grief, trauma & abuse: general information
Life changes may lead to illness: This handout highlights how our current level of
health is deeply affected by events that have happened to us in the past. Grief, trauma
and abuse are examples of such incidents. It is now over a quarter of a century since the
Social Readjust-ment Rating Scale1 was developed by Holmes and Rahe. This scale
consists of 43 different life events ranging from the death of a spouse through
circumstances such as retirement, getting a mortgage or a child leaving home, to more
minor changes like altering eating habits or taking a holiday. Each of these 43 events has
been scored for the intensity and length of time that people felt would be involved in
adjustment to what had happened. It has been shown that the higher one scores on such
life changes in any particular time period, the more likely it is that one will develop some
kind of health problem. The problem might be a transient one like an increased
vulnerability to coughs and colds2, or a more major one like becoming a migraine sufferer3
or developing an anxiety disorder4.
Grief and loss: Holmes and Rahe rated death of a spouse as the most stressful life
event that many of us would ever face (though a child's death is often even worse). It is
however important to realise that loss and mourning are involved not just when others
have died but also with other life events such as divorce, redundancy, disability, and
aging. There is still a good deal of controversy over how often grief results in subsequent
illness. Bereavement can produce some increase in death rate for surviving partners 5 this is particularly true for widowers. In part this increased death rate is likely to be due
to direct effects which weaken the immune system6 and lower resistance to disease. It's
clear that both psychological and physical distress are usual following the death of
someone who is close to us.
Worden in his helpful book on grief7 suggests that there are four major tasks that the
bereaved may face. Not everyone will need to go through all four of these tasks. The
tasks themselves don't necessarily occur in any particular order, but they are likely to
involve: (a) Accepting the reality of the loss rather than in some sense denying internally
that it has happened. (b) Working through the pain of grief rather than remaining
emotionally frozen. (c) Adjusting to an environment in which the deceased is no longer
there, with the changes in competence, role and meaning that this may involve. (d) Being
able to relocate the deceased emotionally so that one can move on with life and keep
one's heart open. As Tolstoy put it "Only people who are capable of loving strongly can
also suffer great sorrow, but this same necessity of loving serves to counteract their grief
and heals them."
Grief often involves feelings of depression. Usually this depression will resolve with time,
though about 20% of the bereaved8 are likely to be still suffering from major depression a
year after their spouses' death. A history of psychiatric problems before their
bereavement and a feeling of lack of social support are particularly important 8 as warnings
that resolution of grief may not precede easily. Sudden death and a conflicted relationship
with the person who has died are further factors that may hinder working through the
grief.
Confiding in others is likely to be beneficial9,10 - this is one of the reasons for valuing the
help offered by organisations such as CRUSE11. An interesting, though puzzling, survey12
showed that support which was found particularly helpful by the bereaved typically
involved an opportunity to express their feelings or to be in contact with others who had
been through similar experiences. Particularly mentioned as unhelpful were support
attempts that involved giving advice or encouraging recovery. On the whole people
attempting to offer support were well aware of these facts. The puzzling aspect of this
survey was that despite appearing to know what was likely to be perceived as helpful or
unhelpful, those offering support so often seemed to get it wrong. Possibly this is because
anxiety about the bereaved person's state gets in the way of supporters saying what they
in fact know is likely to be helpful. In general expressing concern, encouraging contact
with others who have been through similar experiences, providing an opportunity for
expression of feelings, involvement in social activities, and just "being there" are all ways
of providing support that are often perceived as helpful by those who are grieving.
Encouraging recovery, giving advice, forced cheerfulness, minimising the loss, and
claiming to "know how you feel" are all likely to be perceived as unhelpful.
To conclude this section on grief and loss, I would like to highlight the work of Camille
Wortman who emphasises the great variability13 in how people respond to major losses.
It seems that there is a sizeable proportion of people who do not suffer greatly after
bereavement. For reasons that may involve philosophical or religious outlook, coping
style, social support, high self-esteem or other factors, such people recover quickly and
effectively without apparently needing to "work through" the various so-called
stages/tasks of grief. There is a further sizeable proportion who do work through the
described grief processes and seem to benefit by doing so. Lastly there are many people
who do not recover from their loss even after many years. It seems particularly important
to learn how best to identify and help these long-term sufferers7,10,14.
Traumatic events: In the last few years there has been an upsurge of research on the
effects of particularly traumatic life events such as serious accident, personal injury,
robbery, tragic death, traffic accident, sexual & physical assault, fire, war combat, and
other natural & man-made disasters. A recent survey15 of 1000 adults found that 21%
had experienced at least one such violent encounter in the last year alone. At some stage
in their lives, nearly 70% of the adults interviewed had experienced at least one of the ten
violent encounters that these researchers inquired about. Levels of stress in those who
had suffered traumatic experiences were greater than in those who had not. In this broad
ranging study, stress levels were particularly high in those whose traumatic experiences
had occurred in the previous year. When combining both frequency and resultant
psychological upset, this survey remarked "If one event stood out from the pack, it was
motor vehicle crash ..... this is an interesting observation given how seldom this event has
been studied relative to crime, disasters, and bereavement." With about 23% of adults
having been involved in a road accident at some stage in their lives, and with 12% of
these crash victims being found to suffer from current post-traumatic stress disorder, this
means that at least 1 in every 36 adults is likely to be currently seriously psychologically
distressed because of their experience of traffic accidents.
Other research has focussed more on specific types of trauma. A recent British survey 16
found that 1 in 5 women had been sexually assaulted at some stage in their lives and that
1 in 9 had been raped - usually by a male "friend" or acquaintance. Definitions can be
difficult, but this survey used "rape" in its legal sense of non-consenting sexual
intercourse. In New Zealand, a study17 of a large random sample of women from the
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general population found that physical assault - usually quite severe battering by the
individual's male partner - was even commoner than sexual assault. The rates for current
psychiatric "cases" amongst those who had been assaulted/abused and those who hadn't
were compared using both the short form of the Present State Examination (PSE) and the
General Health Questionnaire (GHQ28). Using the PSE, 6.3% of the non-abused
population were rated as psychiatric cases. This compared with 32.8% of those who had
been sexually abused as adults, 15.3% of those who had been physically abused as
adults, and 20.7% of those who had been sexually abused as children. Using a cut off
score of 5 or more on the GHQ as a measure of "caseness", the comparable percentages
were 20%, 54.9%, 32.5% and 31% - making adult physical abuse as damaging as
childhood sexual abuse on this measure, and adult sexual abuse/assault more damaging
than either. Whatever measure one uses, the authors highlight the "dramatically raised
rates of psychopathology" in those who have suffered in these ways. Typically this
involves increased levels of depression, anxiety and phobia. The study also pointed out
that "only a handful of women made any connections, spontaneously or on inquiry,
between the past abuse and any current troubles".
Abuse in childhood: In 1986 there were 2.1 million reports of child maltreatment
made in the USA18 - a 212% increase over the previous decade. There were over a million
substant-iated cases of children suffering harm as a result of maltreatment and 1,100
deaths19. The maltreatment reports were divided into four major subtypes: neglect and
abandonment (62.8%), physical injury (27.6%), sexual abuse or exploitation (15.7%) and
emotional injury (8.3%). Clearly some reports involved more than one type of
maltreatment. It seems likely that the negative effects of this huge amount of abuse
routinely extend into the rest of these individuals' lives. Sexual abuse, although important,
is just one component of this maltreatment.
Bachmann and co-workers reviewed the literature on childhood sexual abuse and
reported20 that 15-38% of adults were sexually abused as children. Broader definitions of
sexual encounter eg. involving verbal harassment or exhibitionism, are likely to produce
even higher figures. The New Zealand community study17 that I described earlier used a
rather narrower definition. It found abuse, involving some form of genital contact aged
twelve or less, in about 10% of women. Childhood and adolescent sexual abuse of males
possibly runs at half to two thirds the rates for women21,22. One could speculate though
that boys may be abused with physical violence as or more often than girls. Overall these
figures on childhood abuse show that it is common. An easy figure to remember is
Bachmann's estimate that on average 1 in every 4 women has a nonvoluntary sexual
encounter (usually involving physical contact) during childhood or adolescence. These
estimates can be approximately halved if dealing with men or with sexual abuse involving
genital contact in children. Worryingly though, these figures can be increased
considerably if one adds in the probably equally damaging effects of abuse involving
physical violence and neglect.
So far I have talked about estimates of abuse frequency in the general population. Such
figures underestimate the commoness of abuse in groups who are already seeking help for
health related problems. Janet Surrey and co-workers described a survey23 of 140 women
in a general psychiatric outpatient clinic. 64% reported a history of sexual or physical
abuse. 37% reported sexual abuse and 51% physical abuse (these figures include 25%
who reported both sexual and physical abuse). Three quarters of these women reported
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that the abuse first occurred before the age of eighteen. The definition of sexual abuse
was quite strict - being pressured either against your will or when too young to
understand into forced contact with the sexual parts of your body or his/her body. In
general, for those who are or have been psychiatric inpatients, the figures for abuse are
even worse than for outpatients. One study24 found that 72% of women psychiatric
inpatients reported a history of sexual or physical abuse. 54% reported sexual abuse and
51% physical abuse (these figures include 33% who reported both sexual and physical
abuse). 59% said the abuse had first occurred at age fifteen or younger. Clearly abuse
becomes a commoner experience as one moves from the general population to more
distressed groups of women.
Effects: Abuse produces suffering and often leads to adult illness. A review20 of the
literature on childhood sexual abuse shows that the most commonly cited consequence for
adult women is depression. The review goes on to state that "Some women also
experience anxiety, low self-esteem, a sense of isolation, substance abuse, sexual
problems, and self-destructive behaviors. They are more likely to be victims of
subsequent episodes of nonvoluntary sexual contact, and parenting skills are often
negatively influenced." Longstanding damage associated with a history of abuse has been
reported across a series of different populations - community samples, psychiatric
outpatients and psychiatric inpatients. The New Zealand study17 of a large random sample
of women from the general population, found that women who reported being sexually
abused as children were more than three times as likely to be suffering from a psychiatric
disorder than women who had no such history of abuse. The study also found that there
was no evidence of spontaneous "healing" of these effects with the passage of time. It is
worth noting that the psychological and interpersonal damage associated with a history of
abuse does not demonstrate a cause-effect relationship. At times the history of abuse and
the later adult dysfunctions may both be the result of grossly inadequate parenting.
Simply treating the history of abuse may at times be missing the importance of a generally
deficient early childhood experience. It is worth remembering this point as we look at the
helpfulness of therapy.
What helps? There is a tremendous amount of work going on trying to improve the
effectiveness of treatments available for the long term effects of grief, trauma and abuse.
I have already mentioned the research12 which showed that the bereaved often find
helpful support that involves expressions of concern, encouragement in contacting others
who have been through similar experiences, opportunities to express feelings, involvement
in social activities, and people who are "just there for them". This research also has
relevance for victims of trauma and abuse. Worden's book7 on Grief Counselling and Hall
& Lloyd's book25 on Surviving Child Sexual Abuse are examples of the many helpful books
in these areas. There are telephone help lines and self-help groups for both the
bereaved11 and those who have been abused26,27 or raped27.
It is clear that part of the damage caused by these horrid life traumas is due to holding
the pain inside without sharing with others. Pennebaker's book, Opening Up, explains
how this happens. Sharing with others or even simply writing about what has occurred can
help one ease the stress of holding on to such "secrets", work through the emotional pain,
and gain perspective and a sense of greater control. The handout on "Freewriting"
explains these issues in more detail. In general, standard psychological and
pharmacological treatments for depression, anxiety, phobias, post-traumatic stress
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disorders, and sexual problems are likely to help a lot when the symptom picture suggests
their relevance. There is so much that can be done to help with the short and long term
effects of grief, trauma and abuse - and the effectiveness of this help improves as we
learn more and more.
Books, references & other resources:
1. Holmes,T.H. & Rahe,R.H. (1967) The social readjustment rating scale. J Psychosom Res 11: 213-8.
2. Cohen,S.,Tyrrell,D.A.J. & Smith,A.P. (1991) Psychological stress and susceptibility to the common cold. N Engl J
Med 325: 606-12.
3. De Benedittis,G.,Lorenzetti,A. & Pieri,A. (1990) The role of stressful life events in the onset of chronic primary
headache. Pain 40: 65-75.
4. Blazer,D.,Hughes,D. & George,L.K. (1987) Stressful life events and the onset of a generalized anxiety syndrome.
Am J Psychiatry 144: 1178-83.
5. Jones,D.R. & Goldblatt,P.O. (1987) Cause of death in widow(ers) and spouses. J Biosocial Science 19: 107-21.
6. Schleifer,S.J.,Keller,S.E.,Camerino,M.,Thornton,J.C. & Stein,M. (1983) Suppression of lymphocyte stimulation
following bereavement. JAMA 250: 374-77.
7. Worden,J.W. (1991) Grief counselling and grief therapy: a handbook for the mental health practitioner (2nd ed).
London, Routledge.
8. Nuss,W.S. & Zubenko,G.S. (1992) Correlates of persistent depressive symptoms in widows. Am J Psychiatry
149: 346-51.
9. Pennebaker,J.W. & O'Heeron,R.C. (1984) Confiding in others and illness rate among spouses of suicide and
accidental-death victims. J Abnormal Psychol 93: 473-6.
10. Pennebaker,J.W. (1990) Opening up: the healing power of confiding in others. New York, Avon Books.
11. CRUSE Bereavement Care, 3 Rutland Square, Edinburgh, EH1 2AS. Tel: 031-229 6275. See your phone book for
other groups outside Edinburgh, or contact CRUSE Scottish Office, 18 South Trinity Rd, Edinburgh EH5 3NR. Tel: 031551 1511.
12. Lehman,D.R.,Ellard,J.H. & Wortman,C.B. (1986) Social support for the bereaved: recipients' and providers'
perspectives on what is helpful. J Consult Clin Psychol 54: 438-46.
13. Wortman,C.B. & Silver,R.C. (1989) The myths of coping with loss. J Consult Clin Psychol 57: 349-57.
14. Klerman,G.L.,Weissman,M.M.,Rounsaville,B.J. & Chevron,E.S. (1984) Interpersonal psychotherapy for
depression. New York, Basic Books.
15. Norris,F.H. (1992) Epidemiology of trauma: frequency and impact of different potentially traumatic events on
different demographic groups. J Consult Clin Psychol 60: 409-18.
16. Public Eye. (1992) Acquaintance rape - hidden from view, hidden from justice? BBC2, 8.00pm., Friday 14th
February.
17. Mullen,P.E., Romans-Clarkson,S.E., Walton,V.A. & Herbison,G.P. (1988) Impact of sexual and physical abuse on
women's mental health. Lancet i:841-45.
18. American Humane Association (1988) Highlights of official child neglect and abuse reporting. Denver, CO:
Author.
19. U.S. Department of Health & Human Services (1988) Study findings: study of national incidence and prevalence
of child abuse and neglect. Washington, DC: Author.
20. Bachmann,G.A., Moeller,T.P. & Benett,J. (1988) Childhood sexual abuse and the consequences in adult women.
Obstet Gynecol 71:631-42.
21. Finkelhor,D.H. (1979) Sexually victimized children. New York, The Free Press.
22. Landis,J.T. (1956) Experiences of 500 children with adult sexual deviation. Psychiatr Q 30(suppl); 91.
23. Bryer,J.B., Nelson,B.A., Miller,J.B. & Krol,P.A. (1987) Childhood sexual and physical abuse as factors in adult
psychiatric illness. Am J Psychiatry 144;1426-30.
24. Surrey,J., Swett,C., Michaels,A. & Levin,S. (1990) Reported history of physical and sexual abuse and severity of
symptomatology in women psychiatric outpatients. Amer J Orthopsychiat 60:412-17.
25. Hall,L. & Lloyd,S. (1989) Surviving child sexual abuse: a handbook for helping women challenge their past.
Basingstoke, Hants: Falmer Press. The appendix gives numerous suggestions for further reading and useful
addresses including 17 possible contact groups/centres around Scotland.
26. Edinburgh Action Against Incest, c/o 61a Broughton Street, Edinburgh.
27. Edinburgh Rape Crisis Centre, P.O. Box 120, Edinburgh. There is an associated Incest Survivors Group and Incest
Survivors Line. Tel: 031-556 9437 - There is an answering machine and at a number of times during the week the
line is staffed either for those who have suffered rape or incest.
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