What Is Traumatic Grief and How Do We Treat It? A Therapists Research and Perspective

Today’s blog comes from my own questions about traumatic grief: What’s the actual difference with grief and traumatic grief? How can we accurately capture the difference between the two experiences? How does the traumatic element shift the experience of grief? How does the bereavement element shift the experience of trauma? 

A quick google search did not give me the answers I was looking for, so I decided to do a deeper dive in the literature. You’ll find this blog structured around the questions that I was asking, quotes from the literature and my clinical impressions as I was reading.

While I've tried to quote as applicable, I know I did not do a good job (both with the citations themselves- what's APA??- and the lack of citations). If any of my uni profs are reading this, please forgive me.

What is traumatic grief/bereavement?

Often called traumatic bereavement in the literature, it involves “enduring symptoms of trauma, such as intrusive thoughts, and of grief, such as yearning for the loved one. {…}  the symptoms associated with traumatic loss are significantly more intense and prolonged than those following a natural death. They are also more pervasive, affecting virtually all aspects of the survivor’s life. Moreover, it has also been found that survivors of traumatic loss often have difficulty accepting what has happened, struggle with issues surrounding responsibility and guilt, question their religious beliefs, worry that their loved one may have suffered, and live in fear that they or someone in their family will also die.” (Barlé, N., Wortman, C. B., & Latack, J. A. https://doi.org/10.1037/int0000013)

As I read this quote, I am struck by the subjective the experience of grieving is, and how this definition requires a comparison between experiences. If someone is experiencing grief for the first time, how are they to know if their bereavement is “more pervasive” than another person’s grief? How are they to know what the “usual” path to acceptance is, or how long they might feel guilt before they might deem it as different than the “normal” experience? 

From a clinical perspective, I have seen grief take all shapes and forms, with varying intensity, ability to cope and impacts, and all of it has been what I might deem within the realm of normal. I have yet to see a person lose someone and not have it change their world view; how could it not? When you lose a person, you lose the world that you previously knew, the one they occupied. Is it not natural then, to have to adjust to a new world, now that the person is gone?

What I have previously looked for as a marker of traumatic bereavement are the symptoms that are there alongside the grief, specifically: nightmares, flashbacks and absolutely fear/avoidance of any aspect of the grief.

Let’s explore each in turn, beginning with nightmares.

While dreams about the one we have lost are common, nightmares are less common (unless the person we have lost was abusive, more on that later) and can be a good indicator of traumatic grief. Nightmares that leave them feeling afraid, helpless or overwhelmed are different from dreams that leave a person remembering the lost one, feeling sadness and emotional pain. The difference I look for here is the emotional urge; does it turn the person torwards the pain and allow them to feel the connection (and loss) of the person, or does it turn them away from the experience? 

Secondly, having flashbacks to the death (or a moment in the dying process) might indicate traumatic grief. How does one differentiate normal recollection of the dying process from traumatic flashbacks? The ability to decided if/when these recollections arise is part of it, as is the intensity that arises when the memories resurface. If a memory resurfaces and you can put it aside, knowing now is not the time to examine it, that may be a painful recollection. If a memory resurfaces, you cannot put it aside and it feels like you are back in the moment (i.e. you forget that the present moment exists) this is likely a flashback. 

(If you are experiencing flashback, this blog offers a protocol that may be supportive). Clinicians can explore this difference by asking the client what they do when the memory arises; if the client looks at you like you have 7 eyes and does not comprehend the question, it is likely because there is nothing they believe they can do in the moment to cope, which would indicate that flashbacks are occurring. 

Lastly, an absolute avoidance of the grief can be a strong indicator of traumatic loss. Where a client who is grieving may want to talk about the person, the time they had with them, their feelings and memories, a person experiencing traumatic loss may completely avoid the subject. They may pretend there is no impact what-so-ever but not be willing to discuss the lack of impact. Or they may know their is impact but still be unwilling to explore it. This unwillingness can be seen as a lack of safety, which indicates that the passing was dangerous or they felt extreme helplessness, both of which suggest trauma. 

In my practice, I have found these markers to be of more help than the criteria listed in the quote above. Of course, one symptom alone may not be sufficient to identify traumatic grief, but identifying many together has been effective in my practice. 

“Fundamental to our conceptualization is the view that the phenomenology of reactions to bereavement is influenced by the type of event that has taken place.” {M.S. Stroebe, H.A.W. Schut, C. Finkenauer https://research-portal.uu.nl/en/publications/the-traumatization-of-grief-a-conceptual-framework-for-understand/

While this article is older (2001) it is unfortunate and somewhat shocking to me that research that explores trauma would define it through the lens of what happened. I have never found it possible to define trauma based on events and have only seen this cause distress in people, believing that their experiences “do not count” as trauma. I will not further this harm by listing the specific events the article says may lead to traumatic grief, but sufficient to say I believe traumatic grief should be understood through the lens of the impact and symptoms someone experiences, rather than the event that caused it. 

How does trauma differentiate from grief?

While this question may seem to be a silly one, a dive in the literature suggests it is much more nuanced than it appears. Researchers such as Wolfelt argue that trauma IS grief. In his book Reframing PTSD as Traumatic Grief, Wolfelt states that “helping PTSD sufferers mourn their unacknowledged and “carried” grief over the traumatic events that caused their symptoms is the key to helping them heal.” He argues that trauma is about processing the loss, whether the loss is a sense of safety, the loss of identity, the loss of a person, the loss of a voice, etc. 

A simple example would be the child who experienced abuse form their parents growing up and as an adult choose to go no-contact. Though the parents may still be alive, the decision to be no-contact comes with tremendous grief, especially around the role we hoped that our parents could take. 

My brief review of the literature leaves me recognizing that traumatic grief can occur whether death has happened or not. Again, I turn to symptoms, recognizing that if someone has traumatic symptoms as well as bereavement symptoms (sadness, yearning for the lost person, guilt, anger, fatigue, etc), we can classify it as traumatic grief. 

What are the risk factors for traumatic grief? 

While I do not believe that we can define traumatic grief based on the event, there are factors that the researcher suggest make it more likely that a death is traumatic. Please remember that a death may be traumatic regardless of “how” it happened, but these factors may help someone understand why a loss was so difficult.

I’ve shared the risk factors followed by my thoughts, if I felt they were relevant to include.  All of these factors are from this article by Solomon and Hensley https://spj.science.org/doi/full/10.1891/EMDR-D-20-00031 

Suddenness and lack of anticipation

See below for research suggesting this may not be true for all developmental stages

Unnaturalness of the death

How does one define this? In the article, they discuss specifically deaths related to Covid-19 and how one was not able to say good bye or attend an in-person funeral. While I agree with the examples provided, this risk factor does feel so vague that the only way to properly assess this risk factor would be to explore a person’s expectation and narratives around death and see if this aligns with what happened. That being said, this feels impossible to me, as I have yet to see a client be able to accurately anticipate how a loss and their subsequent feelings will unfold. Maybe it is more about the degree to which the expectations were not met and the meaning that they were not met. 

Physical or emotional suffering

This links back to the aforementioned idea of helplessness; to se someone we love hurting and not be able to help them is distressing and makes sense to me this is a risk factor 

Preventable deaths

I have noticed that when a death seems to be one that is preventable, people tend to believe they should have somehow prevented it. I wonder how much this shame is the core of the traumatic experience. 

Randomness

Lack of control or lack of safety is at the core of trauma, as such, a death that seems random may strip someone of the belief that they are safe or that they have control in their world

Multiple deaths 

Nothing to add to this one; my thought process here was simply "checks out".

Threat to one’s own life

Again, connects back to the loss of safety, which we know is a foundation of the traumatic experience 

Untimeliness

The researchers here are speaking to the age of the person who has died, with researchers seeing more of an impact on people when a child or young person dies, versus an elder. This is likely because of the expectations that we hold about life and death; we do not expect someone young to die, and when they do, it shifts the sense we have of the world. This can lead us to questioning all expectations that we previously held as true about the world. 

Social support

Gabor Mate famously explains that trauma is not what happened, but who is there to support us, after the event happens. Naturally then, the amount of support will impact the likelihood something is traumatic. Further, if the person who dies is a primary supporter, the risk of the death being traumatic increases. 

Violence 

This could be a risk factor because it breaks assumptions about the world and/or because it threatens our sense of safety

Intentional death

Again, we hold assumptions about how the world operates, and intentional deaths often make us question the beliefs that we hold about how the world operates. 

Ambiguous death (i.e. lack of confirmation of the death)

When we do not know if a person has passed or not, it is possible that a person is focused on figuring this out, rather than fee

Stigmatized deaths

When we (as a society) stigmatize the way that someone has died, there is likely two impactful factors: the person’s sense of shame and social support. Shame may prevent someone from getting social support or allowing themselves to process the death. Others may be less willing to offer social support or be confused about how to do so. 

In what ways does prior abuse by the deceased influence the grieving process?

Thus far, the reading I have done seems to centre around the loss of a safe loved one. How does the experience differ though if the one who passes was abusive or generally not safe? In my office, I have seen a lot of distress at the passing of an abusive person, leading to feelings of relief, fear, guilt and shame, among others. 

“Elevated emotional abuse values are a contributing factor [ to prolonged grief disorder]. […]individuals who developed early maladaptive schemas exhibited more intense grief reactions and experienced greater difficulty in integrating the loss.” https://doi.org/10.3389/fpsyt.2025.1606183

A shock to no one who has experienced this, the research finds that if you experienced abuse, including emotional abuse, you are more likely to experience a more intense grief response and have a harder time integrating the loss. It also suggests that this intensity is related to how young you were when you experienced the grief.

How does developmental stage impact the experience of the traumatic grief? 

I know about research of developmental stages (i.e. a person’s age) and the impact it has on experiences of trauma OR experiences of grief, but what about when the two come together in traumatic grief?

“Children can also develop traumatic grief after deaths that are not unexpected, violent, or sudden. For example, a study of school-age children and adolescents showed that those who experienced the death of a parent due to a prolonged illness were more likely to develop PTSD and maladaptive grief symptoms than those who experienced the death of a parent due to sudden natural causes (e.g., heart attacks) (Kaplow, Howell, & Layne, 2014). This finding suggests that children may develop childhood traumatic grief after many different types of deaths, including those that might not be judged objectively to be “traumatic. […] the attachment and loss of role are most prominent in the child's traumatic grief.” (Cohen, Mannarino, Deblinger https://books.google.ca/books?hl=en&lr=&id=sZvUDAAAQBAJ&oi=fnd&pg=PP1&dq=developmental+grief+trauma+&ots=2NZPUbZSrm&sig=HMmO2DIWjJ58mJ2tRTdWvvSSX_E#v=onepage&q=developmental%20grief%20trauma&f=false)

“Adolescence (defined, for purposes of this paper, as spanning 13-19 years of age) is of special concern for those who study and treat the effects of traumatic bereavement […] Bereavement and ensuing loss created by the deprivation of social provisions and other valued resources previously furnished via one’s relationship with the deceased" (Layne, Warren, et al.,)

Upon reading this, I suddenly felt silly that this was new information to me, because it makes so much sense. For the child and teenager, the attachment wound is of far greater significance than any other part of the loss. Even if they saw very distressing things, their need for attachment  and connection out-weighs any other part of the trauma. For adolescence, the research did not specify which social provisions and valued resources, but it is safe to assume and understand this to be attachment based needs, as it is likely other people in the teens life could meet other needs, but only that one person can offer that exact connection. As such, when we consider treatment options for this age group, focusing on attachment based approaches becomes much more significant. 

Best treatment options for traumatic grief?

Please note as you read this section that I have a clinical preference for bottom-up approaches to all the work that I do. In short, this means that I do not believe that we can change our thinking to change the way we feel. Rather, I want to help someone experience, in my office, a new way of being, which will in turn naturally change the way they think. You can learn about the approaches I generally use for trauma here. In doing this part of my research, I was looking specifically for bottom up approaches to treating trauma AND grief and how this might differ from only treating one at a time. 

While this may seem an easy task, I have found it rather difficult to find research that does not lean on, to varying degrees, cognitive approaches and exposure therapy.  Finally I found an article that had data to back-up what I have seen countless times in my office:

 “While numerous studies have reported significant outcomes from [cognitive interventions], a notable percentage of subjects do not experience meaningful therapeutic benefits. For instance, Bryant et al. found that post-treatment, 37.9% of participants undergoing CBT continued to meet the criteria for prolonged grief disorder.” (Spicer, https://www.frontiersin.org/journals/psychiatry/articles/10.3389/fpsyt.2024.1357390/full)

While this article was helpful to validate my clinical impressions, it was sadly only about prolonged grief and not traumatic grief, leading me to continue my search. Ultimately, I decided that general research was not going to give me the answers that I am looking for, so I narrowed my search to how EMDR, a specific form of trauma therapy, suggests treating traumatic grief. 

“EMDR therapy seems to facilitate the formation of an adaptive inner representation with movement from “I can't connect,” with its consequent deep pain, to “I can connect,” with the emergence of heartfelt memories providing a sense of connection to the loved one. If there was a conflictual history with the deceased, the inner representation may not be positive. Unresolved conflicts and trauma that involved the deceased must still be processed and resolved.” (Solomon, Hensley https://spj.science.org/doi/full/10.1891/EMDR-D-20-00031 )

What EMDR suggest for traumatic grief is two fold: building someones capacity to hold the pain of the grief and process the traumatic elements. I appreciate the focus on being able to connect to the pain, as most healing, not only trauma,  is centred on feeling what lies beneath. 

What are my key take-aways? 

-Traumatic grief is grief with trauma symptoms, or you could say it’s trauma with grief symptoms. Both are saying the same thing.

-Traumatic grief can come from death, or loss in any form. 

-Developmental stage impacts the experience of both trauma and grief; treatment for children and teens experiencing traumatic grief should focus on attachment based healing, as the most wounding part is the attachment rupture. 

-Treatment for traumatic grief should centre on on processing the traumatic elements of the experience and building capacity to feel the pain of the grief.

I would like to see a counsellor for traumatic grief! Any suggestions? 

As I’m sure you guessed, this isn’t a question I was actually asking in my exploration of traumatic grief. But I figure some people reading this may be interested in finding a traumatic grief counsellor for trauma therapy. If you’re in Kamloops, we offer traumatic grief counselling in-person, or we can offer it virtually for BC wide counselling.

Find a Counsellor For Traumatic Grief Here