"The memory of joy is no longer joy; the memory of pain is pain still." Byron
We are witnessing increasing numbers of disturbing events resulting in traumatic loss and bereavement, most notably a series of terrorist atrocities and the tragedy last year of the fire at Grenfell Tower. While these events have been high profile, there are traumatic losses experienced every day by individuals, families and communities and most of these do not make the news. They can happen to anyone, anywhere and anytime; deaths resulting from road traffic collisions, house fires, homicide, suicide, manslaughter, and natural or technological disasters.
A traumatic bereavement is often described as such when the loss is sudden, violent, unexpected and there is a loss of control over events.1 Accessing early support following a traumatic bereavement can make a significant difference to the long-term recovery of individuals and families affected. In my experience, one of the major factors affecting recovery is often the reaction of an employer towards the bereaved employee.
This article focuses on what employers can do to mitigate the impact of such significant life events on the bereaved and their families. I argue that there is significant evidence that structured social support is a major protective factor following trauma and adversity. The enormous difference that employers can make to the lives of their employees should not be underestimated.
Grief and mourning
While the experience of loss is common to us all at some point in our lives, in cases of traumatic loss, an individual or family may lose several members of a family in a single event. An experience of traumatic bereavement can shake or shatter an individual or family’s ‘assumptive world’. As human beings, we hold three basic beliefs or assumptions about the world, others and ourselves. These are often described as ‘silent assumptions’, as we are not conscious of holding these beliefs,2 which include a belief about our personal invulnerability; a sense that the world is meaningful and comprehensible; and a positive sense of ourselves and others.
Yet, the experience of traumatic death can shatter everything that the person holds to be true about themselves and the world. It’s why there is often a profound sense of violation, confusion, loss of identity, and meaning; as if the world had been turned upside down for an individual, a family, a community or workplace.
Role of the employer
For all organisations, their most valuable assets are their people and so while it is compassionate and humane to care for employees following bereavement, it also makes sound economic sense. Many if not all of those who are traumatically bereaved will be in a state of shock for many months. Their distress will be further compounded if they witnessed the death, if it took place abroad or if other family members were present. Often, those affected may find themselves unable to continue to work for a variety of reasons.
Employers need to be made aware of the significant impact of such traumatic losses and to be empathic to a realistic time frame for employees to return to the workplace. At the time of writing, many victims and bereaved families in the UK are experiencing a range of additional stressors brought about through ongoing involvement with a range of agencies, including the police, health and social care, financial institutions, insurance companies, the Criminal Injuries Compensation Authority (CICA), and in some cases, national and international legal and justice systems.
The bereaved will have to deal with the deceased’s financial affairs (which may be complex), as well as decisions regarding memorials and related matters. Given the inevitable differences in the wishes and opinions within families, this can present additional stress. There may also be severe economic hardship, as the deceased may have been the sole provider for the family. Worrying about how to manage financial affairs is common, including having to navigate a path through pension agencies, banks, inquests and other institutions.
Therefore, a return to work that is gradual and supported by the employer will help individuals to adjust to new challenges and stressors.
A review carried out in 2011 by the Victims’ Commissioner3 noted the significant challenge of returning to work.
Clear policy and protocol
It’s usual that the employers of those who work in ‘high risk’ occupations, such as the emergency services and the military, will have considered what support needs to be in place for bereaved relatives. Worryingly, it is not unusual for other public and private sector organisations, regardless of their size, not to have a clear policy in place, which outlines the support needed for those employees bereaved by a traumatic loss.
How a supportive employer can help
Anyone who has been traumatically bereaved will need time to ‘recalibrate’ the minutiae of their lives, and time needs to be allowed for this. The myriad of practical and financial issues and trying to meet the needs of other surviving family members, can all be overwhelming. Timely social and organisational support can make a significant difference to employees in the aftermath of a traumatic bereavement.
Emotional and practical support
In the first few days, the individual and family will feel ‘in crisis’, and the most useful form of help is emotional support, which provides a person with reassurance that others are able and willing to help in the struggle to regain emotional equilibrium. Sending flowers, a personal letter or card from a line manager or a senior member in the organisation, tends to be appreciated. Emails tend not to be perceived as caring or supportive, though in the latter stages, using email as a regular and supportive form of contact, tends to be viewed favourably by traumatically bereaved employees. As the weeks turn into months, there are ‘deficit states’, in which practical help may be needed to remedy an imbalance between needs and tangible resources.
Information and meetings
Over time, the bereaved will feel as if they are in a ‘transition’, while they struggle to make sense of what has happened. At the earliest opportunity, arrange a meeting with the bereaved employee’s direct line manager, an HR representative, and/or staff members, who need to be in contact with the bereaved individual and their family. Meetings need to be emotionally supportive in nature and informally structured to help to provide a sense of ‘safety’. Providing the individual/family with a summary of each meeting or after a series of meetings, can be helpful as it can often be difficult to retain information when under conditions of continuous stress. The summary may need repeating.
Ongoing support
Regular, consistent and non-intrusive contact with an employee is helpful and can alert employers to any ongoing or forthcoming events likely to impact on an employee’s wellbeing, such as anniversaries, or dates for trials and inquests. Allowances should be made for the impact this may have on the employee’s emotional state, working performance and general functioning.
Returning to work
Practical aspects that may impact on a return to work need to be considered eg the physical work environment, access to private space if needed, offering flexible working hours as well as one or more colleagues who may be able to provide peer support and help with the process of ‘recalibration’. In certain cases, where there is more of a direct impact on the employee, eg if they witnessed the death or were present at the time, attention should be given to practical measures which will help them cope with their hypervigilance, heightened sensitivity to levels of threat and physiological arousal.
Caring responsibilities
Consider the employee’s family commitments, as they may be sole carers for elderly relatives or have significant childcare responsibilities, which will also take up their energy and emotional resources.
Role of organisational counselling services
Many of the current mental health services, including the Improving Access to Psychological Therapies (IAPT) services and other mental health providers, either within the NHS or other settings, are not geared up for or may be unwilling to see individuals impacted by a traumatic loss. The general perception of many health professionals is that the responses and reactions of those recently bereaved are ‘normal’ and that formal therapy or counselling is not necessary.
However, there can be a tendency to ‘overpathologise’ the loss and become therapeutically overzealous, which can cause individuals and families to become alienated from a process that is intended to be helpful. Experience with traumatically bereaved individuals and families, indicates that an approach I have developed at the Centre for Trauma, Resilience and Growth in Nottingham, known as structured social support, is effective.4
While research into the effectiveness of early interventions for traumatic loss are lacking, there are some findings that show it can be effective in reducing long-term psychological complications.5 Early structured support can also help the bereaved to manage their expectations of themselves and others following the bereavement. Often, following trauma, there is a powerful need to talk, so rather than therapy, structured social support can support the bereaved to work through their experiences and help them to process and come to terms with their loss. This can be invaluable for people as they search for meaning in their experience. Furthermore, there is a significant amount of evidence which indicates that the provision of social support is a protective factor following exposure to trauma – conversely, the lack of social support is a strong predictor of long-term problems.6,7
The role of the therapist
In cases where the therapist provides individual support to the bereaved, their role may expand beyond the therapy room, acting as an advocate, communicating with a range of organisations, including the widower’s employer, the children’s school and other relevant agencies. Highlighting the practical and emotional needs of bereaved families can greatly assist an employer, as too many don’t have policies or plans to refer to.
The therapist also needs to be experienced at supporting bereaved individuals and families who have faced traumatic loss, as well as the capacity to be flexible and adapt their therapeutic model to provide a containing, structured and problem-solving approach. The role is often to be an experienced guide or companion, helping the bereaved to navigate the challenging and often unforgiving landscape of loss.
Closing thoughts
In my work with individuals and organisations, I’ve seen first-hand how structured social support can help bereaved individuals and families through the challenges they will inevitably face. While early interventions for trauma have always been cautioned against by the National Institute for Care Excellence (NICE), there are anecdotal accounts (as evidenced by the recent NHS response to the Grenfell Tower fire), that this is being reconsidered. There has been a significant and proactive response by local NHS IAPT services in the area around Grenfell to engage with survivors much sooner than would have previously been encouraged.
While this is to be applauded, it does beg the question as to why this approach is not utilised for all manner of traumatic loss other than those that are high profile disasters? Undoubtedly, there was a political imperative to provide support following the Grenfell disaster, to a community who for multifaceted reasons had been disenfranchised over the years.
The provision of early NHS trauma support challenges the existing NICE Guidelines, which tend to recommend ‘watchful waiting’ before offering psychological interventions. However, the research into the benefits of early interventions resulting from traumatic loss is lacking, with too much focus on prolonged grief disorder8 and the development of PTSD following traumatic loss.9 Recent revisions in psychiatric diagnostic manuals are attempting to describe persistent, disabling reactions to bereavement and have led to much debate pathologising normal responses to loss.10
Too many individuals and families have reported their frustration and distress at being given conflicting advice about how they should be supported to manage their loss. A frequent refrain I hear is: ‘It’s so confusing; we have been told that how we are feeling is normal and we don’t need counselling, and that we should wait for some months before asking for help…’ and ‘…the mental health service said it was too complicated for them.’
This really isn’t good enough, especially in an age when seeking out talking therapies and support is encouraged. It is vital that a balanced debate about new diagnostic developments also considers improving access to early support, which could help support employers and their employees in the event of a sudden death. Further research into an approach which embraces therapeutic pragmatism and provides a proactive model of support with traumatically bereaved individuals and families, is long overdue.
Stephen Regel is the Founder, Director and Clinical Lead of the Centre for Trauma, Resilience and Growth, Nottinghamshire Healthcare NHS Foundation Trust/University of Nottingham. He is Professor in the School of Education and a regular contributor to the MA in Trauma Studies.
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References
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2 Bulman RJ. Shattered assumptions: towards a new psychology of trauma. New York: Free Press; 1992.
3 Casey L. Review into the needs of families bereaved by homicide. Report of Victims Commissioner. [Online.] https://www.justice.gov.uk/downloads/news/press-releases/victims-com/review-needs-of-families-bereaved-by-homicide.pdf. (accessed 23 February 2018).
4 Regel S, Joseph S. Post-traumatic stress: the facts (2nd edition). Oxford: Oxford University Press; 2017.
5 Dyregrov A. Early intervention: a family perspective. Advances in Mind-Body Medicine 2001; 17: 160–196.
6 Brewin CR, Andrews B, Valentine JD. Meta-analysis of risk factors for post-traumatic stress disorder in trauma-exposed adults. Journal of Consulting and Clinical Psychology 2000; 68(5): 748–766.
7 Gender, social support and PTSD in victims of violent crime. Journal of Traumatic Stress 2003; 16(4): 421–427.
8 Jordan AH, Litz BT. Prolonged grief disorder: diagnostic, assessment and treatment considerations. Professional Psychology: Research and Practice 2014; 45(3): 180–187.
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10 Bryant RA. Grief as a psychiatric disorder. The British Journal of Psychiatry 2012; 201(1): 9–10.