It didn't take long for the psychologists to begin arriving on the scene. Just hours after Tim K. fired the last bullet in the Albertville secondary school in the southwestern German town of Winnenden on Wednesday, dozens of grief and trauma specialists arrived to help, some from hundreds of kilometers away. By Thursday, there were 50 of them in the small town near Stuttgart.
Fifteen people died in the massacre, not counting K. himself. Twelve of them were killed in the classrooms and hallways of the school, many shot from close range in the head. For those who witnessed the brutal events, the shock is deep; for those who lost friends and family, the grief profound. The specialists now in Winnenden are there to give pupils comfort, but also to encourage them to confront what they saw and experienced. Already, 1,000 calls have come in to a special crisis hotline officials set up soon after the shooting, with many of those calling asking how they should best go about working through their feelings and emotions.
More Harm than Good?
The answer, though, might not be what we have come to expect. New research suggests that showing no symptoms of trauma at all may actually be a sign of health, rather than being a sign of problems. What's more, some researchers believe that well-intentioned clinicians may be causing more harm than good.
Losing a loved one is undoubtedly one of life's most painful experiences. Psychotherapists have long been trained to recommend "grief work" or "working through" the trauma à la Sigmund Freud, and facing the loss head on has long been considered the proper course of treatment for all those who have experienced distress, partially in order to ward off symptoms of trauma and depression. Clinicians typically interpret symptoms such as depression, social withdrawal, and ample tearfulness as necessary to the normal bereavement process. This involves talking about the loss, gaining insight into its meaning, and arriving at a sense of resolution.
But even though a majority of mental health professionals endorse grief counseling, there is actually a surprising lack of scientific evidence to support its usefullness. Studies have found that it isn't nearly as effective as conventional forms of talk therapy. Indeed, it isn't even clear that grief counseling is beneficial at all to the majority of those who have lived through loss.
Research has consistently shown that about 50 percent of those who experience trauma remain resilient. By contrast, Post Traumatic Stress Disorder has been observed in only 5 to 10 percent of people exposed to such circumstances. And while concern about chronic grief symptoms -- which is characterized by a dramatic, high-level depression and can persist for several years -- is widespread, only about 10 percent of bereaved people show chronically elevated grief symptoms, though the number rises when the loss is extreme or involves violence.
For decades, convention has held that the mourner feels intense anger, guilt and ambivalence toward the deceased. Primarily, though, such emotions are predominant in people experiencing "complicated bereavement," in which those experiencing loss had a troubled relationship with the departed before they died. These conflicts can linger for the living, and without a future opportunity to resolve them, can lead to a full-blown depression. But it is far from the norm.
Similarly, "breaking off ties" with the deceased, or an emotional "letting go," was also considered a mandatory step toward getting over grief. But research now indicates that bereaved people who have best come to terms with their loss maintain an emotional attachment to their loved ones long afterwards. In light of these findings, there is growing concern among mental health professionals that the methods and goals of grief counseling may actually destabilize rather than shore up psychological resources.
"Most bereaved people do not need and will not benefit from clinical intervention," psychologists George Bonanno and Scott Lilienfeld wrote in a 2008 article for the journal Professional Psychology: Research and Practice. The scientists even went as far as to say that researchers' notion that grief counseling might be as effective as conventional forms of therapy is "dangerous" and amounts to "unwarranted optimism."
Four Tasks for Grieving
Grief counselors regularly rely on the classic text by Harvard psychologist J. William Worden, "Grief Counseling and Grief Therapy: A Handbook for the Mental Health Practitioner," originally published in 1982. Now in its third edition, Worden established four tasks of grieving: to accept the reality of the loss, to experience the pain of grief, to adjust to the environment in which the deceased is missing, and to withdraw emotional energy and reinvest it in another relationship. He recommended that grief counseling should be completed on a time-limited basis, specifically 8 to 10 sessions.
Grief counselors who have loosely and liberally drawn from Worden's theories, though, now insist that treatment simply takes as long as it takes. This often means a several-month or several-year long treatment. Is this reasonable? Even Dr. Worden has publicly expressed lament that his book, which was meant merely to serve as a resource for mental health providers, has inadvertently helped generate a flourishing industry of grief counseling, from specialized private practices to large-scale federal programs.
"I don't know what I've spawned," Worden once lamented to Time magazine.
The danger of encouraging people to discuss their pain over and over becomes particularly apparent when it comes to crisis counseling. Whenever there is a traumatic event, such as the Sept. 11, 2001 terrorist attacks in New York and Washington D.C., grief and crisis counselors descend in droves. Tents are set up as makeshift clinics. Pamphlets describing "normal" bereavement are everywhere.
It has, of course, been proven that symptoms of grief are elevated when people lose their loved ones under particularly violent or horrific circumstances. Studies now show, however, that interrogating distraught individuals about their feelings of loss until they have a cathartic reaction can be harmful and even delay recovery. Bessel Van der Kolk, a psychiatrist at Boston University and the Medical Director of the Trauma Center in Allston, MA, argues that one crucial stage in bereavement is to allow the body to calm down. He believes that barraging freshly traumatized individuals with such probing questions induces physical stress, and consequently interferes with this important step in the natural grieving process.
Is there a time when grief counseling might be helpful? "I don't know if it's ever helpful until these counselors clarify what it is they're trying to do," says Bonanno, who is a professor at Columbia University in New York.
Despite his strong misgivings about this form of therapy, Bonanno is in favor of seeking treatment if the bereaved person expresses the desire on his or her own. He further believes that the most difficult challenge for those facing a loss is to preserve their identity. Thus, clinicians should encourage their clients to construct a new sense of meaning in their lives. It also seems that counseling is most useful for those who had psychological troubles before the loss, and which were exacerbated by their grief.
But treating pre-existing conditions isn't grief work. It's just therapy.