Grief vs. Trauma

Julie Kaplow: So, what I want to do now is move toward talking about traumatic bereavement and what we mean by that. And so, what I'd like to do is share with you two actual case studies. These were children that we treated in the Trauma and Grief Center. And, what I'd like you to do is kind of picture in your own mind what these kids would look like if they were presenting to you. So, if they were coming to your office, or you were in a school and working with these kids, what would that picture look like? The first scenario is a nine-year-old girl who's in a tragic car crash with her mother and father. Her mother is killed after suffering from numerous internal injuries. The child is not hurt but observes her mother's lifeless body from the back seat of the car. The second scenario is a twelve-year-old boy who experiences the anticipated death of his mother after she had suffered from breast cancer. For three years the child served in a caretaking role during that time and had ample opportunity to say goodbye. So, what I'd like to do now is present you with two quotes and I'd like you to think in your mind which child said what. So, the first quote is, “This is a child who presents with extremely high levels of PTSD, minimal symptoms of maladaptive grief. During the interview. The child states, ‘I just keep remembering it and I feel like I'm right back there again. I can't get it out of my mind.’” So, we have a polling question for you that Ashley is going to launch. So, who said this? Was this the girl whose mother died in the car crash or the boy whose mother died of breast cancer? Okay, so it looks like the majority are saying that this is the girl whose mother died in the car crash. So now, what we're going to do is move on to the next quote and this is, “The child presents with high levels of separation distress. existential distress, minimal symptoms of PTSD. During the interview states, ‘My mom was like my best friend. I just want her back. I just want to see her again.’” So, the next polling question, who said this: the girl whose mother died in the car crash or the boy whose mother died of breast cancer? So, it looks like the majority thought that this was the boy whose mother died of breast cancer. Okay, well, thank you for participating in that. And I want to share the results with you. And I will admit that I tricked you on purpose as a learning opportunity, because truthfully, I had the very same responses that you did before we saw these kids. So, in the first scenario, this is a nine-year-old girl who presents with extremely high levels of separation distress and existential distress, minimal symptoms of PTSD, during the interview states, “My mom was like my best friend. I just want her back. I just want to see her again.” So, I have to tell you that, you know, when we were doing when we were working with these kids. The way it was set up is that at our TAG Center, we would have our postdoc fellows or our trainees doing the interviews with the children and then there was a team of us behind the mirror watching. And usually there were seven or eight of us behind the mirror. And, I will say that this was the first and only time I remember not a dry eye behind the mirror and the reason for that is because this child's separation distress was palpable. You could literally feel her yearning and longing for her mom. And what was fascinating is that, when we talked about this case before she came in, we all anticipated high levels of PTSD. She was actually in the car at the time; she saw the whole thing. She was witness to it. And we anticipated she'd have high levels of post-traumatic stress. But when she came in the room, that is not what she presented with. And, in fact, when we did our evidence-based assessment of her, what we found is exactly that very minimal symptoms of PTSD, very high levels of separation and existential distress. And, what I thought to myself at the time was, “Well, maybe this will change over time.” It never changed. So, our postdoc did wonderful work with this girl and her father over the course of the year and what this child really needed was finding healthy ways of connecting to her mom. What she did not need was what would have probably typically been done in more of a trauma-focused CBT kind of orientation, where they would ask her to go through her trauma narrative and talk about the car accident in great detail; what she saw, what she felt, what she remembered. But to be honest with you, I think if we had gone down that road it could have caused much more harm than good. And, in fact, again, what she needed in order to help with the separation distress and identity distress was enlisting Dad and finding ways to feel connected to Mom. Now, the next example is also a little bit counterintuitive for some. So, this is a twelve-year-old boy who presents with extremely high levels of PTSD, minimal symptoms of maladaptive grief. During the interview, he states, “I just keep remembering it, hearing my parents crying together in their bedroom, and my mom saying, ‘I know the treatment isn't working.’ I feel like I'm right back there again, and I can't get it out of my mind.” So, obviously, I left a piece of this out, otherwise it would have given it away. But what we know about kids who are anticipating the death of a loved one is that they are often subject to very traumatic elements of that precipitating of that death that they know is about to happen, that adults may not always be aware of. And so, this is where wonders and worries comes in, you know thinking about, how can we help to prepare those kids better in order to deal with what is about to happen? And so, you know, in this situation, what we want to keep in mind is that this child was witness to cries of distress and cries of distress are actually one of the most potent trauma reminders for children and adolescents. And so, hearing that, recognizing that the treatment might not be working and hearing the cries of pain from his parents was extremely traumatic. And so, what we want to ensure is that we don't immediately judge the situation by its cover, meaning that if we think to ourselves. “Well, the child's going to have closure or they're going to have ample time to say goodbye, then PTSD is not a consideration.” We know that that's not true.