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. Author manuscript; available in PMC: 2016 Jan 31.
Published in final edited form as: Death Stud. 2014 Oct 8;39(2):84–91. doi: 10.1080/07481187.2014.893274

Death Thoughts and Images in Treatment-Seekers After Violent Loss

Jenna L Baddeley 1, Joah L Williams 2, Ted Rynearson 3, Fanny Correa 4, Connie Saindon 5, Alyssa A Rheingold 6
PMCID: PMC4281506  NIHMSID: NIHMS617938  PMID: 25101789

Abstract

Violent loss survivors often describe experiencing recurrent imagery about their loved one’s death. The Death Imagery Scale assesses five kinds of imagery: reenactment, rescue, revenge, reunion, and remorse. We explored the frequency of these forms of imagery and their associations with PTSD, depression, and/or complicated grief (CG) among 130 treatment-seeking survivors who were, on average, 3.5 years post-loss. Reenactment, rescue, and remorse imagery were most frequently endorsed, and all forms of imagery were associated with PTSD, depression, and CG. Bereaved parents reported more remorse and reunion imagery than others. Homicide survivors reported more revenge imagery than suicide and accident survivors.

Keywords: violent loss, trauma, homicide, assessment

Many survivors of violent loss (i.e., family and friends who lost a loved one to homicide, suicide, or fatal accidents) are at increased risk for a variety of psychological symptoms and disorders including post-traumatic stress disorder (PTSD), depression, and substance abuse (e.g., Amick-McMullen, Kilpatrick, & Resnick, 1991; Kaltman & Bonanno, 2003; McDevitt-Murphy, Neimeyer, Burke, Williams, & Lawson, 2012; Zinzow, Rheingold, Hawkins, Saunders, & Kilpatrick, 2009) as well as complicated (or prolonged) grief (Lobb et al., 2010). Complicated grief is a psychiatric disorder characterized by separation distress that can manifest in intense yearning for the deceased and feeling that life is meaningless without the deceased (Shear et al., 2011). These psychological symptoms and disorders may persist at elevated rates for years after the death (Murphy et al., 1999).

A common feature of bereavement-related PTSD, depression, and complicated grief is frequent, intrusive mental imagery associated with aspects of the loved one’s death. This death imagery includes dreams as well as thoughts, or mental content without a visual image experience, such as verbal content. Indeed, the criteria for both PTSD and complicated grief include symptoms such as intrusive thoughts about a horrifying, unwanted experience (e.g., a loved one’s death) and ruminations about the circumstances of the death, respectively (APA, 2013; Shear et al., 2011). Images are not part of the formal diagnostic criteria for major depression, but a large proportion of depressed patients also report experiencing intrusive images of important autobiographical events including, in many cases, a loved one’s death (Patel et al., 2007). Therefore, imagery involving reenactment of a loved one’s death (i.e., repetitive thoughts and imaginings of the loved one’s dying) may be commonplace among individuals experiencing serious forms of bereavement distress in the wake of violent loss.

Although the vast majority of violent loss survivors are not present at the time of their loved one’s death, survivors may still experience highly distressing reenactment imagery, reconstructing memories based on details gathered from third party sources (e.g., police and/or news reports). In the restorative retelling model of bereavement after violent loss, survivors of violent loss replay in their imagination the scenario of their loved one’s death in an attempt to make sense or meaning from what is essentially a senseless event (Rynearson, 2001). In a descriptive study of 15 homicide survivors, none of whom had witnessed their loved one’s death, all reported daily or weekly reenactment imagery (Rynearson, 1984). Among 18 homicide survivors, only one of whom witnessed their loved one’s death, all but one experienced reenactment imagery (Rynearson & McCreery, 1993).

Death imagery may also emerge in forms other than imaginal reenactments of a loved one’s death. In cases where the death resulted from another person’s intended action or error, survivors may imagine exacting revenge on the person responsible for the death or accident that resulted in the death. Indeed, survivors of homicide report revenge desire (Amick-McMullan et al., 1991; Rynearson, 1984), which is associated with distress and non-recovery from loss (Weinberg, 1994). Survivors may also experience death imagery as fantasies of rescuing or otherwise preventing their loved one from dying. Imagery associated with preventing a loved one’s death may play an especially important role in complicated grief given that guilty ruminations about one’s inability to prevent the death are a core feature (Shear & Mulhare, 2008).

Another common form of death imagery involves actively imagining reunion with the deceased loved one. Separation distress, including yearning and longing for the deceased, is a key feature of grief (e.g., Maciejewski, Zhang, Block, & Prigerson, 2007). A prolonged yearning and longing for the deceased is central to complicated grief, and thoughts of reunion are common in this population (Shear & Mulhare, 2008). However, questions remain as to whether thoughts of reunion and other forms of death imagery differ among individuals experiencing different forms of bereavement distress (i.e., PTSD, depression, complicated grief).

Forms of death imagery may also vary in relation to aspects of the loss. The recency of the death, the nature of the bereaved person’s relationship to the deceased, and how the deceased died are all associated with adjustment during bereavement (Baddeley & Singer, 2009). Specifically, over time bereaved individuals typically experience less bereavement-related distress and fewer negative affective experiences when thinking about the deceased (Carnelley, Wortman, Bolger, & Burke, 2006). Therefore, distressing forms of death imagery such as reenactment imagery may lessen in frequency and intensity as more time passes after a loss.

In terms of the survivor’s relationship to the deceased, parents of the deceased are more distressed than spouses or adult children of the deceased (Leahy, 1993-1994; Middleton et al., 1998) and may be more likely to experience recurring death imagery. Also, individuals who had more positive pre-bereavement relationships with their spouse experienced more yearning (Stroebe, Abakoumin, & Stroebe, 2010), which may be associated with more reunion-related imagery. Means of death may also be relevant in terms of understanding the nature of death imagery (e.g., suicide survivors may experience fewer revenge-related images because the death was facilitated by the deceased loved one), although few studies have addressed this issue.

Overall, evidence suggests that death imagery may be an important part of the experience of violent loss, but factors associated with qualitatively distinct manifestations of death imagery (e.g., reeneactment, revenge, reunion) are largely unknown. To explore the role of death imagery in adjustment to violent loss, the current study examines (a) the frequency of death imagery in a treatment-seeking sample of violent loss survivors, (b) associations between death imagery and bereavement-related PTSD, depression, and complicated grief, and (c) whether death imagery varies as a function of different loss-related characteristics.

Method

Participants

Participants were 130 violent death survivors who sought (and received) therapeutic treatment at a community health care clinic in the Pacific Northwest or in Southern California between 2001 and 2011. Both clinics specialize in the treatment of individuals who have lost a loved one as a result of a violent death. This study is part of a larger record review of treatment seeking survivors who completed measures before beginning a violent loss treatment program. We examined only baseline data (not post-treatment data). Table 1 describes participants’ characteristics. In summary, this sample was mainly well-educated, middle aged Caucasian women who lost a loved one to homicide on average 3.5 years ago. See Table 2 for further characteristics of the loss. Overall, participants varied with respect to their relationship to the deceased, and approximately 39% of survivors were parents of the deceased. Just under half of these survivors reported that they viewed the death scene at some point, and approximately 15.2% of survivors reported seeing the deceased at the scene of the death or injury.

Table 1.

Participants’ demographic characteristics.

Characteristic Mean or Frequency (SD or %) n answering question
Women 100 (76.9%) 130
Age (years) 46.50 (12.37) 130
Race/Ethnicity 130
 European-American, non-Hispanic 109 (83.8%)
 African-American 7 (5.4%)
 Hispanic 7 (5.4%)
 Other 6 (4.6%)
College educated 88 (67.7%) 128
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Note. Numbers outside brackets in the first column are means for continuous variables and counts for categorical variables; numbers in brackets represent standard deviation for continuous variables and percent of total sample for categorical variables.

Table 2.

Characteristics of the loss

Characteristic Mean or Frequency (SD or %) n answering question
Means of death 128
 Homicide 81 (62.3%)
 Suicide 29 (22.3%)
 Accident 17 (13.1%)
 Multiple types of losses 1 (0.8%)
The survivor is the deceased person’s ___ 129
 Parent 51 (39.2%)
 Romantic partner 21 (16.2%)
 Child 19 (14.6%)
 Sibling 21 (16.2%)
 Other relative or friend 14 (10.8%)
 Multiple losses 3 (2.3%)
Quality of relationship to the deceased 7.73 (1.68) 118
Months since loss 44.4 (97.1) 127
Experience of the loss
 Saw the scene of the death 57 (43.8%) 125
 Saw the person when they were injured 31 (23.8%) 123
 Tried to help 20 (15.4%) 100
 Prevented from helping 22 (16.9%) 99
 Saw victim at scene of death 20 (15.4%) 120
 Witnessed loved one’s death 15 (11.5%) 120
 First person to discover victim 13 (10.0%) 122
 Saw victim be taken to the hospital 9 (6.9%) 123
 Did the victim say anything? 13 (10.0%) 112
Learned about the loss 122
 Immediately 76 (58.5%)
 Kept from me for awhile 46 (35.4%)
Participation in loss-related rituals
 Attended the funeral 110 (84.6%) 121
 Participated in other rituals 92 (70.8%) 118
Experience of other losses
 Had other significant losses lately 71 (54.6%) 121
 This loss reminds you of other losses 55 (42.3%) 117
Thoughts about the deceased
 Previously felt frightened for the deceased 80 (61.5%) 120
 Believed the deceased was at risk 76 (58.5%) 118
 Wish the deceased had done something differently to prevent the death 98 (75.4%) 115
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Note. Unless otherwise specified, numbers outside brackets in the first column are means for continuous variables and counts for categorical variables; numbers in brackets represent standard deviation for continuous variables and percent of total sample for categorical variables.

Measures

All participants filled out an assessment battery requiring approximately 20-30 minutes to complete. This battery included:

Demographics and loss characteristics included survivor gender, age, race/ethnicity, marital status, education, and relationship to the deceased. Also, we asked the deceased person’s gender, age at time of death, time since loss, means of death, and whether the survivor witnessed the death.

Relationship quality included seven dimensions of the closeness and quality of the relationship that the survivor had with their loved one (closeness, peacefulness, ease, supportiveness, compatibility, attachment, and dependency). The first five were rated on a Likert scale of 1-10 where 1 is the least and 10 is most; the last two were rated on a Likert scale where 1 is the least and 5 is the most, and these were multiplied by 2. The 7 scores were then averaged to form a total relationship quality score. Cronbach’s alpha for the scale was .87 in this sample. As Table 2 shows, participants generally reported having good, close relationships with the deceased.

Death Imagery Scale (DIS; Rynearson & Correa, 2008, see Appendix A) is a 5-item scale that assesses the frequency with which survivors of violent loss experience five different kinds of post-loss, grief-related imagery: reenactment, rescue, revenge, reunion, and remorse. The questionnaire items ask whether the respondent experienced death imagery in the form of thoughts, visual “flashbacks”, or dreams. Items include, “I experience a fantasied replay of the dying,” “I experience a fantasy of rescuing the person from dying,” and “I experience a fantasy of retaliation for this dying.” Items are scored on a 4-point scale ranging from 0 to 3 where higher scores are associated with more frequent death imagery. The DIS is an unpublished scale, and no data currently exists regarding its psychometric properties. The DIS demonstrated adequate internal consistency in the current sample (Cronbach’s α = .74).

Beck Depression Inventory (BDI; Beck, Ward, Mendelson, Mock, & Erbaugh, 1961), a 21-item self-report scale, is among the most widely used instruments to measure depression. Each item contains four statements reflecting current manifestations of depression in increasing intensity, from neutral (e.g., “I am not particularly discouraged about the future.”) to severe (e.g., “I feel that the future is hopeless and that things cannot improve.”). Each item is scored 0 to 3 and total scores range from 0 to 63, with higher scores indicating greater depressive severity. Of the 21 items on the scale, 13 assess depressive symptoms that are primarily psychological in nature, while 8 measure symptoms that are somatically-oriented. In the current sample, the BDI had high internal consistency (Cronbach’s α = .90).

Impact of Events Scale – Revised (IES-R; Weiss & Marmar, 1997) is a commonly used 22-item self-report measure that assesses distress related to the trauma symptom clusters of intrusions, avoidance, and hyperarousal. Items are rated on a 5-point scale from 0 (“not at all”) to 4 (“extremely”). In the current sample, the IES-R had high internal consistency (Cronbach’s α = .89).

Complicated Grief Assessment Self-Report (CGA-SR), a widely used self-report, is based on the Inventory of Complicated Grief (Prigerson et al., 1995), and permits both diagnosis of complicated grief as well as a total intensity score (ranging from 9 = no symptoms, to 45 = extreme symptoms). Assessed are Criterion A (separation distress); Criterion B (other symptoms such as difficulty with the following: accepting the death, trusting others, experiencing feelings other than numbness, moving on; as well as feeling bitter, as though life were meaningless, as though the future holds no purpose, and on edge); Criterion C (impairment in functioning); and Criterion D (duration of symptoms greater than 6 months). In the current sample, the nine items assessing symptom intensity had high internal consistency (Cronbach’s α = .84).

Results

For these analyses, the DIS item scores were collapsed into a series of binary variables: (1) ever having the thought occur (monthly, weekly, or daily) vs. never having the thought occur; and (2) daily vs. less frequent occurrence of the thought (weekly, monthly, or never). The current study includes numerous statistical analyses, increasing the probability of a type 1 error. In keeping with the exploratory nature of the study, we used a conventional significance level of p < .05 when reporting statistically significant findings (instead of using a more conservative family-wise error rate).

Most (n = 121, 93.1%) participants reported having experienced at least one of the five DIS categories, and over half reported at least four of the categories (n = 67, 51.5%). Nearly half (n = 63, 48.5%) reported daily occurrence of thoughts or images in at least one of the DIS categories. As Table 3 shows, although most survivors reported at least some experience of thoughts related to re-enactment, rescue, reunion, and remorse, most denied ever experiencing thoughts of revenge (χ2(4) = 85.20, p < .001). Also, rescue thoughts occurred less than reenactment, remorse, and reunion.

Table 3.

Frequency of death imagery among survivors of violent loss who present for services.

Re-enactment (n=130) Rescue (n=127) Revenge (n=123) Reunion (n=129) Remorse (n=122)
None 24 (18.5%)a 56 (43.1%)b 77 (59.2%)c 33 (25.4%)a 30 (23.1%)a
1x/month 27 (20.8%) 19 (14.6%) 13 (10.0%) 29 (22.3%) 27 (20.8%)
1x/week 42 (32.3%) 31 (23.8%) 24 (18.5%) 26 (20.0%) 31 (23.8%)
1x/day 37 (28.5%)a 21 (16.2%)b 9 (6.9%)c 41 (31.5%)a 34 (26.2%)a
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Note. Numbers outside parentheses are ns; numbers in parentheses are percents of the total sample. Superscripts indicate the results of significance testing of differences in frequency among the different types of imagery; numbers in the same row with different superscripts are significantly different from each other whereas numbers in the same row with the same superscript do not differ from each other significantly.

As one might expect, all dimensions of the DIS were positively associated with depressive symptoms, intrusive thoughts, hyperarousal, avoidance, and complicated grief symptoms (see Table 4).

Table 4.

Associations between death imagery, BDI, IES, and CGA.

Item BDI IES intrusions IES avoidance IES hyperarousal CGA
Re-enactment .42*** (125) .55*** (125) .24** (126) .43*** (126) .47** (43)
Rescue .26** (122) .37*** (122) .18* (123) .24** (123) .12 (42)
Revenge .19* (118) .31** (118) .36*** (119) .39*** (119) .54*** (43)
Reunion .35*** (124) .34*** (124) .18* (125) .29** (125) .35* (43)
Remorse .51*** (117) .44*** (117) .24** (118) .37*** (118) .51** (40)
DIS average .44*** (125) .54*** (125) .35*** (126) .48*** (126) .65*** (43)
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*

p < .05

**

p < .01

***

p < .001

Time since loss was negatively associated with overall DIS scores (r = -.26, p = .003), reenactment (r = -.33, p < .001), rescue (r = -.20, p = .028), and remorse (r = -.31, p = .001). Time since loss was not significantly associated with DIS imagery of revenge or reunion, depressive symptoms, PTSD symptoms (intrusions, avoidance, hyperarousal), or complicated grief symptoms (ps > .10) although all associations were in the expected direction.

The most heavily represented relationship to the deceased was the parent (survivor) – child (deceased) relationship. Parents had higher DIS scores (M = 1.56) than non-parents (M = 1.24; F(1,127) = 4.86, p = .029, η2 = .04), but did not differ significantly on any of the five types of thoughts (ps > .10). However, parents were significantly more likely than other survivors to experience daily thoughts of reunion (43.1% of parents vs. 24.7% of other survivors; χ2(1)=4.80, p=.028), and remorse (43.5% of parents vs. 18.7% of other survivors; χ2(1)=8.69, p=.003). Interestingly, relationship to deceased (parent vs. non parent) was not significantly associated with BDI, IES intrusions, avoidance, and hyperarousal, or complicated grief symptoms (ps > .05).

A positive association was found between relationship quality with the deceased and thoughts of reunion (r = .29, p = .002), but relationship quality was not significantly associated with any other DIS item. Relationship quality was not significantly associated with DIS average, depressive symptoms, intrusive thoughts, avoidance, hyperarousal, or complicated grief symptoms.

The means of death was unrelated to frequency of death imagery for reenactment, rescue, reunion, or remorse. However, differences emerged among the three groups (i.e., homicide, suicide, and accident survivors) in the frequency of revenge-related thoughts (χ2(2)=8.40, p=.015). Follow-up tests indicated that, as one might expect, homicide survivors were significantly more likely to report thoughts of revenge (45.3%) compared to suicide survivors (14.8%; χ2(2)=7.91, p=.005). Means of death was not significantly associated with DIS average, depressive symptoms, intrusive thoughts, avoidance, hyperarousal, or complicated grief symptoms.

Individuals who reported seeing their loved one when he or she was injured were no more likely to endorse any of the five types of thoughts than individuals who did not see their injured loved one (ps > .10). However, individuals who reported seeing their loved one when he or she was injured were more likely to experience daily reenactment imagery (41.9%) than individuals who did not see their injured loved one (23.9%; χ2(1)=3.70, p=.05). A non-significant trend also emerged such that those who saw their loved one when he or she was injured were also more likely to experience daily thoughts of remorse (41.4%) than those who did not see their injured loved one (23.3%; χ2(1)=3.55, p=.06). Individuals who saw their loved one at the scene of the death or injury were no more likely than individuals who did not see their loved one at the death scene to endorse any of the five types of thoughts (ps > .10).

Discussion

Present results indicate that death images and thoughts are positively associated with depressive symptoms, a range of PTSD symptoms (intrusive thoughts, avoidance, and hyperarousal), and complicated grief symptoms in this sample of treatment-seeking survivors of violent loss. Most of these individuals whose loved one died violently experienced at least some form of death-related imagery. Even though most of these survivors did not see their loved one post-injury or at the death scene, they still had these thoughts and images. Further, those who did not see their loved one post-injury or at the death scene were just as likely as those who did to experience some form of death-related imagery. These bereaved individuals reported more reenactment, reunion, and remorse thoughts and images than rescue and revenge thoughts and images. These findings are consistent with previous research suggesting that reenactment imagery is associated with treatment seeking among violent loss survivors (Rynearson, 1995). Although reenactment is conceptually similar to intrusive thoughts and thoughts of reunion are at the core of complicated grief, remorse is not central to either condition, but such thoughts are still very common in this population, perhaps because violent death is perceived as preventable.

Death imagery seemed to dissipate over time, unlike PTSD, depression, and complicated grief symptoms. However, this finding supports previous research finding no differences in PTSD-related reexperiencing symptoms, depressive symptoms, or complicated grief symptoms among homicide survivors who were less than and more than two years post-loss (McDevitt-Murphy et al., 2012). Not all forms of death imagery assessed with the DIS, though, were associated with time since loss. Indeed, only reenactment, rescue, and remorse imagery were associated with time since loss such that more time since the loss was associated with less frequent death imagery. Evidence from neuroimaging studies suggests that yearning for a deceased loved one is associated with activation of neural reward pathways (O’Connor et al., 2008), which may in part explain the persistence of complicated grief – and thoughts of reunion specifically – over time. Similarly, revenge promises to reduce suffering by reducing the unfairness of the situation (Amick-McMullen et al., 1991) and in this way, may partially explain the persistence of revenge-related thoughts and images over time when other forms of thoughts and images subside.

The literature suggests that the loss of a child is associated with more intense distress than other losses of loved ones (Leahy, 1993-1994; Middleton et al., 1998). In the current study, however, parental status was not associated with higher scores on measures of PTSD, depression, or complicated grief. Bereaved parents were, on the other hand, more likely to report daily thoughts of reunion and remorse than were other bereaved individuals. This finding suggests that although the severity of distress overall may not distinguish parents from others in a treatment-seeking sample, parents’ thoughts and experiences may differ on some dimensions by virtue of their social role in the relationship to the deceased person. So, clinicians working with violently bereaved parents may benefit from ongoing assessment and discussion of these thoughts and experiences, as parents’ insight into factors sustaining reunion and remorse imagery may provide fruitful content for the therapeutic process. Furthermore, these results call attention to the need for future research into the association between death imagery and survivors’ relationships to the deceased.

Those who had more rewarding relationships experienced more thoughts of reunion, but not necessarily more PTSD, depression, or complicated grief. Notably, the range of relationship quality was relatively small, with a majority of the sample reporting generally positive and rewarding relationships with the deceased, thus limiting the range of variability in terms of relationship quality.

Predictably, survivors of homicide-related losses were more likely to report thoughts of revenge compared to survivors of suicide. The heightened desire for revenge in homicide survivors may be because there is an agent who intentionally inflicted harm on one’s loved one. Moreover, survivors may feel that the agent received less grave consequences than he or she deserves (i.e., consequences of insufficient magnitude to be a fair punishment for inflicting pain and suffering on the survivor’s loved ones; Amick-McMullen et al., 1991).

The current paper provides a look into the experience of death imagery in treatment-seeking survivors of violent loss, the population for whom the DIS was developed. Although items from both the relationship quality measure and DIS have been variously used in previous studies with adult and adolescent violent loss survivors (Rynearson, 1995; Rynearson, Favell, Belluomini, Gold, & Prigerson, 2006), the psychometric properties of these instruments have not been evaluated – a limitation of the current study. Treatment-seeking survivors of violent loss are likely more distressed than survivors who choose not to enter treatment (Rynearson, 1995); thus, the results of the current study may not be generalizable to violent loss survivors as a whole. The small sample sizes used in some of the comparisons (i.e., accident and suicide survivors, and individuals experiencing revenge-related thoughts) mean that those analyses must be interpreted with caution, and future studies incorporating larger samples of accident and suicide survivors into these comparisons may help clarify the nature of these associations. This study also relied on self-report data, which is subject to all of the biases inherent in self-report data. Moreover, this sample consisted predominantly of women, suggesting that further research is needed to better understand the frequency and experience of death imagery among men who survive a violent loss.

Despite these limitations, this study has several implications for clinicians and mental health professionals working with violently bereaved individuals. Many symptom inventories assessing PTSD, depression, and/or complicated grief do not ask about the particular content of death-related imagery. Thus, the DIS provides a richer picture than psychological symptom measures of the death-related thoughts and experiences of bereaved individuals who are seeking treatment following a violent loss. Clinicians might assess their clients for the presence of reenactment, revenge, remorse, rescue, and reunion thoughts as these may have implications for treatment planning and intervention. For example, according to the restorative retelling after violent dying treatment model (Rynearson & Correa, 2008), the goal of traumatic grief treatment is restorative – to restore a caring and meaningful role for the survivor in the narrative of a violent death they rarely witnessed. Because each of the fixating thoughts and images may produce a constrictive narrative direction and focus, restorative therapy deconstructs and widens the fixating focus to provide the survivor a more autonomous and meaningful role within the grieving narrative. Retelling may be amplified in grief therapy to include not only a dyadic retelling between therapist and survivor, but a triadic retelling between therapist, survivor, and the projected deceased person whose imaginary voice can serve as a catalyst for both deconstruction and reconstruction (Rynearson, 2012). This projected presence may be evoked through imaginary conversation, writing, and drawing with adults or play therapy with children. With the narrative now suspended and retold between the three voices there is rich opportunity for revision rather than extinction – to counterbalance the fixated thought or image through a series of open ended questions to all three voices in strengthening compensatory thoughts or images – with reenactment fixation (how might you have saved the deceased?), remorse fixation (how can you redeem yourself from your failed obligation to save your loved one?) or reunion (how can you begin to relinquish your identity with the deceased to establish your own revised identity?). So, better understanding the nature of survivors’ death imagery may help survivors and clinicians assess not only the survivor’s current level of distress but also suggest therapeutic strategies for coping with the debilitating traumatic thoughts and images of the violent dying and death of a loved one.

Acknowledgments

FUNDING

This research was supported by South Carolina Clinical & Translational Research Institute voucher award (NIH/NCRR#UL1RR029882, voucher #3013-5057 PI: Rheingold). Preparation of this manuscript was supported by the National Institute of Mental Health Training Grant T32 MH18869-26.

Appendix A

Death Imagery Scale

Below is a list of images reported after the death of a friend or relative (as thoughts or visual “flashbacks” [i.e., wide awake] or dreams while asleep). Please underline the type of types of imagery experienced and check their frequency within the last month.

Frequency
None Once/month Once/week Daily
1. Reenactment: I experienced a fantasied replay of the dying (as thought, visual “flashback”, dream).
2. Rescue: I experience a fantasy of rescuing the person from dying (as thought, visual “flashback”, dream).
3. Revenge: I experience a fantasy of retaliation for this dying (as thought, visual “flashback”, dream).
4. Reunion: I experience a fantasy of reunion with the deceased family member and/or friend (as thought, visual “flashback”, dream).
5. Remorse: I experience a fantasy that I should have somehow prevented the dying from happening (as thought, visual “flashback”, dream).
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Contributor Information

Jenna L. Baddeley, Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, South Carolina, USA

Joah L. Williams, Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, South Carolina, USA

Ted Rynearson, Separation and Loss Services, Virginia Mason Medical Center, Seattle, Washington, USA.

Fanny Correa, Separation and Loss Services, Virginia Mason Medical Center, Seattle, Washington, USA.

Connie Saindon, Survivors of Violent Loss Program, San Diego, California, USA.

Alyssa A. Rheingold, Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, South Carolina, USA

References

  1. American Psychiatric Association (APA) Diagnostic and statistical manual of mental disorders. 5. Washington, DC: Author; 2013. [Google Scholar]
  2. Amick-McMullan A, Kilpatrick DG, Resnick HS. Homicide as a risk factor for PTSD among surviving family members. Behavior Modification. 1991;15:545–559. doi: 10.1177/01454455910154005. [DOI] [PubMed] [Google Scholar]
  3. Baddeley JL, Singer JA. A social interactional model of bereavement narrative disclosure. Review of General Psychology. 2009;13:202–218. [Google Scholar]
  4. Beck AT, Ward CH, Mendelson M, Mock J, Erbaugh J. An inventory for measuring depression. Archives of General Psychiatry. 1961;4:561–571. doi: 10.1001/archpsyc.1961.01710120031004. [DOI] [PubMed] [Google Scholar]
  5. Carnelley KB, Wortman CB, Bolger N, Burke CT. The time course of grief reactions to spousal loss: Evidence from a national probability sample. Journal of Personality and Social Psychology. 2006;91:476–492. doi: 10.1037/0022-3514.91.3.476. [DOI] [PubMed] [Google Scholar]
  6. Kaltman S, Bonanno GA. Trauma and bereavement: Examining the impact of sudden and violent death. Journal of Anxiety Disorders. 2003;17:131–147. doi: 10.1016/s0887-6185(02)00184-6. [DOI] [PubMed] [Google Scholar]
  7. Leahy JM. A comparison of depression in women bereaved of a spouse, child or a parent. Omega: Journal of Death and Dying. 1993-1994;26:207–217. [Google Scholar]
  8. Lobb EA, Kristjanson LJ, Aoun SM, Monterosso L, Halkett GKB, Davies A. Predictors of complicated grief: a systematic review of empirical studies. Death Studies. 2010;34:673–698. doi: 10.1080/07481187.2010.496686. [DOI] [PubMed] [Google Scholar]
  9. Maciejewski PK, Zhang B, Block SD, Prigerson HG. An empirical examination of the stage theory of grief. Journal of the American Medical Association. 2007;297:716–723. doi: 10.1001/jama.297.7.716. [DOI] [PubMed] [Google Scholar]
  10. McDevitt-Murphy ME, Neimeyer RA, Burke LA, Williams JL, Lawson K. The toll of traumatic loss in African Americans bereaved by homicide. Psychological Trauma: Theory, Research, Practice, and Policy. 2012;4:303–311. [Google Scholar]
  11. Middleton W, Raphael B, Burnett P, Martinek N. A longitudinal study comparing bereavement phenomena in recently bereaved spouses, adult children and parents. Australian and New Zealand Journal of Psychiatry. 1998;32:235–241. doi: 10.3109/00048679809062734. [DOI] [PubMed] [Google Scholar]
  12. Murphy SA, Das Gupta A, Cain KC, Johnson LC, Lohan J, Wu L, Mekwa J. Changes in parents’ mental distress after the violent death of an adolescent or young adult child: a longitudinal prospective analysis. Death Studies. 1999;23:129–159. doi: 10.1080/074811899201118. [DOI] [PubMed] [Google Scholar]
  13. O’Connor M, Wellisch DK, Stanton AL, Eisenberger NI, Irwin MR, Lieberman MD. Craving love? Enduring grief activates brain’s reward center. Neuroimage. 2008;42:969–972. doi: 10.1016/j.neuroimage.2008.04.256. [DOI] [PMC free article] [PubMed] [Google Scholar]
  14. Patel T, Brewin CR, Wheatley J, Wells A, Fisher P, Myers S. Intrusive images and memories in major depression. Behaviour Research and Therapy. 2007;45:2573–2580. doi: 10.1016/j.brat.2007.06.004. [DOI] [PubMed] [Google Scholar]
  15. Prigerson HG, Maciejewski PK, Reynolds CF, Bierhals AJ, Newsom JT, Fasiczka A, Miller M, et al. Inventory of complicated grief: A scale to measure maladaptive symptoms of loss. Psychiatry Research. 1995;59:65–79. doi: 10.1016/0165-1781(95)02757-2. [DOI] [PubMed] [Google Scholar]
  16. Rynearson EK. Bereavement after homicide: A descriptive study. American Journal of Psychiatry. 1984;141:1452–1454. doi: 10.1176/ajp.141.11.1452. [DOI] [PubMed] [Google Scholar]
  17. Rynearson EK. Bereavement after homicide: A comparison of treatment seekers and refusers. British Journal of Psychiatry. 1995;166:507–510. doi: 10.1192/bjp.166.4.507. [DOI] [PubMed] [Google Scholar]
  18. Rynearson EK. Retelling Violent Death. Philadelphia: Brunner/Routledge; 2001. [Google Scholar]
  19. Rynearson EK. Invoking an alliance with the deceased after violent death. In: Neimeyer RA, editor. Techniques of grief therapy: Creative practices for counseling the bereaved. New York, NY: Routledge/Taylor & Francis Group; 2012. pp. 91–94. [Google Scholar]
  20. Rynearson EK, Correa F. Accommodation to violent dying: A guide to restorative retelling and support. 2008 Unpublished manuscript. [Google Scholar]
  21. Rynearson EK, Favell J, Belluomini V, Gold R, Prigerson H. Restorative Retelling with incarcerated juveniles. In: Rynearson EK, editor. Violent death: Resilience and intervention beyond the crisis. New York, NY: Routledge/Taylor & Francis Group; 2006. pp. 275–291. [Google Scholar]
  22. Rynearson EK, McCreery JM. Bereavement after homicide: A synergism of trauma and loss. American Journal of Psychiatry. 1993;150:258–261. doi: 10.1176/ajp.150.2.258. [DOI] [PubMed] [Google Scholar]
  23. Shear MK, Mulhare E. Complicated grief. Psychiatric Annals. 2008;38:662–670. [Google Scholar]
  24. Shear MK, Simon N, Wall M, Zisook S, Neimeyer R, Duan N, Keshaviah A, et al. Complicated grief and related bereavement issues for DSM-5. Depression and Anxiety. 2011;28:103–117. doi: 10.1002/da.20780. [DOI] [PMC free article] [PubMed] [Google Scholar]
  25. Stroebe W, Abakoumin G, Stroebe M. Beyond depression: Yearning for the loss of a loved one. Omega: Journal of Death and Dying. 2010;61:85–101. doi: 10.2190/OM.61.2.a. [DOI] [PubMed] [Google Scholar]
  26. Weinberg N. Self-blame, other-blame, and desire for revenge: Factors in recovery from bereavement. Death Studies. 1994;18:583–593. [Google Scholar]
  27. Weiss DS, Marmar CR. The Impact of Event Scale-Revised. In: Wilson JP, Keane TM, editors. Assessing Psychological Trauma and PTSD: A Practitioner’s Handbook. New York: Guilford Press; 1997. pp. 399–411. [Google Scholar]
  28. Zinzow HM, Rheingold AA, Hawkins AO, Saunders BE, Kilpatrick DG. Losing a loved one to homicide: prevalence and mental health correlates in a national sample of young adults. Journal of Traumatic Stress. 2009;22:20–27. doi: 10.1002/jts.20377. [DOI] [PMC free article] [PubMed] [Google Scholar]

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