and to work through their ambivalent relation-
ship with the deceased. Using the Goldberg
GHQ, individuals in the intervention group
were found to have improved more than
controls on measures of anxious symptoms,
depressive symptoms, and somatic symptoms.
Less efficacious findings were reported by
Kato and Mann (1999) on the eight group
interventions they reviewed. According to
these reviewers, six or eight group interven-
tions showed no beneficial effects (Barrett,
1978; Duran, 1987; Sabatini, 1988; Tudiver,
Hilditch, Permaul, & McKendree, 1992; Walls &
Meyers, 1985; Weidaw, 1987). The predomi-
nant intervention used in these group studies
was a combination of lectures about the
grieving process and an open discussion of
grief-related emotions. All of these groups were
led by professionals in psychology, nursing, or
mental health, with the exception of Tudiver
and colleagues (1992), which was a self-help
model led by volunteer widows. While study
participants in the intervention conditions in
all groups did improve over time, so did
individuals in the control condition. The study
by Constantino (1988), one of the two group
interventions judged to be effective by Kato
and Mann (1999), consisted of bereaved
widows long after the loss and may therefore
more accurately be measuring individuals
experiencing more chronic grief.
Kato and Mann’s (1999) meta-analysis of the
11 studies found a very small positive effect for
physical health, and no effect for depression or
other stress-related outcomes. Their separation
of group and individual interventions reveals
that much of this effect is accounted for by
bereavement interventions offered to individ-
uals rather than in the form of support groups.
Further, those individual interventions which
were found to be effective were either offered
to individuals more highly distressed (Brom,
Kleber, & Defares, 1989; Gerber et al., 1975;
Raphael, 1977) or were most effective for those
individuals starting the intervention with
higher levels of distress (Vachon et al., 1980).
Litterer Allumbaugh and Hoyt (1999) focused
on client factors associated with better or
poorer outcomes. They found that younger
individuals (25–35 years) and the elderly (66–
85) experienced less helpfulness from inter-
ventions. Further, spouses seemed to benefit
less from grief-related interventions than did
nonspouses. Finally, individuals who voluntar-
ily sought treatment benefited more from
interventions than did individuals who re-
sponded to study-recruitment strategies. Con-
trary to expectations, the researchers did not
find a difference in outcomes for complicated
bereavement and normal bereavement; how-
ever, it was suggested that this was due to
inconsistent definitions of complicated bereave-
ment between studies.
Noting that Kato and Mann excluded a num-
ber of studies in their review, Neimeyer (2000)
conducted a meta-analysis of 23 randomized
controlled studies offering individual, family,
or group interventions to individuals who were
mourning the death of a loved one. Like Kato
and Mann (1999), he concluded that the overall
effect upon all individuals seeking counseling
following loss was positive but very small.
According to his analysis, the average person
seeking counseling for bereavement was better
off than only 55% of bereaved persons re-
ceiving no treatment at all. This outcome did
not appear to be related to treatment type
(individual, family, or group) or treatment
approach; however, most studies in his review
shared the common theme of facilitating the
REGEHR AND SUSSMAN
298 Brief Treatment and Crisis Intervention / 4:3 Fall 2004
working through highlighted in the theoretical
literature. The author did find that individuals
who were seeking counseling for normal grief
experienced no positive effect, while those
seeking counseling for more complicated grief
(violent nature of the death, chronic bereave-
ment) showed a reliable positive effect.
Schut, Stroebe, van den Bout, and Terheg-
gen (2001) conducted a review of the be-
reavement literature separating studies
examining interventions offered to all be-
reaved individuals (to prevent grief-related
complications) from studies examining inter-
ventions aimed at individuals at higher risk
for bereavement-related complications and
studies examining interventions aimed at
individuals experiencing some form of com-
plicated grief. These authors concluded that
(1) people with otherwise normal patterns of
grief do not seem to benefit from bereavement
interventions in the long term, especially if
they are grieving the loss of a spouse, and (2)
people showing signs of more complicated
grief seem to benefit the most from inter-
ventions. They caution, however, that studies
looking at individuals with complicated grief
offer interventions much later on in the grief
process than other studies and that the
individuals participating in the intervention
studies tend to be help seekers (i.e., looking
for an intervention) rather than study recruits
(i.e., accepting an intervention by agreeing to
participate in a study).
Two recent studies compared the effects
of two group interventions for individuals
deemed to have elevated levels of grief-related
symptoms 3 months following the loss of
a loved one (Ogrodniczuk, Piper, McCallum,
Joyce, & Rosie, 2002; Piper, McCallum, Joyce,
Rosie, & Ogrodniczuk, 2001). These researchers
randomly assigned individuals to either a sup-
portive treatment or an interpretive treatment.
The researchers found that individuals with
more secure attachments to the deceased
(Ogrodniczuk et al., 2002) and more psycho-
logical mindedness (Piper et al., 2001) did better
in both treatments. However, individuals with
higher-quality relations with all attachment
figures (i.e., better relational capacity) did
better in the interpretive group, and individ-
uals with lower-quality relations did better in
the supportive group.
In summary, when the short-term efficacy of
bereavement interventions is studied, results
are somewhat positive for individuals experi-
encing normal patterns of grief. However,
examining results over time reveals that in-
dividuals who are experiencing higher than
average levels of distress benefit from a variety
of interventions offered individually, while
individuals with normal patterns of grief seem
to experience temporary gains only. Further,
even when individuals are deemed ‘‘at risk’’ for
grief-related complications (i.e., they had
ambivalent relationships with the deceased,
were experiencing concurrent life crises, or the
deceased died suddenly or violently), they do
not necessarily benefit from bereavement
interventions unless they are actually experi-
encing higher levels of distress. Treatment for
individuals experiencing loss in tragic or
traumatic circumstances will be discussed
further in the section on interventions for
traumatic loss.
Summary of Grief Treatment Research
Limited evidence supports the view that
expression of grief leads to resolution.
Those with normal grieving patterns do
not seem to benefit from intervention,
while those with complex grief seem to
benefit from individual treatment.
Those with ambivalent relations with the
deceased may benefit from relationally
focused treatment.
Intersections Between Grief and Trauma
Brief Treatment and Crisis Intervention / 4:3 Fall 2004 299
Those with lower relational capacity may
benefit more from therapy aimed at
providing immediate support and problem
solving rather than interpretation and
conflict exploration.
Empirical Evidence for Trauma
Interventions
Similar to the process of evaluating grief
interventions, one of the issues in evaluating
posttraumatic stress interventions is the degree
to which symptoms spontaneously remit. For
instance, Rothbaum, Foa, Riggs, Murdock, and
Walsh (1992) reported that while 94% of the 95
rape victims in their study met the criteria for
PTSD at 1 week postrape, this reduced to 47%
at 94 days postrape. It has been suggested that
once the 3-month marker is reached or sur-
passed, symptoms of PTSD become relatively
persistent (Cohen & Roth, 1987; Kilpatrick,
Resick, & Veronen, 1981). Nevertheless, Tar-
rier, Sommerfield, Reynolds, and Pilgrim (1999)
discovered that 11% of patients with chronic
PTSD improved with clinical assessment and
self-monitoring to the extent that they no
longer qualified for a diagnosis. Thus, while
there are hundreds of original reports de-
scribing the effectiveness of treatments for
individuals who have been exposed to trau-
matic events, the vast majority are not empir-
ically based studies (Solomon & Johnson, 2002).
Yet, the natural diminution of symptoms of
PTSD requires that controlled studies be
considered when discussing efficacy.
While many excellent reviews and meta-
analyses exist of the research related to
treatment efficacy for traumatized individuals,
it is generally acknowledged that only cogni-
tive-behavioral and psychopharmacological
methods have been subject to rigorous evalua-
tion with controlled trials (Ehlers & Clark, 2003;
Hembree & Foa, 2003; Katz, Pellegrino, Pandya,
Ng, & DeLisis, 2002; Solomon & Johnson, 2002).
Pharmacological treatment for trauma sufferers
has yielded positive results in assisting with
symptom management. In particular, selective
serotonin reuptake inhibitors have shown
positive results (Albucher & Liberzon, 2002),
and mood stabilizers have shown promise
(Albucher & Liberzon, 2002; Katz et al., 2002),
as have beta-blockers (Katz et al., 2002).
Follette, Ruzek, and Abueg (1998), Harvey,
Bryant, and Tarrier (2003), and Rothbaum and
Foa (1996) provide extensive overviews
of the effectiveness of cognitive-behavioral
approaches for posttraumatic stress disorder.
They conclude that cognitive-behavioral ther-
apy (CBT) is effective in reducing the severity of
PTSD symptoms in individuals who have
experienced a wide range of traumatic events
and in those who suffer from both acute and
chronic symptoms. CBT has been demonstrated
to have superior effects over supportive treat-
ment in the treatment of PTSD in a number of
controlled studies (Bryant, Sackville, Dang,
Moulds, & Guthrie, 1999). Cognitive therapies
come in a variety of forms. Exposure therapy is
based on the notion that the common strategy of
avoiding trauma-related memories and cues
interferes with emotional processing of the
event by reinforcing erroneous cognitions and
fears. During imaginal and in vivo exposure and
recounting the event, individuals are assisted to
manage the resulting anxiety and allow distress
to habituate. Stress inoculation training, based
on social learning theory, teaches individuals to
manage fear and anxiety through cognitive-
behavioral techniques. Cognitive therapy as-
sists individuals to identify trauma-related
dysfunctional beliefs that influence response
to stimuli and subsequent physiological and
psychological distress. Some studies have pro-
vided evidence that exposure therapy in
combination with stress inoculation training
or cognitive therapy yields the most positive
results (Hembree & Foa, 2003); others have
REGEHR AND SUSSMAN
300 Brief Treatment and Crisis Intervention / 4:3 Fall 2004
provided evidence that inoculation does not
necessarily enhance other cognitive methods,
which, of themselves, are equally effective
(Harvey, Bryant, & Tarrier, 2003; Tarrier,
Pilgrim, et al., 1999). It is important to note that
exposure methods are more selective in the
criteria for inclusion, and it is suggested that this
model of treatment be used only when a sound
therapeutic alliance has been formed and a thor-
ough assessment completed (Calhoun & Atke-
son, 1991). Individuals in this type of treatment
group should be assessed to have the capacity to
tolerate high anxiety arousal and to have no
active suicidal ideation, comorbid substance
abuse, or, most importantly, current life crises
(Foy et al., 2000). Thus, if they are equally
effective, CBT methods without exposure may
yield a lower risk of iatrogenic effects.
Group treatment methods are less clear-cut.
One form of group treatment is the single-
session debriefing, which has been the subject
of much controversy regarding efficacy. In
general, however, findings suggest that profes-
sionals exposed to trauma in the context of their
job subjectively find single-session debriefings
to be helpful and supportive, although such
sessions do not relieve trauma symptoms and
may in fact exacerbate them (Regehr, 2001).
When applied to victims of trauma, however,
the results raise more concerns. Mayou, Ehlers,
and Hobbs (2000) randomly assigned traffic
accident victims to a psychological debriefing
group or a no-treatment group. At 4 months
postinjury, the researchers reported that the
psychological debriefing was ineffective, and at
3 years, the intervention group remained
significantly more symptomatic compared with
no treatment. They concluded that patients
who initially had high intrusion and avoidance
symptoms remained symptomatic if they re-
ceived intervention but recovered if they did
not receive intervention. Bisson, Jenkins,
Alexander, and Bannister (1997) reported that
burn victims who received debriefings had
significantly higher rates of anxiety, depres-
sion, and PTSD 13 months following their
injury compared with burn victims who did not
receive debriefings. It has been suggested that
the exposure elements of this group interven-
tion are responsible for the iatrogenic effects in
victims (Regehr, 2001).
Longer-term group models using CBT have
more promising results. Foy and colleagues
(2000) reviewed six studies of CBT group
treatment with trauma survivors (three wait-
list control and three single group pretest–
posttest) and indicated that all showed positive
outcomes on PTSD symptom measures. Re-
ported effect sizes ranged from 0.33 to 1.09,
with a mean of 0.68. Larger treatment effects
were reported for avoidance symptoms than
intrusion symptoms.
Thus, while trauma-resolution treatment
approaches described in the literature are
diverse, there is evidence that cognitive-
behavioral methods are effective in symptom
reduction. Several different models of CBT
exist, some focusing on cognitive restructuring,
some on symptom management, and some on
exposure to traumatic imagery followed by
anxiety management. As evidence suggests that
each method may be effective, the concern that
exposure therapy may increase distress and
increase treatment dropout in high-risk groups
suggests that this method should be used with
caution. Pharmacological treatment for indi-
viduals with extremely high levels of distress
should also be considered.
Summary of Trauma Treatment Research
Good evidence exists that individual
CBT treatment reduces trauma
symptoms.
Single-session groups may exacerbate
symptoms.
Exposure treatment, while effective with
Intersections Between Grief and Trauma
Brief Treatment and Crisis Intervention / 4:3 Fall 2004 301
treatment completers, may require
screening out of individuals with high
anxiety, suicidal ideation, or other
concurrent life crises.
Toward an Empirically Based Model for
Treating Traumatic Grief
In reviewing existing studies on traumatic
grief, it is difficult to differentiate those who
have complicated grief due to relational issues
with the lost loved one from those who lost an
individual in a traumatic manner such as in
a natural disaster or by murder, accident, or
suicide. Based on our conceptual model of the
co-occurrence of trauma and loss, we have
included the few studies that evaluated treat-
ment of individuals experiencing both in this
section. As with grief and trauma, we must be
cautious not to assume that all those who are
confronted with traumatic loss will require
intervention. For instance, despite a common
belief that losing a family member to homicide
is highly traumatizing, one study (Freedy,
Resnick, Kilpatrick, Dansky, & Tidwell, 1994)
found that only 16% of those who had
experienced such an event sought treatment.
While it may be tempting to attribute this
absence of treatment seeking to negative causes
such as denial or avoidance, this finding may
also reinforce the notion that individuals have
a remarkable capacity to deal with the after-
math of tragedy.
Four studies utilized confrontation and
exposure techniques for traumatic or compli-
cated grief. Both Mawson, Marks, Ramm, and
Stern (1981) and Sireling, Cohen, and Marks
(1988) studied an intervention of guided
mourning for bereaved individuals who were
identified as having experienced chronic grief
for at least 1 year. The behavioral intervention
involved exposure to feared and avoided
bereavement cues. The control group was
instructed to avoid painful memories and
fearful bereavement cues. In both studies,
individuals in the intervention group im-
proved more than those in the control condi-
tion; however, both groups improved. Mawson
and colleague’s 6 participants specifically
improved in phobic symptoms and phobic
distress and on the Texas Grief Inventory.
Sireling, Cohen, and Marks’s 26 participants
had a significant improvement in cue avoid-
ance, avoidance distress, and somatic symp-
toms compared with the antiexposure group.
However, both the exposure treatment group
and the group instructed to avoid triggers
improved on the Texas Grief Inventory and
measures of anxiety, depression, work func-
tioning, and social functioning, lending some
support to the notion that both grief confron-
tation and grief avoidance can lead to grief
resolution (or that symptoms remit regardless
of intervention). Brom, Kleber, and Defares
(1989) evaluated a treatment intervention for
individuals with loss-related instrusions, de-
nial, avoidance, anxiety, sleeplessness, and
guilt. Individuals were randomly assigned to
a wait-list control; a trauma desensitization
intervention, in which they were helped to
relax and then confront their grief; a hypnosis
therapy intervention, in which they were
hypnotized and then encouraged to confront
their grief; and a psychodynamic intervention,
in which the therapist focused on discovering
and solving psychological conflicts related to
loss. Compared with the control, all three
treatment groups had fewer symptoms as
measured by the Impact of Events Scale;
however, these results were not statistically
significant. Individuals in intervention and
control groups did not differ on somatization,
social inadequacy, anger, trauma symptoms, or
hostility. Shear et al. (2001) report the results of
a treatment protocol involving exposure and
interpersonal therapy with 21 people experi-
encing traumatic grief. While those who
REGEHR AND SUSSMAN
302 Brief Treatment and Crisis Intervention / 4:3 Fall 2004
completed treatment had significantly lower
levels of anxiety and depression than the
control group, of note was that the 8 individ-
uals who did not complete treatment were
more likely to be grieving violent deaths by
accidents, murder, or suicide, suggesting that
these individuals may not have been able to
tolerate treatment. Thus, it is not clear that
exposure treatment is superior to avoidance
or no treatment in individuals with complex
or traumatic grief. Further, those in the
Shear et al. study who had the most traumatic
forms of loss did not complete treatment,
perhaps because exposure was too anxiety
provoking.
Murphy and colleagues (1998) studied the
effects on parents who had recently lost a child
to homicide, suicide, or accident. Identified as
a high-risk group, these parents were randomly
assigned to a combined emotion-focused and
problem-focused group or a no-treatment con-
trol. Of note was the trend that mothers start-
ing the intervention with high amounts of
grief symptomatology and high levels of
distress improved more in the intervention
group than control. Conversely, those experi-
encing low symptomatology were worse off in
the intervention than those in the control
group, suggesting again that for those with
normal grieving, intervention may in fact be
iatrogenic. Fathers did not show long-term
improvements from the intervention.
Summary of Treatment for
Traumatic Grief
Not all people with traumatic loss require
treatment.
Those with unresolved relationship issues
toward the deceased may benefit from
relationally based therapy.
CBT aimed at cognitive restructuring and
symptom management appears to be
effective.
Those with traumatic loss may experience
increased distress in exposure therapy.
Conclusions
In summary, two divergent areas of study have
focused on the experiences of bereavement and
grief and on trauma and its aftermath. Begin-
ning with the treatment efficacy literature in
grief, several important issues emerge. First,
there is little empirical evidence to suggest that
individuals must work through their loss by
expressing negative emotions and evaluating
their relationship with the deceased. In partic-
ular, sharing these experiences with others in
a group-treatment format does not appear to
relieve symptoms of distress. Of note is that
those who are experiencing normal grief (that
is, grief that does not interfere with social,
physical, or emotional functioning for pro-
longed periods of time) seem to not benefit from
treatment. However, those with more complex
forms of grief do appear to benefit from
some individual models focused on relational
components.
From the trauma treatment efficacy research,
there is evidence that individually focused
cognitive behavioral methods do lead to symp-
tom reduction. There is some cause for caution
surrounding exposure treatment methods, how-
ever. While exposure treatment has demon-
strated efficacy when used appropriately, it may
result in iatrogenic effects for those who are
highly distressed or have concurrent chal-
lenges. These iatrogenic effects may be partic-
ularly problematic in single-session groups.
Pharmacological treatments can be of benefit
when symptoms of distress are overwhelming.
Integrating the findings from grief and
trauma, it is first necessary to acknowledge
the spontaneous remission of symptoms expe-
Intersections Between Grief and Trauma
Brief Treatment and Crisis Intervention / 4:3 Fall 2004 303
rienced by both those individuals suffering
from grief and those suffering the aftereffects
of trauma. This speaks to the strength and
resilience within individuals for managing
distress and the importance of natural support
mechanisms. Combined with evidence that
some individuals not only do not benefit from
treatment but in fact experience increased
distress, we must be cautious about inferring
that treatment is necessary for all individuals
encountering traumatic loss. Frances, Clarkin,
and Perry (1984) suggest that no treatment
should be recommended when (1) no response
to treatment can be expected or (2) there is
a risk that the patient will have a negative re-
sponse to treatment. While therapists may find
it difficult to acknowledge the limitations and
risks of treatment and accept that treatment
may not benefit some extremely distressed
and needy patients, no treatment may at times
be the most responsible course of action. This
avoids the pretense of therapy when no
beneficial therapy exists, protects patients from
iatrogenic harm, and allows patients to discover
their own strengths and capabilities (Frances,
Clarkin, & Perry, 1984).
That being said, there is evidence that when
individuals are suffering from traumatic grief
and seek assistance for distress, treatment ap-
proaches can be of assistance. Depending upon
the nature of the distress, a combination
of relational therapy aimed at resolving re-
lational ambivalence and developing a new
sense of self and cognitive-behavioral ap-
proaches aimed at reducing symptoms of
intrusion, anxiety, and avoidance have dem-
onstrated effects and are least likely to result
in iatrogenic effects.
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