Making SENSE of traumatic bereavement: A trauma informed approach

Recognising the widespread impact of trauma and stress, and the potential for re-traumatisation is key to supporting individuals who have experienced a traumatic bereavement. In this blog, psychological trauma consultant and clinical adviser to Sudden, Nicola Lester discusses the SENSE trauma-informed approach to support, which she originally developed in collaboration with the Tim Parry Johnathan Ball Peace Foundation.

The SENSE model is a trauma-informed approach to support suddenly bereaved people and was first developed in response to the Manchester bombing in May 2017, as a way of structuring the delivery of support in the immediate aftermath of the attack. Since then it has been adapted and used across a variety of different contexts both in the UK and overseas in the Middle East and Afghanistan.

The SENSE model is underpinned by an understanding of best practice in the field of psychological trauma and informed by the six principles of trauma informed practice to create a structured approach to the delivery of support as part of an early intervention approach. Adopting a ‘trauma informed’ approach to bereavement care provides a framework for organisations and professionals providing support to bereaved families in the aftermath of a traumatic loss.

Fostering resilience and coping

A trauma informed approach is one which recognises the widespread impact of trauma and stress and the potential for re-traumatisation. It actively seeks to reduce this possibility by understanding what is needed to foster resilience and coping and by promoting opportunities for recovery.

It is comprised of six key guiding principles to underpin practice:

  1. Safety – ensuring physical and emotional safety
  2. Choice – restoring choice and control
  3. Facilitating connections
  4. Supporting coping
  5. Responding to identity and context
  6. Building strength

Bereavements which occur under external traumatic circumstances may be regarded as traumatic. This is a term indicating the interface between trauma and loss, where in such circumstances grief symptoms are overlaid with trauma symptoms. In fact, because the impact of sudden, traumatic loss is so devastating, it may result in symptoms of post traumatic stress disorder (PTSD), meaning that the bereaved are faced with the dual task of mourning the loss as well as coping with the trauma that accompanied the death.

In addition there is growing recognition that the processes which occur after a bereavement may also leave the bereaved family susceptible not just to the effects of primary grief but may also serve to exacerbate their distress, as they are required to navigate a myriad of medical, legal and criminal processes, which may prioritise organisational procedures and requirements over the needs and wishes of the bereaved family.

Supporting bereaved families to navigate such processes, increasing their sense of voice and capacity to actively participate is essential and a key part of the support which is provided by the Sudden service and the SENSE model provides an effective way to structure the delivery of this care. In addition, the five stages of the SENSE model are designed to respond to the immediate practical and emotional needs of those who are bereaved, support their coping, mobilise and strengthen their access to social support and identify and address their longer-term support needs by engaging them with relevant services and professionals.

The five interventions of the SENSE model

The SENSE model is comprised  of five interventions: Stabilisation, Education, Normalisation, Social support and Engagement; all of which have been recommended as best practice by both the National Institute for Health and Care Excellence and the broader trauma literature.

In creating the word ‘SENSE’, the order of the letters in turn reflect the chronology in which the interventions should be offered. For example, as part of an early intervention approach the emphasis is on stabilisation to ensure the physical and emotional safety of the person affected and that their immediate needs are met.

This is followed by providing information and education about the signs and symptoms of trauma and promoting an understanding of how trauma may affect someone as a way of ‘normalising’ or validating their experiences and offering reassurance. We recognise that for many in our society death and loss remain taboo subjects shrouded in both secrecy and judgment about how people should be coping and grieving when they are bereaved.

Helping people to understand how they feel and validating their experiences by providing a non-judgemental space in which to access support is intended to shift the focus from how someone should be coping to instead to support and enhance how they are coping recognising their resilience.

Empowering the bereaved person

The normalisation of symptoms coupled with education, introduces the idea of empowering the person and their wider social support network to monitor their symptoms and where necessary to facilitate early referrals to formal psychological services, which is known to improve outcomes over the longer-term. The importance of social support in both reducing the impact of stressful life experiences and in protecting those affected from going on to develop PTSD and other mental health difficulties is well established, suggesting that it is essential to assess the presence and availability of social support as the fourth stage of intervention.

The final stage is engagement; either encouraging engagement with specialist support services; promoting the individual’s engagement with their wider social support network or assisting them to re-engage with their own values and goals and to regain a sense of purpose and control. At this final stage we plan for the longer-term to ensure access to relevant and appropriate services capable of providing the right support, at the right time based on an understanding that everyone is unique and affected by traumatic bereavement in different ways.

Delivering the SENSE model

The five stages of the SENSE model can be delivered in a variety of different ways, including face to face, via email, telephone and online. Whilst it is suggested that the five stages are implemented in chronological order to provide a sense of structure and purpose, each stage can be delivered as a standalone intervention, depending on the needs of those you are working with. It may be beneficial to explain the stages, as this will help the person to feel that they are making progress, particularly if you build in regular opportunities for review.

About the author

Nicola Lester is a psychological trauma consultant and clinical adviser to Sudden and Brake, the road safety charity.

Bereavement challenges in a time of pandemic

After a death from COVID-19, and after a death from any cause in a time of pandemic, there are bereavement challenges that are new and hard, for both bereaved people and their carers. In this blog, Sudden chief executive Mary Williams OBE discusses the impact of death on families and bereavement services at this time of COVID-19 and applauds the efforts of the bereavement NGO community to offer support.

While governments still battle the spread of COVID-19, a new challenge is emerging: the challenge to help bereaved people in a time of pandemic.

A death from COVID-19 is a shocking, sudden death after a short and increasingly severe illness. To prevent infection, it is usually not possible for families to say goodbye in a normal way.

A death from any cause in a time of pandemic brings additional challenges for everyone who is bereaved. For example, it is ill-advised, or forbidden, for people to meet and hold a normal memorialising event such as a funeral. People whose normal cultural or religious practices involve washing or dressing a dead person’s body are now prevented from doing these things.

Governments are rightly concerned about the perils of isolating people through ‘lockdowns’ that aim to contain the virus, particularly the potential harm to people who are suffering major life challenges, such as poverty, addiction, and problems relating to mental health and physical health. There is also the enormous challenge of being both isolated and bereaved.

As we applaud our medical practitioners for saving so many lives, for those families who are bereaved by COVID-19 (and also by any other causes, particularly sudden causes) their challenges are just beginning.

For some people bereaved at this time, there are acute practical challenges that require immediate intervention from health and social services. For example, imagine the needs of an elderly person with dementia, perhaps also suffering from COVID-19, who was previously cared for by their partner who has died.

For all people who are suddenly bereaved at this time, there will be a range of challenges, compounded by the need for social distancing. Contact from family, friends, carers, and basic human needs, such as to have a hug, are prevented. Or these things are restricted to people with whom the bereaved are self-isolated.

Bereavement charities and mental health services around the world are working to ensure we help, as best we can, with the resources we have. A wealth of information is being published online and bereavement helplines are open.

Across the world, we are all having to help each other in new, and often virtual, ways. We are blessed with the power of phone lines and the internet to enable many people to access information, talk and share their feelings and thoughts online, at a time when, cruelly, it is not possible to say goodbye to someone who is dying, it is not possible to help prepare their body for a funeral event, it is not possible to safely hold a mass gathering of family and friends to mourn and celebrate.

We know, from the findings of academia and practitioners, that early care of suddenly bereaved people is very important. It can prevent the onset of serious conditions such as post-traumatic stress disorder (PTSD) that can blight lives for years.

People who have been bereaved suddenly need to be looked after in the early weeks. They need to feel safe. They need to be informed about symptoms of sudden bereavement so they are prepared. They need to feel supported, through simple tips regarding self-care at this time.

The good news is that meeting suddenly bereaved people’s practical needs and giving them information and support to enable self-care can really help make a difference to their mental health outcomes and enable a normal grieving process.

I applaud all bereavement services for rallying together, to help people bereaved by any cause, including COVID-19, in these very challenging times, and urge a focus on a straightforward approach that helps people through the early weeks in practical, simple ways that enable people to feel safe and supported.

About the author

Mary Williams OBE is chief executive of Sudden. Sudden is a global initiative to help people bereaved by any sudden cause and also to help the professional standards of their carers. Mary is also chief executive of Brake. Brake is a road safety charity providing the National Road Victim Service in the UK for families bereaved by death on the road, including an acclaimed and government-backed national helpline and information service. Brake also operates globally and has a domestic branch in New Zealand too.

How Do Children Respond To Sudden Death And Trauma?

After a traumatic event or sudden bereavement, children can react in very different ways. Several inter-relating factors that can influence how well a child copes. In this blog, bereavement expert Erica Brown discusses the impact that trauma can have on children, and provides advice on how children can best be supported.

Sudden deaths such as road crashes occur unexpectedly, turning everyday experiences upside down and destroying the belief that ‘it couldn’t happen to us’.

Children’s responses to trauma

A road crash where someone dies is a traumatic event, and children’s responses to the trauma they experience will vary widely. For some children, reactions will be minimal or short-lived, whereas others will experience anxiety, fear and phobias. Sleep disturbances are also common, and many children have problems at school, both with their learning and their behaviour.

Little is known about children’s individual responses to traumatic events, or why some children are more vulnerable than others. A child’s individual personality, and the amount of time that they were exposed to the event, can influence their response. Severe reactions are linked to the suddenness of the event, and the degree to which the child was rendered powerless during the trauma.

Stress reactions in children are complex, but they are in fact normal human responses to unanticipated sudden and frightening events. The child’s world has become unpredictable. In some cases, the nature of the trauma seems to determine the nature of the stress. If the trauma involved noise, some children may experience more intense reactions. Likewise, injury or threat to life may cause particularly severe traumatic responses. Other factors such as the duration of exposure to the trauma, and whether the event was experienced in isolation or with other people, can play a significant part in how a child responds.

Imagery

Matt was 12 when he witnessed a fatal road crash. He was returning from school at the end of the day. It was dark and raining. Suddenly, in front of him, a car overtook an oil tanker and hit a car coming in the opposite direction. The cars hit head on and one was thrown under the wheels of the tanker, leaving only the rear visible.

For Matt, imagery of the event is one of the recurring effects of trauma: “It all happened so fast and to this day I can remember thinking, ‘Oh my God, there is going to be a prang!’ The noise of the skidding and of the metal buckling under the tanker wheels keeps haunting me. It is as if a recording has been made in my mind and it keeps replaying all the time. I am just dozing off at night and I hear the dreadful skidding and squealing of brakes.”

Some children experience a phase of denial and numbing immediately after a stressful event. After this phase the child may be confronted with intrusive, repetitive recollections of the event, including nightmares and flashbacks.

Searching for meaning

All survivors of traumatic events need to make sense of their experience. For children there may be questions such as ‘Why did it happen to me?’, ‘Why did I survive?’ and ‘Why do I feel the way I do?’

Many children believe they were in some way responsible for what happened. Others may be confused about why they were singled out to witness the event. Why a child has survived when others haven’t may pose a myriad of questions to which there are no definitive answers. These questions often lie at the heart of survivor guilt.

Children may also battle with the intensity of their emotions and may not have the language to describe how they feel. Some may not have experienced intense emotions before, and it is not unusual for them to attempt to repress unknown feelings. The world is unfamiliar and frightening.

Coping and support

How well a child copes after a traumatic event is dependent on several inter-relating factors. These include the child’s cognitive ability and capacity to express emotions, the maintenance of familiar routines and levels of support from within and outside the child’s home.

For anyone supporting a child who has experienced trauma, there are both proactive and reactive ways of giving support.

Proactive ways of supporting children include providing opportunities for the child to communicate their experiences, acknowledging the trauma they are experiencing, and allowing opportunities for them to integrate the traumatic event into their life and to move on. The help of specialist support networks may also be required.

More reactive ways of giving support include reassuring the child that their response is normal, keeping routines as normal as possible and encouraging the child to join in activities with their peers. It’s also important to work closely with other professionals who are supporting the child’s family.

About the author

Erica is a qualified teacher and has worked in a variety of roles in the Education and University Sectors. She has experience of teaching Early Years classes and has worked as a Senior Teacher, Head of Department and Head Teacher in Special Schools.

Erica’s academic career has included roles as Senior Lecturer, Principal Lecturer and Principal Research Fellow. She has also worked as Head of Research and Development of Care at Acorns Children’s Hospice and Head of Special Education at Oxford Brookes University.

Erica’s recent research interests have involved supporting children and families who are experiencing loss, and in 2012 she was made a fellow of The Royal Society of Arts in recognition of her work with life-limited children, young people and their families.

An overview of the Adult Attitude to Grief Scale and Range of Response to Loss Model

In this blog, bereavement expert Dr Linda Machin shares insights into her pioneering models of bereavement and grief, the Range of Response to Loss (RRL) model and Adult Attitude to Grief (AAG) scale, and provides an overview of how these approaches can be practically applied. 

Range of Response to Loss (RRL)

In my research and practice into bereavement, I have observed a wide range of experiences and expressions of grief [1].

As I began to develop a conceptual framework to capture this diversity, what became clear from my own work and that of other theorists was that grief can be seen as being made up of two dimensions.

The first is the instinctive, reflexive reactions to loss, which represent the ways in which we have learned to react to distressing circumstances, and are expressed in a range of feelings and functioning modes [2].

The second is the conscious way in which we cope with the loss that has occurred [3]. When feelings and functioning can be balanced, there is resilience; but where these cannot be managed, for a variety of reasons, vulnerability will result.

These two dimensions can be represented as intersecting elements of grief, as shown in the model below.

RRL in practice

Underpinning this concept of grief are the social and cultural factors that shape reactions and responses to loss. These can include:

Ethnic identity and belief systems

The source of identity and beliefs can vary – they may be shaped by the family, grow from social influence or be conveyed and influenced by political organisations. The media, including social media, can also have a major impact on identity.

Specific social and circumstantial factors

Alongside influence from ethnic, social and religious identity, a range of additional factors can contribute to emotional vulnerability, and may impact response to loss. Difficult relationships, or problems relating to mental or physical health, can cause emotional vulnerability. Further challenges can be caused by economic difficulties or unemployment, which may lead to increased stress and strain. If an individual has suffered multiple life losses, this can also contribute to emotional vulnerability.

Cause of the death

Factors surrounding the cause of the death can also impact on the bereaved. A bereavement caused by a sudden, traumatic death is likely to contribute significantly to psychological vulnerability.

In practice, we might see the following characteristics in the four quarters of the RRL model:

Adult Attitude to Grief (AAG) scale

The AAG scale was devised as a tool to test both the validity of the grief reactions – overwhelmed feelings and controlled functioning – and also the resilient capacity to balance these elements. The AAG consists of nine items on a five-point Likert scale, from strongly agree (score 4), to strongly disagree (score 0). The AAG is now used extensively as an assessment or evaluation tool, and to enhance therapeutic conversation.

The AAG scale incorporates nine concepts, under the three headings of ‘Overwhelmed’, ‘Controlled’ and ‘Balanced/resilient’.

          The 9 concepts represented in the AAG scale

OverwhelmedControlledBalanced/resilient
Disturbingly intrusiveUnremittingly painful

Robbing life of meaning

Valuing stoicismDenial of, or covering distress

Focus on day-to-day living

Courage in facing the lossSense of personal resourcefulness

Hopefulness

Validating the use of the scale to calculate vulnerability was based on the following formula, where O represents Overwhelmed, C is Controlled and R is Balanced/resilient:

Adding O + C scores and adding reversed R scores = an Indication of Vulnerability             

The research confirmed the psychometric properties of the scale and its use to classify different levels of vulnerability. Where the highest level of vulnerability is 36 and the lowest 0, the following classifications are made [4]:

Severe              >24

High                 21-23

Low                  <20

Practice issues

When applying these ideas and this assessment scale to practice, a primary goal is to address the issues that contribute to vulnerability, and focus on enhancing resilience. Vulnerability may result from practical circumstances or personal factors that need to be recognised, understood and dealt with supportively. Effective practical help and empathy with emotional vulnerability will begin to lead to increased resilience. Helping people recognise the strengths they have and encouraging them to discover hopefulness and meaning can be difficult, especially after an unexpected and traumatic loss.

We know from others who have travelled that journey that new meaning can be found through having a goal or a cause to follow. For example, meaning can be found through memorialising the lost person in some way, through experiences that reconnect with love and beauty, and through beginning to adjust perspectives from tragedy – to the capacity to triumph. None of this may seem easy at the beginning of a loss, but many survivors of the worst of human experience, such as the Holocaust, testify to the possibilities.

Future plans

Research and practice developments continue with the RRL model and the AAG scale, including exploring whether the RRL model and the AAG scale are ‘culturally transferable’ and can be used by services offering bereavement care to diverse ethnic groups. Work is also progressing in validating other versions of the AAG, including adapting it for use in pre-bereavement with patients and carers, and also with children and young people.

For more information, see www.keele.ac.uk/mappinggrief

For copies of the AAG scale, contact Linda Machin: l.machin@keele.ac.uk

About the author

Linda began her career as a medical social worker, and from this experience developed an interest in bereavement. Following this, she began to conduct pioneering research into bereavement for the Anglican diocese of Lichfield. These findings led to the development of published material on grief, and the setting up of a service for the bereaved, Bereavement Care (now the Dove Service) in North Staffordshire.

An academic career followed at Keele University, with Linda teaching on both social work and counselling courses. She has an MA and PhD for her research into bereavement and is now an Honorary Research Fellow at Keele University. Throughout her career, Linda has conducted a range of research into bereavement care and grief, and continues to do so. Her book Working with Loss and Grief [5]  is used extensively in health and social care settings.

In this blog, Linda discusses how she developed the RRL model and AAG scale, and provides an overview of how these approaches can be practically applied.


References:

[1] Machin, L. (2001) Exploring a Framework for Understanding the Range of Response to Loss; a Study of Clients Receiving Bereavement Counselling. Unpublished PhD Thesis: Keele University, UK.
[2] Attig, T. (2011) How We Grieve: Relearning the World (revised edition). New York: Oxford University Press.
[3] Stroebe, M.S., Folkman, S., Hansson, R.O. and Schut, H. (2006) The Prediction of Bereavement Outcome: Development of an Integrative Risk Factor Framework. Social Science and Medicine 63: 2440–2451.
[4] Sim, J., Machin, L. and Bartlam, B. (2013) ‘Identifying Vulnerability in Grief: Psychometric Properties of the Adult Attitude to Grief Scale’, Quality of Life Research.
[5] Machin, L. (2009; 2014). Working with Loss and Grief. London: Sage.

Further reading:

Ainsworth, M.D.S., Blehar, M.C., Waters, E. and Wall, S. (1978). Patterns of Attachment: A Psychological Study of the Strange Situation. Hillsdale, NJ: Erlbaum.
Cooper, M. and Mcleod, J. (2011). Pluralistic Counselling and Psychotherapy. London: Sage.
Machin, L. and Spall, R. (2004). Mapping Grief: a Study in Practice Using a Quantitative and Qualitative Approach to Exploring and Addressing the Range of Response to Loss. Counselling and Psychotherapy Research,4(1), 9–17.
Machin, L. (2007). The Adult Attitude to Grief Scale as a Tool of Practice for Counsellors Working with Bereaved people. A study report sponsored by Age Concern, Tameside and Keele University.

Neimeyer, R.A. and Harris, D.L. (2011). Building Bridges in Bereavement Research and Practice. In R.A. Neimeyer, D.L. Harris, H.R. Winokuer and G.F. Thornton (eds), Grief and Bereavement in Contemporary SocietyNew York: Routledge. pp. 403–418.

Relf, M., Machin, L. and Archer, N. (2010). Guidance for Bereavement Needs Assessment in Palliative Care (2nd edition). London: Help the Hospices.
Stroebe, M. and Schut, H. (1999). The Dual Process Model of Coping with Bereavement: Rationale and Description. Death Studies 23, 197–224.
Worden, W. (1983/1991/ 2003). Grief Counselling and Grief Therapy. London: Tavistock/Routledge.