International Society for Traumatic Stress Studies

Military Matters: Grief Responses in U.S. Military Families Following Soldier Loss

Posted 24 October 2016 in StressPoints by Holly B. Herberman Mash, PhD, Joscelyn E. Fisher, PhD, and Alexander G. Liu, MPH

Grief has increasingly become a focus of attention within the military, with 80 percent of redeployed soldiers reporting knowing someone who was seriously injured or killed in theater (Thomas et al., 2010; Toblin et al., 2012). Among 15,938 military service members (SMs) who died between 2001-2011, the majority of the deaths were the result of traumatic events, including accidents (34 percent), suicides (15 percent), homicides (3 percent), and terrorism (less than 1 percent) (Cozza et al., in press). Further, 32 percent of deceased SMs died in combat, a military-specific sudden and violent cause of death.

Psychological responses to a death can be complex, with the characteristics of this response varying greatly across several dimensions, including type, chronicity, and severity (Zisook & Shear, 2009). Factors that influence these responses, such as whether the death occurred at an early age, as well as other circumstances of the loss, are particularly relevant to SM deaths because deceased SMs are often young and their deaths are likely to have been sudden and violent. Family members’ grief can also be profoundly affected by deployment-related separations from the SM prior to the death and the closeness of the relationship between SMs and family members (Kaplow, Layne, Saltzman, Cozza, & Pynoos, 2013; Mash, Fullerton, Shear, & Ursano, 2014).

The majority of bereaved individuals experience a transient period of grief (Bonanno et al., 2002; Bonanno et al., 2007; Shear et al., 2011). Nevertheless, a substantial proportion of bereaved persons (10-41 percent) develop chronic pathological symptoms that may be debilitating and last for several years (Bonanno & Kaltman, 2001; Horowitz et al., 1997; Prigerson et al., 2009; Shear et al., 2011; Zisook et al., 2010). Symptoms associated with prolonged, severe grief responses include: persistent yearning and longing, preoccupation with the deceased or circumstances of the death, difficulty accepting the death, bitterness and anger related to the loss, avoidance of reminders of the deceased or the death, and feeling life is meaningless without the deceased (Bonanno & Kaltman, 2001; Horowitz et al., 1997; Prigerson et al., 2009; Shear & Mulhare, 2008; Shear et al., 2011; Zisook et al., 2010).  This condition has been included in the DSM-5 as Persistent Complex Bereavement Disorder (PCBD), a provisional condition for further study (APA, 2013). It can be distinguished from normal grief and is distinct from other disorders (e.g., depression and posttraumatic stress disorder) (Prigerson et al., 2009; Shear et al., 2011). However, research on PCBD has been limited to civilian samples, leaving a paucity of information about grief among military families.

To better understand the distinctive impact of military SM death on families, a series of bereavement studies has been conducted by the Center for the Study of Traumatic Stress (CSTS) at the Uniformed Services University of the Health Sciences. Initial research, in collaboration with Sesame Workshop, evaluated a multimedia kit designed to help military and civilian children cope with the death of a parent. Families that used the grief materials indicated that they were helpful and had a positive impact on coping (Ortiz, Cozza, Fullerton, & Ursano, 2013).

As a result of this preliminary research, CSTS developed the National Military Family Bereavement Study (NMFBS) to comprehensively examine how various factors (e.g., pre-existing psychological and physical health, support, coping, genotype) affect grief and other bereavement outcomes in military families. Over 2,200 adult participants completed an initial questionnaire. Additionally, 850 adults and 120 children enrolled in the longitudinal phase of the study which consists of annual interviews over three years.

One of the first NMFBS publications evaluated the DSM-5 PCBD criteria (Cozza et al., 2016). Findings indicated that 48.6 percent of participants endorsed either elevated grief or depression, and 23.5 percent endorsed both responses. The DSM-5 PCBD criteria accurately identified 53.5 percent of individuals classified as clinical cases and accurately excluded 99.9 percent of nonclinical cases. These findings provide important information regarding the utility of the DSM-5 PCBD criteria, and suggest further investigation.

In response to elevated grief symptoms reported by surviving military family members, CSTS partnered with the Center for Complicated Grief at Columbia University to develop Stepping Forward in Grief, a randomized-controlled study that develops and tests an app-based/Internet support program. The program is based on Complicated Grief Therapy, which is designed to reduce grief symptoms and risk for long-term problems. It is anticipated that the program will be available for individuals who have lost a military SM in order to address the particular needs of this population.

Finally, CSTS researchers have partnered with Voices of September 11, a not-for-profit organization for 9/11 families, and the Canadian Resource Centre for Victims of Crime, an organization that supports family members bereaved by the Air India Flight 182 bombing on June 23, 1985. This collaboration resulted in a study to investigate long-term positive and negative bereavement outcomes following a terrorism-related death. This study of over 400 bereaved participants will increase our understanding of the risk and protective factors for those bereaved by terrorism-related deaths, and inform interventions for disaster and terrorism victims and their families.

The bereavement projects at CSTS aim to better understand the unique needs and diverse challenges following loss, and identify individuals who may be at particular risk for problematic grief responses. This information will promote the development of preventive intervention programs, and provide resources for clinicians to support families affected by disaster, terrorism, or military SM deaths. Finally, CSTS has made available a number of online resources to assist clinicians, researchers, and bereaved family members and servicemembers, including, for example, fact sheets on depression following military loss, disaster anniversary events, the importance of rituals (e.g., funerals and memorials) and the role of leaders in grief recovery. These resources are available here.

About the Authors

Holly Herberman Mash, PhD, is a Research Assistant Professor in the Department of Psychiatry at the Uniformed Services University of the Health Sciences in Bethesda, Maryland, and a scientist at the Center for the Study of Traumatic Stress. Her primary research interests include the risk and protective factors for complicated grief following traumatic events, suicidal behavior, and alcohol use disorders.

Joscelyn E. Fisher, PhD, is a Research Assistant Professor in the Department of Psychiatry at the Uniformed Services University of the Health Sciences in Bethesda, Maryland, and a scientist at the Center for the Study of Traumatic Stress. Her research has primarily focused on how cognitive and emotion processes are related to symptom manifestation. Dr. Fisher is currently investigating predictors of depression, anxiety and grief symptoms in bereaved military family members.

Alexander Liu, MPH, is a Center Program Manager at the Center for the Study of Traumatic Stress. His primary research interests include understanding and examining the bereavement process of service member loss on military families. Other areas of interest include examining current military mental health programs and initiatives and their relationship with health outcomes, such as incidence in PTSD and suicide rates.  

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