Part of this article was presented at the International Conference: Conflict and Reconciliation in Groups, Couples, Families and Society, organized by the European Federation for Psychoanalytic Psychotherapy and the Hellenic Society of Group Analysis and Family Therapy, Athens, 24-27 May 2012.
Summary
Murder within the family, as when the father kills the mother in front of their children, is an extremely traumatic and shocking experience with devastating effects on the children. The presentation of a clinical case will highlight some of the emerging issues. The primary figures of attachment become the source of violence, terror, fear, anxiety and grief, and, as a consequence, children are left alone, experiencing multiple losses and conflicts of loyalty accompanied by contradictory emotions such as shame, guilt, anger, pain, horror, love, hate helplessness, etc. All these issues usually remain hidden and unspoken because of their traumatic nature and the lack of a supportive environment.
The grief that results from a traumatic loss is particularly difficult to deal with and usually becomes unresolved and unprocessed, impeding the elaboration and integration of trauma and preventing the bereaved from finding some reconciliation for his/her loss.
**Key words: ** attachment, loss, grief, trauma, intergenerational transmission.
Introduction
Relationships between family members are the most emotionally intense and involve the highest level of attachment, affection and commitment. However, severe traumas can occur in the context of family life that disrupt ordinary life causing family members extreme pain, disorder and chaos, shaking their beliefs about safety and shattering their assumptions of trust. It is widely acknowledged that children are unfortunately at the greatest risk of harm in their own homes, at the hands of either their parents or other carers, or through the effects of knowing about and watching other family members behave violently (Vetere et al., 2010). An extreme example of such violence is witnessing one parent killing the other, as in the clinical case example that will be presented.
Anna's story
Anna, a married woman of 43, came to the Family Therapy Unit after her 23-year-old daughter was diagnosed with meningitis and hospitalized. Her daughter's problem distressed her, made her feel vulnerable and evoked her fears of death. Shortly after starting therapy she said she had experienced a very tragic, violent loss when she was 11: she and her younger siblings witnessed her father killing their mother with a knife. Her mother was 32 years old, and at the time of the murder she was six months pregnant. Her parents were quarreling very often, because father was jealous and possessive of his wife. He was frequently suspicious of his wife having an affair and he used to spy on her or search her possessions, but he never found any proof of infidelity. Just before the murder her parents were arguing when her father suddenly took out a kitchen knife and stabbed his wife in the back and then in the chest. Anna tried to stop the quarreling of her parents, intruded and had her hand injured. After the murder her father called the police, was arrested and imprisoned. Anna and her siblings were separated and placed in different orphanages.
Anna was born in a town in Albania and was the first of five children. Next came her sister Maria, 39 years old, who has left her husband and son and lives alone, refusing to take medication although she has been diagnosed with schizophrenia. Then follows her brother Costas, 38, who is married with two children and suffers from paranoia, her brother Aris, 36, who lives alone and suffers from depression, and her youngest sister Elena, 35, married, mother of a 4-year-old daughter, who is also diagnosed with depression. Anna is very concerned about her siblings and she is very close and supportive to them.
At the end of our first meeting Anna offered me a box of chocolates. She said she wanted to thank me for listening to her. Ι felt it was not right to accept her offer. As I listened to her story I realized that she was very concerned about the needs of others. That offering was a protective shield which made her feel strong and in control, but behind it she concealed unacknowledged, unmet needs or more vulnerable parts of herself. I said to her : "I really appreciate your kind offer, but I feel it would be best if I did not take the chocolates so that you could offer them to yourself. I believe that offering to others is of the greatest value, provided one doesn't forget oneself”. Anna gave me a surprised look, smiled uncertainly and left the therapy room.
Attachment, Grief and Trauma
The British psychiatrist and psychoanalyst Bowlby developed an attachment theory that integrated his psychoanalytic work with concurrent studies in ethology, systems theory, cybernetics, and cognitive psychology. In the beginning of his career he studied maternal deprivation and separation and its effect on children. He used the term attachment to describe the affective bond that develops between the newborn baby and the primary caregiver. The presence of an attachment figure provides a secure base from which a child can explore, safe in the knowledge that the parent is available and will offer protection when needed. According to Bowlby (1969, 1973, 1980), attachment bonds have four defining features: proximity maintenance (wanting to be physically close to the attachment figure, especially in times of stress or need), separation distress (unwanted separation from the attachment figure elicits distress, protest and efforts to achieve reunion), safe haven (retreating to caregiver when sensing danger or feeling anxious), and secure base (exploration of the world while knowing that the attachment figure will protect the infant from danger). In Bowlby's view, human beings are genetically predisposed to want access or proximity to an attachment figure for survival reasons. They create strong affectional bonds with others to maintain themselves physiologically as well as emotionally. We could say that attachment theory and research provide a useful psychobiological framework for understanding both the origin and the symptoms of trauma, grief and loss. Bowlby was the first to link the notions of attachment, grief and trauma, providing an understanding of the emotional reaction that occurs when these bonds are threatened or broken.
About trauma
As Garland (1991) has vividly described, a traumatic event breaches and floods the structure of the internal capacity to contain.
_"Trauma is a Greek word meaning to pierce […] It suggests that the event which _
_creates the breach is of a certain intensity or violence and the consequences for _
_the organism are long lasting. From there it is a small step to the metaphorical use _
_of the concept, to the sense of an event which in the same intense and violent _
_way ruptures the protective layer which surrounds the mind with equally long _
l _asting consequences for psychic organizations" (p.509 ). _
According to Van der Kolk (1987), trauma occurs when an individual loses the sense of having a safe place to retreat to and process his or her emotions or experiences, resulting in a feeling of helplessness.
The fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV, American Psychiatric Association, 1994) describes a traumatic event as one in which a) the individual experiences, witnesses, or is confronted with event(s) that involves actual or threatened death or serious injury, or a threat to physical integrity of oneself or others and b) the individual’s response involves intense fear, helplessness, horror, or disorganized or agitated behavior.
We should note that the experience of trauma depends not only upon exposure to a traumatic event but also on the individual’s response to that event. There are studies that indicate that a significant proportion of survivors of childhood traumatic stress are at risk of developing psychopathology (Lundin, 1984; Murphy, 1996). However many studies have found that most survivors appear resilient, do not develop enduring trauma symptoms but experience transformation and positive growth. Several factors, including developmental level, inherent or learned resiliency, and external sources of support, may influence which course a person will take. Studies of posttraumatic growth have found positive individual changes in five areas: (1) emergence of new opportunities and possibilities; (2) deeper relationships and greater compassion for others; (3) feeling strengthened to meet future life challenges; (4) reordered priorities and fuller appreciation of life; and (5) deepening spirituality (Tedeschi & Calhoun, 1996; Calhoun & Tedeschi, 1999, 2006).
Anna's story
When Anna was 10 months old she was diagnosed with asthma and her parents were advised to take her to a better, less humid climate, so they decided she should live at the village of the paternal family. She remained there until she became 8 years old and her asthma got better. Her parents visited often, but she missed them very much. When she returned home, her family had already had two more children, and her mother was pregnant with a fourth. The period between 8 and 11 years old, before the murder of her mother, seems to have been the happiest period in Anna's childhood. She was with her beloved parents who were very tender and generous to her. On the other hand she was trying hard to please them, helping her mother with the house and the upbringing of her siblings. She has good memories from both her parents and these were the strengths that helped her cope with the very difficult years after the traumatic loss of her mother. The only bad moments during that period were when her father got jealous of his wife.
After the mother’s murder, Anna's life changed dramatically. She lost her parents, her home, her school, the daily contact with her siblings, her sense of family she has missed so much before, because of the asthma, which surprisingly disappeared after the tragedy. She couldn't bear the thought that her father, whom she had admired and loved so much as a child, had taken the life of her mother so violently. The same person who was a provider of safety and wellbeing became a source of terror and fear. She felt lost and confused, unable to understand why such a tragedy had occurred in her life. At the same time the act of the murder produced alienation and conflict between the two sides of the family—the family of the murderer and the angry, grieving relatives on her mother’s side. Anna felt split. Before the murder she had been more closer to her paternal family, since she had spent the first years of her life with them and had an affectionate relationship with her grandfather. After the murder she felt confused and numbed her feelings towards the father's family. She remembered her grandfather visiting her at the orphanage. Although she longed for him, she suppressed her feelings because part of herself felt she would betray her mother. For her maternal family, the father's family was the family of the murderer.
**When father kills mother **
Intra-familial murder often takes place in a context of domestic violence, where familial dynamics of conflict, control and abuse are common themes (Salloum and Renearson, 2006). When a father kills the mother in front of his children, this is an extremely traumatic, shocking and incomprehensible experience, with devastating effects on the children. A murder is an unnatural death, sudden, violent, stigmatized and incomprehensible, but it can also be accompanied by a feeling of guilt for failing to prevent it. The primary figures of attachment become the source of violence, terror, fear, anxiety and grief, and as a consequence children are left alone, confused, abandoned in an unsafe, insecure, chaotic, meaningless world which has changed abruptly and irrevocably. Harris-Hendrinks and his colleagues, who have great expertise in planning and providing services for children who have experienced or witnessed violence, report that the magnitude of secondary losses for these children is enormous. They suffer multiple losses as they lose in fact both parents, with one being dead and the other in jail. At the same time they may lose their homes, possessions, friends, familiar settings and habits. Some children may end up living with relatives, in foster care or at orphanages. Moreover, they experience a lot of symbolic losses, such as loss of control, self esteem, predictability and security and so on. They may also experience conflicts of loyalty: often they both hate and feel attached to the murderer; it can be very hard to accommodate this ambivalence. Surviving family members may feel contradictory emotions such as shame, guilt, anger, blame, confusion, pain, horror, love, hate, helplessness or betrayal, and may take sides for or against the perpetrator and/or the victim. This severs family ties and may ultimately result in the family being torn apart (Harris - Hendriks et al., 1993).
About grief and loss
Grieving allows us to heal, to remember with love rather than pain. It is a sorting process. One by one you let go of things that are gone and you mourn for them. One by one you take hold of the things that have become a part of who you are and build again . Rachael Naomi Remen
Coping with the loss of a loved one is considered one of the most demanding, painful, frightening, overwhelming but also unavoidable human experiences. The term _grief _ embraces a wide range of reactions that are prevalent following loss and reflect separation from the attachment figure (Bowlby, 1980). A grief reaction involves emotional, behavioral, cognitive and somatic components including sadness and yearning, preoccupation with the deceased, withdrawal from social activities as well as sleep and appetite disturbances (Worden, 1991). Grieving is the inevitable hard work that we must do to accept the loss, process its meaning in our lives and be able to involve ourselves once again in the world. To Fleming and Robinson (1991), grief is not an illness needing treatment, neither it is pathological or a clinical problem—although it may become one. It is simply the price we pay for loving. While it is understood that virtually any death may be perceived as personally traumatic by the survivor, there are some variables that determine trauma for most. A useful perspective could be to view deaths on a continuum, from minimally traumatic on the one end to extremely traumatic on the other (Weeks, 1996). Let us consider:
** What is traumatic loss?**
A traumatic loss is the loss of a loved one under traumatic circumstances; a loss that is sudden, unanticipated, outside the normal range of experience (Gilbert, 2009). It can be violent, mutilating or destructive (as in the clinical case on hand) and understandably creates special problems for survivors. Three of the most common ones are intensified grief, the shattering of a person's normal world, and the occurrence of a series of concurrent crises and secondary losses (Doka, 1996). These losses profoundly overwhelm the resources of the bereaved, and are highly likely to complicate the grief process. Grief that results from traumatic loss differs from "normal" grief in several ways: there is no time to anticipate the death, to say goodbye or finish unfinished business. A generalized sense of horror, helplessness, and loss of control is ever present for the bereaved; their lives feel disordered and disjointed, nothing appears safe anymore and they now see the world as a dangerous place (Gilbert, 2009).
Factors that can make a death traumatic (and may therefore complicate the grieving process) include: (i) suddenness and lack of anticipation, (ii) violence, mutilation and destruction, (iii) preventability and/or randomness, (iv) loss of a child, (v) multiple deaths and (v) the survivor's personal encounter with death, where there is either a significant threat to his or her own survival or a massive and/or a shocking confrontation with the death and mutilation of others (Rando, 1994). The mourner’s history of losses, personality style, pre-morbid mental health adjustment, the nature of the relationship with the deceased, the centrality of the relationship to the bereaved person's life, the circumstances of the death, and social variables (for example, lack of social support) are all factors with an impact on the grief process that influence the way in which the bereaved adjust to loss (Rando, 1993; McKissock and McKissock, 1991).
**Anna's story **
The tragedy that took place in Anna's family caused an overwhelming amount of pain, setting the stage for a delayed grief response. Her painful feelings were once so unbearable that they were "forgotten". Forgetting became a way of protecting herself from the tragic reality and the danger that came with it, but at the same time she paid the price for not processing her painful experiences. As a result, her grief became stuck and unresolved. She suppressed her suffering and tried hard to adapt to her new life at the orphanage. Her maternal family, whom she and her siblings visited during holidays, never talked about the tragic event. Their mother's death became a taboo subject and there was a conspiracy of silence surrounding the death under a mistaken belief of protection.
Anna tried to compensate for her losses by identifying with her mother's role. She put herself in her shoes and focused on caring for and comforting her younger siblings, a promise she had given to her mother before her death. She could recognize that, after the family tragedy, she took strength from a language of kindness. She was quiet, well behaved, friendly with everyone and as a result everyone liked her. By giving to others she tried to repair her wounded self-esteem, feel good about herself (instead of being the daughter of the murderer), and try to compensate for her father’s crime. Taking care of others was for Anna a mechanism of resilience, a kind of survival strategy, a way to conceal her lost childhood and her trauma. She felt in control, a defense against the terror of being helpless, and she annihilated the vulnerable emotions she felt when she was separated suddenly and violently from her attachment figures. She detached herself from mixed, complicated feelings of sorrow, sadness, angry and rage or from any signs of weakness and expressions of dependency. If she became like her mother she wouldn't feel her absence, and by not allowing anyone to care for her she remained loyal to her beloved mother.
However, now it was time to reconsider some of these beliefs that had helped her survive but were perhaps no longer needed. It was time for better solutions that would be less self sacrificing and would enable her to take better care of herself, acknowledging her personal suffering instead of identifying with the pain of others. It was the time to turn her gaze inwards and address her personal wound; to examine her fears, her terrors, her anxieties, her pain, her loneliness; in other words, to face her traumatic losses.
**The interaction of trauma and grief **
In the fields of trauma and bereavement there is increasing recognition of the intertwining of trauma, loss, and grief (Figley, 1998; Litz, 2004; Neimeyer, 2001). Recent research has been directed toward exploring the similarities, differences and overlap between grief and trauma (Fleming and Belanger, 2001). Rando (1997) has pointed out that similarities between grief and trauma are found in three broad areas: (i) their characteristic symptoms, (ii) the altered states of intrusion and avoidance, and (iii) the essential role of affective release together with cognitive reconstruction in the treatment process.
According to Simpson (1997) grief and trauma share many of the same behavioral features. Bereavement is often similar to trauma in that they both may involve a death encounter under either catastrophic or violent circumstances, which can facilitate traumatic stress reactions along with a grief response (Tolstikova et al., 2005). Lifton (1993) emphasizes the elements of loss, bereavement and grief within the traumatic stress symptoms, and suggests that many of the symptoms in the traumatic syndrome have precisely to do with impaired mourning, where grief is too overwhelming to be resolved. Johnson (1993) sees PTSD and grief reactions as "two inextricably intertwined strands […] ultimately inseparable, because the experience of loss is itself part of the trauma" (p.482).
The combination of trauma and grief may affect the bereavement process in a number of ways: a) the interplay of grief and trauma may intensify symptoms common to both (such as re-experiencing, avoidant/numbing and arousal symptoms); b) thoughts of the deceased, an essential part of bereavement following traumatic death, may lead to traumatic recollections—for example, thoughts of the manner in which the death occurred; c) traumatic aspects of the death may hinder or complicate issues of bereavement, including, for example, the ability to recover from shock related to the loss, reminiscing, grief-related dreaming, relationship with the deceased, issues of identification, and the processing of anger and rage; finally, d) a sense of post-traumatic estrangement or aloneness may interfere with healing interactions (Nader,1997).
According to Redmond (1996) the major effects experienced by survivors of violent, traumatic loss are:
i. Cognitive dissonance, disbelief. Traumatic loss overwhelms one's ability to make the loss meaningful. The death does not make sense, and the mind cannot comprehend the meaning of the death. ii. Murderous impulses and anger. iii. Conflict of values and belief system. Devastating life events such as experiencing violent loss tend to shatter basic world assumptions that give meaning to one's existence, and disintegrate the meaning of the self in the world. Murder is a violation of everything we have been taught to be right, honest, safe or expected in life. Beliefs about whether the world is still a good and safe place, that people are generally trustworthy, that there is meaning in life experiences and that the individual has value and worth are all challenged by traumatic death (Janoff- Bulman, 1992). Parkes et al. (1997) refer to the process of revising "basic assumptions, habits of thought and behavior that have been learned over many years and which we tend to take for granted" (p. 246) as psychosocial transition (PST). iv. Withdrawal of support due to the stigma of murder, and emotional withdrawal. As early as 1944, Lindemann defined psychological trauma as "the sudden uncontrollable disruption of our affiliative bond”. In the traumatic state one stands alone and loses all sources of feelings of security. There is a break in the continuity of life, an emotional separation from all one’s emotional connections and experiences that preceded the traumatic event. The bonds linking people are shattered with a loss of the sense of commonality. Freitag and his colleagues (Freitag et al.,2003) observe that after a sudden death "...we are not only cut off from the one who is lost, but also from parts of ourselves" (p. 31). The rupture of the bond leaves the self fragmented and helpless.
The search for meaning and the demands of reconstituting one's shattered assumptive world is one of the overlapping phenomena associated with both grief and trauma and represent the core challenges in adapting to loss and trauma (Fleming and Belanger, 2001). Treating traumatic grief or loss requires an understanding of trauma, grief and the interaction of the two. Normal grief resolution may be impeded without first attending to the traumatic nature of the death. It appears that when trauma and grief symptoms are both present, it is advisable, and often essential, to address and at least partially resolve the trauma issues before the grief issues can be successfully addressed (Nader, 1997).
In general, we should bear in mind that we may have grief without much trauma but we can never have much trauma without grief. "Ignoring the trauma component of grief, or the grief component of trauma, is surely negligent" (Simpson, 1997, p 6). Moreover, as Briere and Scott (2006) point out: "Not all psychological injury can be encompassed by a list of symptoms or disorders. Trauma can alter the very meaning we give to our lives, and can produce feelings and experiences that are not easily categorized in diagnostic manuals" (p. 17).
**Complicated or Traumatic Grief **
The phenomenological characteristics of both grief and trauma have contributed to the proposed combined entity called complicated grief. With reference to adults, this term has been used interchangeably with the term “traumatic grief” (Prigerson et al., 1997) which seems to capture more precisely the two underlying dimensions of the syndrome (i.e. trauma and separation distress). It has also been called abnormal, atypical, unresolved, dysfunctional, unhealthy, and, most commonly, pathological grief.
Prigerson and his colleagues (Prigerson et al., 1999) developed diagnostic criteria defining the syndrome of Complicated Grief as being composed of both symptoms of separation distress and symptoms of traumatic distress. In the most recent conceptualization, Boelen and Prigerson (2007) have revised the diagnostic criteria for complicated grief, renaming it as prolonged grief disorder (PGD), and it has been proposed for inclusion in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition.
Complicated grief is associated with increased risk of psychiatric comorbidity and physical illness in adults. Any loss that is extremely devastating can cause symptoms of complicated grief. Rando mentions that in all forms of complicated mourning there are attempts to do two things: i) to deny, repress or avoid aspects of the loss, its pain and the full realization of its implications for the mourner, and ii) to hold onto and avoid relinquishing the lost loved one (Rando, 1993). The mourner seems unable to incorporate the death into his or her life.
Anna's story
Understandably Anna was very protective of her daughter Marina, although she felt guilty for being too involved with the problems of her siblings and not spending enough time with her. A very important moment that brought up issues of separation was the time her daughter left home to study in another town. She and her husband escorted her to her new house, miles away from Athens, and they both experienced intense feelings at the time of separation. They were sad and very touched. Anna was thinking that in her own life she never had the chance to have her mother close to her, to feel protected by her and to have her by her side in the transitions of her life. Marina seemed to adjust well to her new student life and make new friends. She sounded happy. However, a few months later a friend of hers accidentally saw her passport and discovered that she was from Albania, something that Marina hadn't disclose to her new friends. The news spread to other friends who became angry and rejected her. This was unbearable to Marina and she decided to quit her studies and return back home.
Anna had great difficulty accepting that her daughter did not show the strength needed to copy with this situation. She felt angry with her for turning away at the first difficulty. She expected her to be strong and was disappointed by her weakness and inability to find a solution. She was so cross with her that she refused to help her move back home. By returning home, Marina deferred her differentiation and separation from her parents. During Anna's therapy, we tried to draw connections between her own traumatic story and her reactions to her daughter's story. Her daughter experienced a kind of community trauma, discrimination by the network of her fellow students. It was very important to realize that she failed to recognize the painful aspect of her daughter's story, and in this way she couldn't be close to her daughter's needs. She was shocked when she understood that she had not been helpful to her daughter in the same way that nobody had stood by her when she faced the traumatic loss of her mother. Moreover, she seemed to reject and punish her for being helpless, something she tried never to feel herself.
The interplay of past and present: The intergenerational transmission of trauma
"Those who cannot remember the past are condemned to repeat it"
Santayana
Clinical observations and empirical research have shown that the consequences of traumatic events are not limited to the persons immediately exposed to the event. It is widely recognized that unprocessed and unexpressed trauma can be transmitted to the next generation. Parents tend to project unconscious material from their own past onto their infant. The contents of these parental projections are dependent on the parent’s own history. According to Möhler and her colleagues (Möhler et al., 2001) the infant represents an aspect of the parental unconscious. Lacking pronounced personal characteristics or differentiated intentions, a newborn child can be shaped and formed by the parent's fantasy. Fraiberg and her colleagues (1980) introduced the metaphor “ghosts in the nursery” to describe how past traumatic experiences may compromise a parent’s ability to offer adequate physical and emotional caregiving, resulting in the repetition of the painful past. The ghosts who disturb the present are " visitors from the unremembered past of the parents”, the carriers of past trauma who are searching for a voice. The affective link – recognizing and remembering the feelings which the parent experienced as a child – will help a parent to avoid repeating the past in the present: “ ... it is the parent who cannot remember his childhood feelings of pain and anxiety who will need to inflict his pain upon his child” (Fraiberg et al., 1980, p. 182).
According to Russel (see Pomini, 2011) the traumatic experience which impedes the development of emotional capacity is related to the phenomenon of compulsive repetition. Something perceived as painful and frightening is repeated unconsciously in an attempt at finding a solution. The mechanism of compulsive repetition is transmitted to the next generation. It seems that children unwittingly recreate a scenario similar to that of their parents, and on the one hand such repetition can be understood as an act of hidden intergenerational loyalty, on the other hand it can be seen and framed as an attempt for resolution, a way of accessing and reprocessing the painful aspects of the traumatic experience.
It has been said that the transmission of trauma can be compared with the traveling of heat, light, sound and electricity. While these models are not visible, they exist and are viewed through the subject's actions (Kellerman, 2001). The same author points out that children who grew up in families in which there was no outright communication regarding the parents' trauma, but where the trauma was silently present in the home (i.e. communicated nonverbally), also seem to be more vulnerable to intergenerational transmission of trauma.
Attachment theory offers useful information when working with intergenerational issues and family of origin issues. In the context of family life there is a continuing process of different attachment patterns that are transmitted down the generations and tend to get repeated. Parents' attachment patterns from their families of origin tend to be replicated in the family relationships they create in the next generation. Research in the area of attachment has shown that adult patterns are empirically correlated with infant patterns (e.g. a secure parent tends to produce a secure infant, a dismissing parent tends to have an avoidant infant) So it is recognized that attachment theory provides a useful model for exploring the ongoing impact of past relationships and gives useful information about issues of unresolved loss or trauma (Akister et al., 2004). Lieberman (1979) points out that if family members are unable to mourn, separately or collectively, a family pattern develops which is subject to transgenerational passage. Morbid grieving as a family reaction pattern is handed down from one generation to another and perpetuates the difficulty in relinquishing emotional bonds. Inevitable losses, such as the separation of younger generations and family deaths, are dealt with in a resistant way. Change in family structure is stultified and the generational hierarchy of the family is frozen against the passage of time, deterring the family's evolution. According to Lieberman (1979) this family stasis is accomplished by shifting the bond from the deceased to another member of the family who acts as a replacement. Additionally, Bowen (1991) described the intergenerational impact of death and loss as an emotional shock wave. It is a network of underground aftershocks of serious life events that can occur anywhere in the extended family system in the months or years following the death of a significant family member. It operates on an underground network of emotional dependence of family members on each other, and occurs most often in families with a significant degree of denied emotional fusion.
Anna's story
Another important issue that Anna discussed in her therapy was her decision to communicate with her father after he was released from prison, nearly ten years after the tragedy. It was a very vulnerable period in her life, having just had a daughter of her own. Her father, who was writing to her from prison letters she never read, tried to approach her. At first she tried to avoid him. Later, being a parent herself, thought that although he had been catastrophic toward his wife, he couldn't but feel love and concern for his children. She realized that it was an opportunity for her and her siblings to have a sense of family again. More importantly, she had a strong need to rebuild the relationship with her father. Her reconnection with her father resulted in disrupting her relationship with her maternal family, and that made her feel guilty. She always felt torn between these two families. It was like betraying her mother because of her need to accept her father.
Meanwhile she discovered that her father's behavior sometimes became problematic, although there were times when he tried hard to be helpful. His greatest problem was that he couldn't trust his children and was always suspicious, creating imaginary scenarios. Anna felt obliged to intervene, taking sides and trying to balance their differences. Some years later her father was diagnosed with cancer and at first seemed to be more insightful and sensitive. Anna remembers a very touching moment when her father talked to her more intimately about the past, saying how much he had loved his wife and children and how much he regretted the suffering he had caused his family. It was a very special moment, and the first time her father appeared confessional. However, soon after that his mood changed and he started accusing his children of being after his money. He left for Albania to see some relatives, but a few days later his health deteriorated and he came back to Greece to be hospitalized. He called Anne, but this time she refused to see him. She was angry with him and didn't even go to his funeral when he died. She says: "He managed to ‘kill’ all those who loved him. I can't forget the extremely pain he caused to our family. I gave him a second chance believing that we could repair our relationship, but I felt betrayed once more although I tried to be close to him, especially when he was ill. The only thought that relieves my anger in a way is that he was mentally ill and never received help for his problem. Sometimes I feel I hate him, others I tell myself he was sick."
From silence to talking
_By putting it into words I can make it whole; this wholeness means it has lost the _
power to hurt me.
Virginia Woolf, Sketch of the Past
When a person dies, families have a story to tell about the events surrounding the death, and such stories which are told and retold by the family members reflect their efforts to make sense of what the loss of their loved one meant, and gain some sense of control over the uncontrollable. Sudden and traumatic losses usually remain unspoken. Walsh and McGoldrick (1991) noted that secrecy, isolation and closed communication channels can follow the stigma of loss through homicide and further exacerbate the traumatic effects of the loss. Families often avoid discussing the death because of its traumatic circumstances, and usually take a defensive “don't ask, don't tell” attitude in an effort to protect themselves and/or others from being in touch with overwhelming, vulnerable, terrifying, painful emotions and unanswerable questions. A lot of very important issues remain hidden and unspoken and even unacknowledged, and as a consequence there is no space for reparation. This survival strategy of silence leave persons handicapped in terms of recovery, as they do not have the opportunity to connect and talk with each other, a process which facilitates searching for meaning and understanding. Under these circumstances, the healing processes that take place in close family relationships through supportive interaction are largely blocked.
The grief that results from a traumatic loss is particularly difficult to deal with and usually becomes unresolved and unprocessed, impeding the elaboration and integration of trauma and preventing the bereaved from finding some reconciliation for his/her loss.
For Anna, telling her traumatic story for the first time in the safe environment of therapy was a beginning of the process of mourning. Initially she cried a lot and couldn't articulate a word. Later on, as she talked in more detail about the evening of tragic event, and as she felt that her therapist could afford and contain the unbearable and terrifying emotions she had experienced, she felt more released. Looking back on the family tragedy she began to realize how frightened and powerless she had felt. She remembered her first day at the orphanage. She was crying and desperately longing for her beloved mother. She felt so lonely. She was hugging her pillow and waiting for her mother. Gradually she allowed herself to grief for her mother's death. With tears in her eyes she said "I miss my mother so much, I didn't get enough of her, I miss her embrace, her touch and the way she cared for me, the sound of her voice. The pain of her loss is so intense, it seems as if she died yesterday. She has a special place in my heart, she is always in my mind and her sudden and traumatic death left me with a fear of losing whatever I love. I am so sorry she never met my own daughter. I regret not talking about her, but the pain in my heart was unbearable. I also want to ask her to forgive me for not having visited her grave. It was something I refused to do, because part of me was still waiting for her”.
A central goal of psychotherapy with survivors of violent traumatic loss is to help them open some space to say what they have not had the opportunity to say, to put words to what has been unmentionable and to recognize and express feelings that had been frightening or unacknowledged. By giving voice to their experiences of trauma, step by step they create a story which integrates the fragmented traumatic experiences more adequately. This story accommodates the shattered assumptive world into a new world view that incorporates death loss, helps them make sense of this loss, and regain a sense of order, control and purpose in life. The ability for survivors of traumatic losses to think and talk about past pain and try to make sense of what happened, gives them the opportunity to establish a more integrated, more coherent story of their suffering that expands the domain of their experience (Neimeyer,1995b) and facilitates growth and healing. Thomas Attig (1996) uses the metaphor "relearning the world" in describing the process of grieving. He says that in the death of a close, loved other, our autobiography comes to an impasse as “we struggle to give new sense and direction to the continuing stories of our lives”. Neimeyer (2001) mentions that like a novel that loses a central character in the middle chapters, a life story disrupted by loss must be reorganized, rewritten, find a new strand of continuity that bridges the past with the future in an intelligible fashion. In case of traumatic loss the bereaved have more difficulty in reconciling themselves to their loss, because as we have already mentioned, experiencing traumatic loss can shatter the fundamental beliefs that give significance to one's existence. Healing from bereavement resulting from homicide confronts people with the challenge of reconstructing meaning in the face of unspeakably meaningless events (Currier and Neimeyer, 2006). The search for making sense out of suffering and giving shape to emotional experience is of great importance for the initiation of the healing process. According to Flemming and Robinson (1991), it is in knowing and living the pain that one finds legacy and transformation; that one finds meaning and growth.
**Anna's story **
A very important and touching moment of Anna's therapy was when she decided to visit her mother's grave in Albania after almost thirty years. She had never being there. She felt a burning in her heart. She allowed herself to cry desperately. It was as if time had gone back and she became the little girl who lost her mother. She took care of the grave and talked to her mother about her life and the life of her brothers and sisters. When Anna returned from her trip she gave me a present that had real authentic meaning. She brought me goods from her village—oregano, honey, almonds. I accepted it with great pleasure and compassion. She was very pleased because apart from visiting her mother's grave she had had the opportunity to restore her relationship with her uncle (her mother's brother), who had been angry with her for getting in touch with her father after his release. She had stopped communicating with him for almost 22 years. The journey to Albania was very emotional and reparative. She got love and warmth from her mother's relatives, and a great relief that she was able to say goodbye to her mum.
Conclusion
Finally, one needs to bear in mind that we cannot heal all the wounds from tragic traumatic losses. What we can do is create a safe context for the establishment of a corrective emotional experience and the elaboration and integration of trauma. Our compassionate witnessing (Weingarten, 2004) for their suffering and struggle and our admiration for their strengths and tolerance is of great value. This simple sharing of someone else's suffering means being with him or her, not leaving that person alone (de Hennezel, 2007) The task of the therapist is that of the fellow traveler on the journey of grief and trauma, walking alongside rather than leading the grieving individual along the unpredictable road to new adaptation (Neimeyer, 1998).
I would like to finish this article with the closing lines of Mary's Oliver's poem "In Blackwater Woods", which capture the essence of grief:
To live in this world
_you must be able _
_to do three things: _
_to love what is mortal; _
to hold it
against your bones knowing
_your own life depends on it; and, when the time comes to let it go, _
to let it go.
References
Akister, J. and Reibstein, J. (2004). Links between attachment theory and systemic practice : some proposals. Journal of Family Therapy, 26 : 2-16.
Attig, T. (1996). How We Grief – Relearning the World. New York: Oxford University Press.
Biere, J., Scott, C . (2006) . Principles of Trauma Therapy: A Guide to Symptoms, Evaluation, and Treatment . Sage Publications
Boelen P., A, Prigerson H., G. (2007). The influence of symptoms of prolonged grief disorder, depression, and anxiety on quality of life among bereaved adults: a prospective study. Eur. Arch. Psychiatry Clin. Neurosci., 257(8):444-452.
Bowen, M. (1991). “Family Reaction to Death” .In F. Walsh and M. McGoldrick (Eds), Living Beyond Loss : Death in the Family. New York: W.W Norton and Company.
Bowlby, J.(1969). Attachment and loss, Vol. 1: Attachment. New York: Basic Books & Hogarth Press.
Bowlby, J. (1973). Attachment and loss, Vol. 2: Separation: Anxiety & anger. New York: Basic Books.
Bowlby, J.(1980).Attachment and loss, Vol. 3: Loss: Sadness & depression. New York: Basic Books.
Calhoun, L.G., & Tedeschi, R.G. (1999). Facilitating posttraumatic growth: A clinician’s guide. Mahwah, NJ: Erlbaum.
Calhoun, L.G., & Tedeschi, R.G. (Eds.). (2006). Handbook of posttraumatic growth: Research and practice. Mahwah, NJ: Erlbaum.
Currier, M. and Neimeyer, R.A. (2006 ). Fragmented Stories: The Narrative Integration of Violent Loss. In E.K. Rynearson (Ed.), Violent death: Resilience and intervention Beyond the Crisis (pp.85-100) New York: Routledge,Taylor & Francis Group.
Doka, K. (1996) Living with grief after sudden loss. New York: Routledge. Fleming, S.J.,& Robinson, P.J.(1991). The application of cognitive therapy to the bereaved. In T.M. Vallis, J.L. Howes, &P.C. Miller (Eds.), The challenge of cognitive therapy : Applications to nontraditional populations (pp. 135-158). New York: Plenum.
Fleming, S. and Belanger, K.(2001). Trauma, grief and surviving childhood sexual abuse. In R. Nemeyer (Ed.), Meaning reconstruction and the experience of loss(pp.311-329). Washington DC: American Psychological Association.
Freitag, Carrie M., & Kerouac, Margaret J. (2003). Aftermath: In the Wake of Murder. Chevron Publishing.
Figley, C.R. (1998). The traumatology of grieving. San Francisco: Jossey-Bass.
Fraiberg, S., Adelson, E. & Shapiro, V. (1980). Ghosts in the nursery: a psychoanalytic approach to the problems of impaired infant-mother relationships. In S.H. Fraiberg (Ed.), Clinical studies in infant mental health. The first year of life (pp. 164-196). London: Tavistock.
Garland, C. (1991). External disasters and the internal world: an approach to the psychotherapeutic understanding of survivors. In J. Holmes (ed.), Textbook of psychotherapy in Psychiatric Practice , Edinburgh: Churchill Livingstone.
Gilbert, K. (2009) Grief in a Family Context, a course offered over the internet.
Harris -Hendricks, J, H, Black, D. and Kaplan, T. (1993 ) . When father kills mother: Quiding children through trauma and grief. London and New York : Routledge
de Hennezel, M. (2007). Intimate Death. Athens : Koan-Synergie.
Janoff-Bulman, R.(1992). Shattered assumptions: Toward a new psychology of trauma. New York: Free Press.
Johnson, S.J.(1993). Traumatic stress reactions in the crew of the Herald of Free Enterprise. In J. Wilson &B. Raphael (Eds.), International Handbook of traumatic stress syndromes(pp.479-485). New York: Plenum Press.
Kellermann, N. P. F. (2001). Transmission of Holocaust trauma – An integrative view. Israel Journal of Psychiatry, 64(3), 256-267.
Lifton, R.J.(1993). From Hiroshima to Nazi doctors. In J. Wilson &B. Raphael (Eds.),International Handbook of traumatic stress syndromes(pp.11-23). New York: Plenum Press.
Lieberman, S. (1979). A transgenerational theory. Journal of Family Therapy, 1: 347-360.
Lindemann, E. (1944) Symptomatology and management of acute grief. American Journal of Psychiatry, 101: 141–149.
Litz, B. (2004). Early intervention for trauma and traumatic loss. New York: Guilford Press.
Lundin, T. (1984). Morbidity following sudden and unexpected bereavement . British Journal of Psychiatry, 144, 84-88.
Mc Kissock and Mc Kissock (1991)Bereavement: a "natural disaster". Responses and adaptations. Med. J. Aust. ,154(10):677-81.
Möhler , E., Resch F., Cierpka, A. and Cierpka M. (2001). The early appearance and intergenerational transmission of maternal traumatic experiences in the context of mother-infant interaction. Journal of Child Psychotherapy , Vol. 27, no 3, 257-271.
Murphy, S.A.(1996). Parent Bereavement stress and preventive intervention following the violent deaths of adolescent or young adult children. Death Studies, 20, 441-452.
Nader, K. (1997). Childhood Traumatic Loss: The Interaction of Trauma and Grief. In C.R. Figley, B.E. Bride,& N. Mazza (Eds.), Death and Trauma: The Traumatology of Grieving. New York : Routledge
Neimeyer, R.A. (1995b).Client generated narratives . In R.A. Neymeyer & M.J. Mahoney (Eds.), Constructivism in Psychotherapy . Washington , DC American Psychological Association.
Neimeyer, R.A. (2001). The language of loss : Grief Therapy as a process of meaning reconstruction. In R. A. Neimeyer (Ed.), Meaning reconstruction and the experience of loss. Washington, DC: American Psychological Association.
Neimeyer , R.(1998) . Lessons of loss: A guide to coping. New York: Mc Graw Hill.
Parkes, C. M., Laungani, P., & Young, B. (1997). Death and bereavement across cultures. London: Routledge.
Pomini, Β. (2011). Diageneaki Metadosi tou Traumatos: Psychodinamikes enies se Sistimico Plaisio. Metalogos, 19 : 48-62.
Prigerson, H. G., Shear, M. K., Frank, E., Beery, L. C., Silberman, R.,
Prigerson, J. (1997). Traumatic grief: A case of loss-induced trauma. American Journal of Psychiatry, 154(7), 1003–1009.
Prigerson, H. G., Shear, M. K., Jacobs, S. C., Reynolds, C. F., III, Maciejewski, P. K., Davidson, J.R.T., Rosenheck, R., Pilkonis, P. A., Wortman, C. B., Williams, J. B. W., Widiger, T. A., Frank, E., Kupfer, D.
J., Zisook, S. (1999). Consensus criteria for traumatic grief: A preliminary empirical test. The British Journal of Psychiatry, 174, 67-73.
Rando, T. (1997). Forward In C.R. Figley, B.E. Bride,& N. Mazza (Eds.), Death and Trauma : The Traumatology of Grieving. Washington ,D.C: Taylor & Francis.
Rando, T.(1993). Treatment of complicated mourning. Illinois : Research Press.
Redmond L., M.(1996). Sudden Violent Death. In K.J. Doka (Ed.),Living with grief after sudden loss. New York : Routledge.
Rynearson, E.,K. (2006) "Violent Death, Resilience and Intervention Beyond the Crisis" . New York : Routledge, Taylor & Francis Group.
Salloum, A. and Renearson E.K. (2006). In E. K. Rynearson "Violent Death, Resilience and Intervention Beyond the Crisis" . New York : Routledge, Taylor & Francis Group.
Simpson, M. A. (1997). Traumatic bereavements and death-related PTSD. In C. R. Figley, B. E. Bride, & N. Mazza (Eds.), Death and trauma: The traumatology of grieving (pp. 3–16). Washington, DC: Taylor & Francis.
Tedeschi, R.G., & Calhoun, L.G. (1996). The Posttraumatic Growth Inventory: Measuring the positive legacy of trauma. Journal of Traumatic Stress, 9, 455–471.
Van der Kolk, B. A. (1987). Psychological Trauma. Washington, DC: American Psychiatric Press.
Vetere, A., and Cooper, J. (2010). Children who witness violence at home. In A. Dyregrov (Ed.), Supporting traumatized children and teenagers. London: Jessica Kingsley Publishers.
Weingarten, K. (2004). Witnessing the effects of political violence in families: Mechanisms of intergenerational transmission of trauma and clinical interventions. Journal of Marital and Family Therapy, 30, 45–59.
Weeks, O.,D. (1996).Using Funeral Rituals to Help Survivors. In K.J. Doka (ed.), Living with grief after sudden loss. New York : Routledge.
Worden , W. (1991). Grief counseling and grief therapy: A handbook for the mental health practitioner (2nd ed.). New York: Springer Publishing Company.