Traumatic images of their loved one’s dying

Dear Dr. Neimeyer,

As a therapist I often work with people who suffer from traumatic images of their loved one’s dying, even when these result from a difficult death in the hospital. Can you comment on how to help the bereaved who are struggling with difficult images and memories? How does one work through traumatic images in therapy? Thank you.–Kerry

Dear Kerry,

Just as you say, troubling or haunting visual memories of the the deceased are not limited to circumstances of violent death bereavement, although evidence suggests that the latter are especially likely to lead to prolonged and complicated grief reactions, and seeing the loved one’s body at the scene of the suicide, homicide or accident has been found to predict more intense struggles in bereavement. Whatever the source of the imagery, it can have remarkable “staying power,” lingering and intruding into the survivor’s consciousness (and nightmares) for years beyond the death, commonly bringing with it waves of anguish, horror and helplessness.

In recognition of this common clinical concern, creative clinicians like Laurie Perlman, Ted Rynearson and their colleagues have developed specialized procedures for working with troubling imagery in grief therapy using a trauma-informed approach. Rynearson’s group, for example, practices “restorative retelling,” a slow motion review of the narrative of traumatic death, typically beginning when the client first discovers or is informed of the dying, and moving forward through one of more “chapters” of the story through the client’s visual recollection or reconstruction of the scene of the dying, whether witnessed or imagined. Stretching over one or more sessions of therapy, such retelling tacks from the external story of what the client saw, heard and smelled, to the internal story of what she or he felt at emotional and embodied levels, as the therapist provides emotion regulation and support for the exposure to these hard realities. The result of one or more such sessions tends to be more mastery of the trauma story and its associated imagery, desensitization to its triggering aspects, and greater meaning making about the event story of the death and its role in the client’s life.

Supplementing this retelling, Rynearson and his colleague Fanny Correa advocate the use of drawings of the scene of dying, both as an aid to reviewing the story, and as a means of externalizing the story and giving it a more public audience with the therapist or support group with whom it is shared. In shifting the scene from private preoccupation with it in their own minds and dreams to a shared processing of it in therapy, many clients report relief and greater capacity to distance from the troubling visual components of the scene. A further step can be taken by asking clients to draw themselves into the scene, not in a way that can reverse the reality of the dying, but in a way that would let them provide some measure of comfort or care for the loved one as it occurs. For example, many people depict themselves holding their loved ones, caressing them, or lifting their spirits to heaven, in a way that restores some measure of empowerment to them that was denied at the time of the death. In such interventions, therapists actively join clients in engaging rather than merely trying to suppress the imagery, and seek to over-write the visualization of the trauma with imagery that embodies the client’s love for the deceased, rather than only his or her horror.

Finally, working with healing imagery directly can be helpful in therapy, especially after the hard but supported retelling described above. For example, Jack Jordan writes about the use of guided visualization of peaceful scenes and settings as an aid to emotion regulation, and I have found it helpful to encourage clients to display pictures of their loved ones at a time of health and happiness in the home to provide prominent portrayals that offer alternatives to troubling images of the deceased at the end of life or after death. Although these more benign interventions alone are often insufficient to over-write traumatic imagery when it is present, they can contribute to a positive reconstruction of memory when such imagery has been processed and de-fused through exposure. For specific procedural descriptions of several of the methods noted above, you might wish to consult Techniques of Grief Therapy: Creative Practices for Counseling the Bereaved, and its companion volume, Techniques of Grief Therapy: Assessment and Intervention.

Dr. Neimeyer

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