Helping patients cope with traumatic loss

When tragedies like the Aurora, Colo., and Newtown, Conn., shootings occur, we wonder whether people can ever overcome their grief and find a way to move on with their lives. Froma Walsh, Ph.D., a leading authority on family resilience, has developed an approach that can be used to strengthen families and communities that have suffered such tragedies.

Dr. Walsh is the codirector and cofounder of the Chicago Center for Family Health, and the Mose and Sylvia Firestone Professor Emerita in the school of social service administration and department of psychiatry at the University of Chicago.

Resilience originally was described as individual resilience. Dr. Walsh, who has broadened that concept, provides us with important steps to understand how to help heal families and communities that suffer from unimaginable trauma and loss.

Individual resilience

Beginning in the 1960s, British psychiatrist Sir Michael Rutter studied youth from inner-city London and on the Isle of Wight. Even though they experienced many risk factors, 25% of the children had a good outcome. The children who showed individual resilience had the following characteristics: an easy temperament; female; a positive school climate; self-mastery; self-efficacy; planning skills; and a warm, close, personal relationship with an adult.

From 1955 to 1985, American researchers Emmy E. Werner, Ph.D., and Ruth S. Smith, Ph.D., studied a high-risk population of children in Hawaii and found that 36% showed individual resilience, despite their risk factors. Resilient personal characteristics found in this study were similar: being female, socially responsible, adaptable, tolerant, achievement oriented, a good communicator, and having good self-esteem as well as a caring environment inside and outside the family.

Acquiring resilient qualities

After traumatic events happen, how do people cope? How does the coping process result in growth? We are all familiar with the saying: "What doesn’t break you makes you stronger." This is resilience. How can we help families and communities become stronger?

Family resilience

Dr. Walsh developed the concept of family resilience and a practice framework, identifying key family processes that clinicians can target to strengthen family resilience. She is quick to point out that resilience does not lie in specific characteristics, but rather in family processes that promote resilience. These family processes include a family belief system that pulls family members together and forward, the ability to have hope, a spiritual or value orientation to draw meaning and new purpose out of a tragedy, being able to organize family life to meet challenges, reaching out to extended kin and community networks, collaborative problem solving, and clear communication between members.

Her article, "Traumatic loss and major disasters: strengthening family and community resilience," identifies ways that professionals can help families cope with traumatic loss (Fam. Process 2007;46:207-27). She identifies nine aspects of family life as being key factors in families being able to cope well with traumatic loss:.

• Making meaning of traumatic loss experience. Families ask "Why us?" Families need to make sense of their experiences in a way that allows them to live on. "New meaning" highlights the strengths of the survivors and shows a "new way" of relating to the world and to others. As psychiatrists, we can support the family in finding their own meaning, by helping them examine their beliefs about blame, responsibility, or negligence; and helping them come to terms with accountability and limits of control in the situation.

• Hope. Families need to regain hope in their future possibilities. How does this family want to continue and what does this family want to become? Although they cannot change what has happened, we can support their efforts to "master the possible" by promoting active agency in doing all they can as they move forward.

• Transcendence and spirituality. Families can use their personal values and faith communities for support and to help with forgiveness. Honoring those who died with memorials, anniversary remembrances, and celebrations of milestones in recovery will facilitate healing and growth. These rituals help affirm social values of goodness and compassion. "Recovery is a journey of the heart and spirit, bringing survivors back to the fullness of life," Dr. Walsh wrote in her article.

• Flexibility and stability. Flexibility allows adaptation in the family and allows it to stabilize. Families need to buffer the upheaval and restore security, reliability, and continuity in daily routines. They might need to construct a "new normal" in their lives.

• Connectedness. Each family member has her own adaptation to loss, but family members need to remain mutually supportive. If relationships have prior unresolved conflicts, distress can be worse. Family therapy can prove helpful.

• Extended kin and social resources. Reach out to friends, neighbors, health care providers, clergy and congregational support, school teachers and counselors, employers and coworkers, and neighborhood or community organizations. Multifamily community support groups can help families exchange information, share painful memories and feelings, provide mutual support, and encourage hope and efforts for recovery.

• Clear, consistent information. Families often need help to clarify facts and circumstances of traumatic events and to help their children understand, as age appropriate.

• Emotional sharing and support. Families and the community will experience a wide range of feelings. It is important to allow painful or unacceptable feelings to be expressed and supported, even when differences are viewed as threatening, to avoid the risk of future somatic and emotional disturbance, destructive behavior, or substance abuse. Journals and artwork are helpful, especially with children.

• Collaborative problem solving. Family and communities can coordinate collaborative efforts to promote recovery and resilience. Learning from their experience, they can take steps proactively to prevent future tragedies. One mother who lost a child in the Newtown massacre said she wanted her family and her community to be defined not by their tragedy and suffering, but by the way they are responding, by galvanizing action to stop gun violence.

Community resilience

Community resilience is promoted by Dr. Judith Landau and Jack Saul, Ph.D. in a book edited by Dr. Walsh and Monica McGoldrick, Ph.D., called "Living Beyond Loss: Death in the Family" (see list of further reading below). Community members can create a support system that connects individuals and families. Community support provides a highly connected and reality based understanding. Ongoing support groups can respond accurately to the community needs. Perhaps the community might create a neighborhood resource center or a public space to gather, a witness project, or a community website. Such interventions can have a long-lasting positive impact on the community and the families.

Professional resilience

Compassion fatigue can occur when witnessing trauma and in experiencing ongoing distress. Mental health professionals cannot heal all wounds, but we can create a safe haven for family and community members to share pain and their seeking a new path.

Kaethe Weingarten, Ph.D., has developed a compassionate witnessing project aimed at helping professionals understand the importance of "witnessing" suffering and struggle. She encourages professionals to become aware of their own responses to witnessing trauma and to develop tools to cope with the effects of witnessing trauma.

A family resilience approach is a very positive and constructive way that we can use to teach families how to make sense of what has happened and how to move forward, as difficult as that may currently seem to be.

Further reading:

Here is a list of additional reading you can do to help patients who are facing unimaginable loss:

• "Common Shock: Witnessing Violence Every Day," (New York: Dutton, 2003)

• "Family Resilience: A Framework for Clinical Practice," (Family Process 2003;42:1-18)

• "Living Beyond Loss: Death in the Family," (New York: Norton, 2004, 2nd ed.).

• "Resilience Concepts and Findings: Implications for Family Therapy," (J. Family Therapy 1999;21:119-44).

• "Strengthening Family Resilience," (New York: Guilford Press, 2006)

 Dr. Heru is with the department of psychiatry at the University of Colorado at Denver, Aurora. E-mail Dr. Heru at cpnews@elsevier.com.

When tragedies like the Aurora, Colo., and Newtown, Conn., shootings occur, we wonder whether people can ever overcome their grief and find a way to move on with their lives. Froma Walsh, Ph.D., a leading authority on family resilience, has developed an approach that can be used to strengthen families and communities that have suffered such tragedies.

Dr. Walsh is the codirector and cofounder of the Chicago Center for Family Health, and the Mose and Sylvia Firestone Professor Emerita in the school of social service administration and department of psychiatry at the University of Chicago.

Resilience originally was described as individual resilience. Dr. Walsh, who has broadened that concept, provides us with important steps to understand how to help heal families and communities that suffer from unimaginable trauma and loss.

Individual resilience

Beginning in the 1960s, British psychiatrist Sir Michael Rutter studied youth from inner-city London and on the Isle of Wight. Even though they experienced many risk factors, 25% of the children had a good outcome. The children who showed individual resilience had the following characteristics: an easy temperament; female; a positive school climate; self-mastery; self-efficacy; planning skills; and a warm, close, personal relationship with an adult.

From 1955 to 1985, American researchers Emmy E. Werner, Ph.D., and Ruth S. Smith, Ph.D., studied a high-risk population of children in Hawaii and found that 36% showed individual resilience, despite their risk factors. Resilient personal characteristics found in this study were similar: being female, socially responsible, adaptable, tolerant, achievement oriented, a good communicator, and having good self-esteem as well as a caring environment inside and outside the family.

Acquiring resilient qualities

After traumatic events happen, how do people cope? How does the coping process result in growth? We are all familiar with the saying: "What doesn’t break you makes you stronger." This is resilience. How can we help families and communities become stronger?

Family resilience

Dr. Walsh developed the concept of family resilience and a practice framework, identifying key family processes that clinicians can target to strengthen family resilience. She is quick to point out that resilience does not lie in specific characteristics, but rather in family processes that promote resilience. These family processes include a family belief system that pulls family members together and forward, the ability to have hope, a spiritual or value orientation to draw meaning and new purpose out of a tragedy, being able to organize family life to meet challenges, reaching out to extended kin and community networks, collaborative problem solving, and clear communication between members.

Her article, "Traumatic loss and major disasters: strengthening family and community resilience," identifies ways that professionals can help families cope with traumatic loss (Fam. Process 2007;46:207-27). She identifies nine aspects of family life as being key factors in families being able to cope well with traumatic loss:.

• Making meaning of traumatic loss experience. Families ask "Why us?" Families need to make sense of their experiences in a way that allows them to live on. "New meaning" highlights the strengths of the survivors and shows a "new way" of relating to the world and to others. As psychiatrists, we can support the family in finding their own meaning, by helping them examine their beliefs about blame, responsibility, or negligence; and helping them come to terms with accountability and limits of control in the situation.

• Hope. Families need to regain hope in their future possibilities. How does this family want to continue and what does this family want to become? Although they cannot change what has happened, we can support their efforts to "master the possible" by promoting active agency in doing all they can as they move forward.

• Transcendence and spirituality. Families can use their personal values and faith communities for support and to help with forgiveness. Honoring those who died with memorials, anniversary remembrances, and celebrations of milestones in recovery will facilitate healing and growth. These rituals help affirm social values of goodness and compassion. "Recovery is a journey of the heart and spirit, bringing survivors back to the fullness of life," Dr. Walsh wrote in her article.

• Flexibility and stability. Flexibility allows adaptation in the family and allows it to stabilize. Families need to buffer the upheaval and restore security, reliability, and continuity in daily routines. They might need to construct a "new normal" in their lives.

• Connectedness. Each family member has her own adaptation to loss, but family members need to remain mutually supportive. If relationships have prior unresolved conflicts, distress can be worse. Family therapy can prove helpful.

• Extended kin and social resources. Reach out to friends, neighbors, health care providers, clergy and congregational support, school teachers and counselors, employers and coworkers, and neighborhood or community organizations. Multifamily community support groups can help families exchange information, share painful memories and feelings, provide mutual support, and encourage hope and efforts for recovery.

• Clear, consistent information. Families often need help to clarify facts and circumstances of traumatic events and to help their children understand, as age appropriate.

• Emotional sharing and support. Families and the community will experience a wide range of feelings. It is important to allow painful or unacceptable feelings to be expressed and supported, even when differences are viewed as threatening, to avoid the risk of future somatic and emotional disturbance, destructive behavior, or substance abuse. Journals and artwork are helpful, especially with children.

• Collaborative problem solving. Family and communities can coordinate collaborative efforts to promote recovery and resilience. Learning from their experience, they can take steps proactively to prevent future tragedies. One mother who lost a child in the Newtown massacre said she wanted her family and her community to be defined not by their tragedy and suffering, but by the way they are responding, by galvanizing action to stop gun violence.

Community resilience

Community resilience is promoted by Dr. Judith Landau and Jack Saul, Ph.D. in a book edited by Dr. Walsh and Monica McGoldrick, Ph.D., called "Living Beyond Loss: Death in the Family" (see list of further reading below). Community members can create a support system that connects individuals and families. Community support provides a highly connected and reality based understanding. Ongoing support groups can respond accurately to the community needs. Perhaps the community might create a neighborhood resource center or a public space to gather, a witness project, or a community website. Such interventions can have a long-lasting positive impact on the community and the families.

Professional resilience

Compassion fatigue can occur when witnessing trauma and in experiencing ongoing distress. Mental health professionals cannot heal all wounds, but we can create a safe haven for family and community members to share pain and their seeking a new path.

Kaethe Weingarten, Ph.D., has developed a compassionate witnessing project aimed at helping professionals understand the importance of "witnessing" suffering and struggle. She encourages professionals to become aware of their own responses to witnessing trauma and to develop tools to cope with the effects of witnessing trauma.

A family resilience approach is a very positive and constructive way that we can use to teach families how to make sense of what has happened and how to move forward, as difficult as that may currently seem to be.

Further reading:

Here is a list of additional reading you can do to help patients who are facing unimaginable loss:

• "Common Shock: Witnessing Violence Every Day," (New York: Dutton, 2003)

• "Family Resilience: A Framework for Clinical Practice," (Family Process 2003;42:1-18)

• "Living Beyond Loss: Death in the Family," (New York: Norton, 2004, 2nd ed.).

• "Resilience Concepts and Findings: Implications for Family Therapy," (J. Family Therapy 1999;21:119-44).

• "Strengthening Family Resilience," (New York: Guilford Press, 2006)

 Dr. Heru is with the department of psychiatry at the University of Colorado at Denver, Aurora. E-mail Dr. Heru at cpnews@elsevier.com.

When tragedies like the Aurora, Colo., and Newtown, Conn., shootings occur, we wonder whether people can ever overcome their grief and find a way to move on with their lives. Froma Walsh, Ph.D., a leading authority on family resilience, has developed an approach that can be used to strengthen families and communities that have suffered such tragedies.

Dr. Walsh is the codirector and cofounder of the Chicago Center for Family Health, and the Mose and Sylvia Firestone Professor Emerita in the school of social service administration and department of psychiatry at the University of Chicago.

Resilience originally was described as individual resilience. Dr. Walsh, who has broadened that concept, provides us with important steps to understand how to help heal families and communities that suffer from unimaginable trauma and loss.

Individual resilience

Beginning in the 1960s, British psychiatrist Sir Michael Rutter studied youth from inner-city London and on the Isle of Wight. Even though they experienced many risk factors, 25% of the children had a good outcome. The children who showed individual resilience had the following characteristics: an easy temperament; female; a positive school climate; self-mastery; self-efficacy; planning skills; and a warm, close, personal relationship with an adult.

From 1955 to 1985, American researchers Emmy E. Werner, Ph.D., and Ruth S. Smith, Ph.D., studied a high-risk population of children in Hawaii and found that 36% showed individual resilience, despite their risk factors. Resilient personal characteristics found in this study were similar: being female, socially responsible, adaptable, tolerant, achievement oriented, a good communicator, and having good self-esteem as well as a caring environment inside and outside the family.

Acquiring resilient qualities

After traumatic events happen, how do people cope? How does the coping process result in growth? We are all familiar with the saying: "What doesn’t break you makes you stronger." This is resilience. How can we help families and communities become stronger?

Family resilience

Dr. Walsh developed the concept of family resilience and a practice framework, identifying key family processes that clinicians can target to strengthen family resilience. She is quick to point out that resilience does not lie in specific characteristics, but rather in family processes that promote resilience. These family processes include a family belief system that pulls family members together and forward, the ability to have hope, a spiritual or value orientation to draw meaning and new purpose out of a tragedy, being able to organize family life to meet challenges, reaching out to extended kin and community networks, collaborative problem solving, and clear communication between members.

Her article, "Traumatic loss and major disasters: strengthening family and community resilience," identifies ways that professionals can help families cope with traumatic loss (Fam. Process 2007;46:207-27). She identifies nine aspects of family life as being key factors in families being able to cope well with traumatic loss:.

• Making meaning of traumatic loss experience. Families ask "Why us?" Families need to make sense of their experiences in a way that allows them to live on. "New meaning" highlights the strengths of the survivors and shows a "new way" of relating to the world and to others. As psychiatrists, we can support the family in finding their own meaning, by helping them examine their beliefs about blame, responsibility, or negligence; and helping them come to terms with accountability and limits of control in the situation.

• Hope. Families need to regain hope in their future possibilities. How does this family want to continue and what does this family want to become? Although they cannot change what has happened, we can support their efforts to "master the possible" by promoting active agency in doing all they can as they move forward.

• Transcendence and spirituality. Families can use their personal values and faith communities for support and to help with forgiveness. Honoring those who died with memorials, anniversary remembrances, and celebrations of milestones in recovery will facilitate healing and growth. These rituals help affirm social values of goodness and compassion. "Recovery is a journey of the heart and spirit, bringing survivors back to the fullness of life," Dr. Walsh wrote in her article.

• Flexibility and stability. Flexibility allows adaptation in the family and allows it to stabilize. Families need to buffer the upheaval and restore security, reliability, and continuity in daily routines. They might need to construct a "new normal" in their lives.

• Connectedness. Each family member has her own adaptation to loss, but family members need to remain mutually supportive. If relationships have prior unresolved conflicts, distress can be worse. Family therapy can prove helpful.

• Extended kin and social resources. Reach out to friends, neighbors, health care providers, clergy and congregational support, school teachers and counselors, employers and coworkers, and neighborhood or community organizations. Multifamily community support groups can help families exchange information, share painful memories and feelings, provide mutual support, and encourage hope and efforts for recovery.

• Clear, consistent information. Families often need help to clarify facts and circumstances of traumatic events and to help their children understand, as age appropriate.

• Emotional sharing and support. Families and the community will experience a wide range of feelings. It is important to allow painful or unacceptable feelings to be expressed and supported, even when differences are viewed as threatening, to avoid the risk of future somatic and emotional disturbance, destructive behavior, or substance abuse. Journals and artwork are helpful, especially with children.

• Collaborative problem solving. Family and communities can coordinate collaborative efforts to promote recovery and resilience. Learning from their experience, they can take steps proactively to prevent future tragedies. One mother who lost a child in the Newtown massacre said she wanted her family and her community to be defined not by their tragedy and suffering, but by the way they are responding, by galvanizing action to stop gun violence.

Community resilience

Community resilience is promoted by Dr. Judith Landau and Jack Saul, Ph.D. in a book edited by Dr. Walsh and Monica McGoldrick, Ph.D., called "Living Beyond Loss: Death in the Family" (see list of further reading below). Community members can create a support system that connects individuals and families. Community support provides a highly connected and reality based understanding. Ongoing support groups can respond accurately to the community needs. Perhaps the community might create a neighborhood resource center or a public space to gather, a witness project, or a community website. Such interventions can have a long-lasting positive impact on the community and the families.

Professional resilience

Compassion fatigue can occur when witnessing trauma and in experiencing ongoing distress. Mental health professionals cannot heal all wounds, but we can create a safe haven for family and community members to share pain and their seeking a new path.

Kaethe Weingarten, Ph.D., has developed a compassionate witnessing project aimed at helping professionals understand the importance of "witnessing" suffering and struggle. She encourages professionals to become aware of their own responses to witnessing trauma and to develop tools to cope with the effects of witnessing trauma.

A family resilience approach is a very positive and constructive way that we can use to teach families how to make sense of what has happened and how to move forward, as difficult as that may currently seem to be.

Further reading:

Here is a list of additional reading you can do to help patients who are facing unimaginable loss:

• "Common Shock: Witnessing Violence Every Day," (New York: Dutton, 2003)

• "Family Resilience: A Framework for Clinical Practice," (Family Process 2003;42:1-18)

• "Living Beyond Loss: Death in the Family," (New York: Norton, 2004, 2nd ed.).

• "Resilience Concepts and Findings: Implications for Family Therapy," (J. Family Therapy 1999;21:119-44).

• "Strengthening Family Resilience," (New York: Guilford Press, 2006)

 Dr. Heru is with the department of psychiatry at the University of Colorado at Denver, Aurora. E-mail Dr. Heru at cpnews@elsevier.com.