Novel Application of Skills for Psychological Recovery as an Early Intervention for Violent Loss: Rationale and Case Examples

Abstract

This article describes a novel application of Skills for Psychological Recovery – a brief, early intervention developed by the National Center for PTSD and the National Child Traumatic Stress Network – for families grieving the violent death of a loved one. Drawing on conservation of resources theory, Skills for Psychological Recovery, or SPR, incorporates cognitive-behavioral skills-building modules to help survivors cope with trauma-related distress and post-trauma resource loss. The authors describe the intervention and illustrate the use of SPR for violent loss by presenting data from two cases involving a suicide survivor and a homicide survivor. Implications for future research are discussed.

Recent national estimates suggest that over 50% of adults in the United States have, at some point during their lifetime, lost a loved one in a sudden, violent death (Kilpatrick et al., 2013). Of these sudden, violent deaths, the most common causes are motor vehicle crashes, suicide, and homicide, with risk for specific forms of violent dying varying by age, gender, and other sociocultural factors (Hoyert & Xu, 2012). Interdisciplinary research on violent death and dying has historically focused on identifying correlates of victimization (e.g., Centers for Disease Control and Prevention, 2014; Rodway et al., 2014) and, in the case of homicide, offending (e.g., Cook, Ludwig, & Braga, 2005), in part because this information can assist in the development and implementation of programs aimed at reducing rates of violent death. While vitally important, a narrow focus on victim and offender characteristics fails to capture the devastating impact that violent death can have on surviving family and friends of the deceased, a group for whom increased intervention efforts are strongly warranted.

Because of the sudden and often gruesome nature of violent losses, these deaths appear to have an especially deleterious effect on survivors, increasing risk for multiple psychiatric conditions across the lifespan (Keyes et al., 2014). Indeed, as many as 50% of violently bereaved persons experience bereavement-related mental health problems, most frequently in the form of major depression, with lower rates of posttraumatic stress disorder (PTSD) and prolonged, or complicated, grief disorder (PGD; Kaltman & Bonanno, 2003; McDevitt-Murphy, Neimeyer, Burke, Williams, & Lawson, 2012; van Denderen, de Keijser, Huisman, & Boelen, 2016; Zinzow, Rheingold, Hawkins, Saunders, & Kilpatrick, 2009). These conditions are often chronic, co-occurring, and associated with significant impairment in functioning (e.g., Williams, Burke, McDevitt-Murphy, & Neimeyer, 2012). Thus, given the scope of the problem and severity of its consequences, ensuring the availability of effective services for the violently bereaved is a public health priority.

In response to this public health priority, clinicians and researchers have developed individual (e.g., Pearlman, Wortman, Feuer, Farber, & Rando, 2014) and group-based interventions (e.g., Murphy et al., 1998; Rynearson, 2001) to address bereavement-related symptoms of PTSD, depression, and PGD in violent loss survivors. Encouragingly, recent evidence suggests that group-based interventions such as Rynearson's Restorative Retelling protocol (Rynearson & Correa, 2008) may be effective at reducing bereavement-related mental health problems. The Restorative Retelling intervention combines distress management skills like relaxation training with activities focused on commemorating the life of the deceased through sharing of positive memories and exposure-based drawings of death imagery to reduce traumatic stress symptoms. In one open clinical trial with 51 violent loss survivors seeking services from a community mental health clinic in southern California, Restorative Retelling was associated with reductions in PTSD, depression, and grief symptoms (Saindon et al., 2014). Results from a second open trial with 91 violent loss survivors seeking services from a medical center-affiliated grief counseling clinic similarly found that Restorative Retelling was associated with reductions in PTSD and depressive symptoms (Rheingold et al., 2015). In practice, however, manualized interventions like Restorative Retelling are not widely accessible to the majority of violently bereaved persons due to the relatively high cost and time commitment associated with implementing 10 to 25-session protocols. Moreover, even when evidence-based services are available, only a small minority of survivors actually engage in mental health treatment for bereavement-related mental health problems (Aguirre & Slater, 2010; Rheingold & Williams, 2015). Therefore, the majority of violent loss survivors may benefit more from brief, early intervention services that aim to prevent the worsening of psychiatric problems than from intensive interventions geared toward treating those same conditions several months or even years after their onset.

Developing and evaluating low-cost early interventions for violent loss survivors intuitively makes sense in that many survivors who report using external, community-based services do so in the first few weeks after the loss. In a sample of 112 homicidally bereaved family members, for example, Horne (2003) reported that survivors were more likely to use counseling, court advocacy, and case management services in the first 8 weeks after the loss than during the second 8 weeks. Survivors are also more likely to seek services from paraprofessional providers, such as chaplains and law enforcement victim advocates, than from mental health service providers (NFO Research, 1999; Rheingold & Williams, 2015), and, unlike mental health treatment protocols, many early interventions can be delivered by paraprofessionals without formal mental health training (National Institute of Mental Health, 2002).

In a commentary on responding to grief and trauma in the aftermath of disasters, Parkes (2015) notes that one of the major objectives of early intervention in situations involving violent loss is to ensure that vulnerable individuals are provided with appropriate help managing the precursors of psychiatric problems. Affectively and cognitively, these precursors may include anxiety and fear responses, helplessness, anger, shame, perceived social isolation, and/or guilt (Parkes, 2008). So, early intervention may include outreach from providers who recognize such precursors before a formal psychiatric condition emerges. Outreach, then, may include psychoeducation about common thoughts and feelings experienced in the aftermath of violent loss and skills training to teach survivors ways of coping with these reactions. One of the most rigorously designed studies to date evaluating an just such an early, preventive intervention for violent loss survivors was conducted by de Groot et al. (2007) evaluating a four-session, family-based, cognitive-behavioral intervention with suicide survivors delivered in-home by psychiatric nurse counselors between three and six months post-loss. Results of a cluster randomized controlled trial found that this intervention did not appear to have an impact on depression, suicidal ideation, or prolonged grief symptoms at 13 months post-loss. It is important to note that this intervention was designed to target family-level rather than individual-level problems and included fixed topics (i.e., cognitive restructuring and consolidation of support) and assignments in the first two sessions.

While there are no gold-standard, evidence-based early interventions for violent loss survivors, clinicians and researchers have offered recommendations regarding key intervention components likely to be useful in the context of an early intervention. Raphael and Wooding (2004), for example, proposed four domains for assessment and intervention in the context of early intervention for violent loss. These domains include: a) exploration of the circumstances of the death, b) a review of the relationship with the deceased, c) discussing aspects of the survivor's life that inform his or her response to the loss, and d) assessing changes and progress over time. The first domain – exploring the circumstances of the death – is recommended to help clinicians assess the bereaved person's perceptions about the deceased and their death, explore details about the circumstances of the death, and promote progressive exposure and desensitization to the traumatic aspects of the loss. The second domain – reviewing the relationship with the deceased – is recommended to assist survivors in addressing affects related to yearning for the deceased, including thoughts and feelings related to regret and guilt. The third domain – discussing aspects of the survivor's life that inform his or her response to the loss – addresses secondary stressors that may inhibit natural recovery from loss, such as available social support and practical needs. The fourth and final domain – assessing changes and progress over time – helps both clinicians and survivors monitor the trajectory of loss over time to determine whether additional services are indicated. Of note, these recommendations are in line with existing consensus guidelines in the field of traumatic stress more generally suggesting that trauma survivors may benefit from interventions that provide information, support, and skills to help address practical, immediate needs in the aftermath of a traumatic event (Litz, Gray, Bryant, & Adler, 2002). Moreover, these guidelines draw on conservation of resources theory in emphasizing that secondary stress associated with post-trauma resource loss, whether loss of a significant attachment figure, financial resources, or ability to engage in meaningful activities, can inhibit natural recovery and compromise an individual's capacity to cope with extreme stress and loss (Hobfoll, 1989; Hobfoll et al., 2007).

One relevant early intervention that meets these criteria is Skills for Psychological Recovery (SPR; Berkowitz et al., 2010). SPR is a structured, manualized intervention developed by the National Center for PTSD and the National Child Traumatic Stress Network that utilizes skills-building components from cognitive-behavioral treatments for trauma-related mental health problems to help facilitate recovery and enhance functioning in the aftermath of a traumatic event. These skills-building components include skills designed to enhance emotional and interpersonal functioning, ensure basic needs are met, and promote healthy coping. Unlike the intervention developed by de Groot and colleagues (2007), SPR is delivered on a one-to-one basis, and skills are taught on an as needed basis depending solely on the survivor's needs. That is, there are no fixed components delivered in a prescribed order. SPR is intended to help bridge the gap between the availability of acute support services such as those offered by first responders (e.g., crisis chaplains, law enforcement victim advocates) and mental health treatments for diagnosable mental health problems (see Figure 1). Preliminary work suggests that health practitioners trained in SPR generally rate the intervention as useful and generally express confidence in their ability to implement the intervention with appropriate training (Forbes et al., 2010). Whether SPR is generally viewed as helpful and acceptable by survivors who actually receive the intervention, however, has yet to be empirically explored. In the following sections, we describe the components of the SPR protocol in detail and provide two case examples to illustrate how the intervention can be implemented with survivors of violent loss.

Figure 1. Skills for Psychological Recovery in the bereavement-care continuum.

Note: Definitions of primary, secondary, and tertiary prevention adapted from Schut, Stroebe, van den Bout, and Terheggen (2001).

Method

In this section, we illustrate the use of SPR for traumatic grief by discussing two cases seen in a hospital-based mental health clinic providing specialty services to victims of violent crime and other forms of trauma. Both patients were over 18 years of age and had experienced the sudden, traumatic death of a loved one within the past three months. Here, both individuals received SPR in five, 50-minute sessions and were seen by the first author. Both authors are licensed clinical psychologists who completed a full-day workshop on the delivery of SPR provided by two of the protocol developers. Patients were assessed pre- and post-intervention for symptoms of PTSD, depression, and PGD. Identifying information has been removed to protect anonymity.

Measures

Posttraumatic Stress Disorder (PTSD)

PTSD symptoms were assessed using the National Stressful Events Survey PTSD Module (NSES; Kilpatrick, Resnick, Baber, Guille, & Gross, 2010), a 20-item self-report measure of PTSD symptoms that correspond to the DSM-5 criteria for PTSD (American Psychiatric Association, 2013). For each item, participants rate how much they have been bothered by a particular symptom in the past month using a five-point Likert scale adapted from the PTSD Checklist (PCL; Weathers et al., 1993) where scores range from 1 (“not at all”) to 5 (“extremely”). The NSES PTSD Module was found to have excellent reliability (α = .94) in a sample of U.S. adults with DSM-5 defined PTSD (Miller et al., 2013) and demonstrated good test-retest reliability in the DSM-5 field trials (Regier et al., 2013).

Depression

Depression was assessed using the Beck Depression Inventory – II (BDI-II; Beck, Steer, & Brown, 1996). The BDI-II is a 21-item self-report measure of depressive symptoms where each item is assessed on a four-point Likert scale ranging from 0 to 3, with higher scores indicating greater depressive symptomatology. The BDI-II has demonstrated good psychometric properties in traumatically bereaved samples (e.g., McDevitt-Murphy et al., 2012).

Prolonged Grief Disorder (PGD)

PGD symptoms were assessed using the Prolonged Grief 13 (PG-13) scale (Prigerson et al., 2009). The PG-13 includes 13 items, 11 of which assess the past month frequency and severity of PGD symptoms. Items are rated on a five-point Likert scale ranging from 1 (not at all/never) to 5 (several times a day/overwhelmingly). The PG-13 has demonstrated excellent internal consistency and test-retest reliabilities in bereaved samples (e.g., Supiano & Luptak, 2014).

Intervention Components

SPR aims to teach survivors five core skills intended to help reduce ongoing distress and manage post-loss stressors. These skills include: (1) building problem-solving skills, (2) promoting positive activities, (3) managing physical and emotional reactions to upsetting situations, (4) promoting helpful thinking, and (5) rebuilding healthy social connections. Skills are taught in a flexible manner depending on a survivor's specific needs. To that end, the first step in SPR is to gather information about current needs to determine whether referral to other services is needed and prioritize SPR intervention strategies. The SPR protocol includes a structured screening form to help clinicians assess survivors' needs and concerns across multiple domains, including physical and emotional difficulties, substance use, and role and interpersonal functioning. After identifying and prioritizing specific problem areas that can be addressed with the clinician, clinicians and survivors work collaboratively to select SPR skills that may be most useful in addressing specific problems. Because many survivors are only available for one or two contacts at most, SPR skills are organized into stand-alone modules that can be delivered individually or in combination with other modules, although expert consensus suggests that three to five sessions are needed for optimal skill acquisition and behavior change (Berkowitz et al., 2010). The full protocol with core SPR skill modules, handouts, and worksheets is available online at www.ptsd.va.gov/professional/manuals/manual-pdf/SPR_Manual.pdf. Note that all handouts referenced in the case examples are available in the manual.

Problem-Solving Skills

Because ongoing, secondary stressors associated with traumatic events and violent loss in particular can be overwhelming for survivors, developing effective problem-solving skills to address these stressors can help survivors regain a sense of control and self-efficacy. Survivors are taught four steps to effective problem-solving. In Step 1, survivors are taught to clearly define the problem and, in Step 2, to set goals with regard to what they want and need in the problem situation. Step 3 involves brainstorming options for meeting the goal defined in Step 2. After identifying multiple options, survivors are taught to evaluate each option based on the likelihood that each option will achieve the desired outcome and then choose a solution in Step 4. A worksheet guiding survivors through each step of effective problem-solving is available in the SPR manual.

Promoting Positive Activities

Helping survivors identify and engage in positive activities can be especially helpful for those with ongoing disruptions in daily routines and/or those survivors with little involvement in pleasant activities. In this module, survivors are taught to identify and plan pleasant, meaningful activities and are provided a Promoting Positive Activities handout to help them identify specific activities that are personally meaningful. After identifying personally relevant activities, clinicians work with survivors to plan and schedule activities to enhance mood and sense of control.

Managing Reactions

Many, if not all, survivors experience some distressing physical and emotional reactions to reminders of traumatic loss, and the managing reactions module aims to provide survivors with psychoeducation about common reactions to trauma and loss as well as adaptive and maladaptive strategies for managing these reactions. Survivors are also taught to identify distressing reactions and their triggers and are provided practical skills to help reduce distress. Specific strategies for helping survivors manage distressing reactions include breathing retraining, writing exercises that guide survivors to articulate thoughts and feelings about the traumatic event, and creating plans to deal with distressing triggers.

Promoting Helpful Thinking

The promoting helpful thinking module aims to guide survivors toward more helpful, less distressing ways of thinking that are thought to maintain trauma-related negative emotions. In this module, survivors are first taught to identify unhelpful thoughts contributing to negative emotions (e.g., “I should have been able to stop my loved one from dying.”) and are then guided through a series of exercises to help them identify more positive, helpful thoughts. A Helpful Thinking worksheet can be used to help survivors identify and challenge unhelpful thoughts. After identifying helpful thoughts, survivors are taught to rehearse helpful thoughts in order to reinforce actively replacing negative thoughts with more positive thoughts.

Rebuilding Social Connections

Social support is a well known buffer against traumatic stress symptoms. Because social support networks are often disrupted following traumatic events, especially in cases of traumatic loss where the death involves the loss of an important attachment figure, the building social connections module aims to help survivors identify individuals immediately available in their support network and the kind of support each person is able to provide (e.g., instrumental, emotional support). After reviewing the survivor's social network, clinicians work with survivors to help them create a social support plan to obtain additional supports as needed.

Case Examples

Ms. S

Ms. S was a married Caucasian female in her mid-50s who was seen for early intervention 19 days after her son was reported missing in an apparent suicide after his car was found abandoned on top of a local bridge. She was self-employed as a tour guide and had not returned to work since her son's disappearance. Due to the recency of her loss, her presentation was consistent with a diagnosis of Uncomplicated Bereavement. Reported symptoms of bereavement included feeling “shocked” about her son's disappearance, intense yearning for her son, and anxiety symptoms associated with intrusive reenactment imagery of what was believed to be her son's dying moments. To help her manage these symptoms, Ms. S reported taking Xanax given to her by a family member daily.

During our first session, we completed a SPR screening form to assess problem areas most important to Ms. S, and she identified emotional difficulties as her primary concern, explaining that she felt intense symptoms of “anxiety” when exposed to triggers of her son's apparent suicide. After identifying emotional difficulties as her most pressing concern, we discussed the rationale for completing the managing reactions module. We also discussed common reactions to trauma and loss, and Ms. S was provided with psychoeducational handouts (included in the SPR manual) describing common responses to trauma and loss. In addition, Ms. S was provided psychoeducation on helpful and problematic ways of coping with distressing reactions, including problems associated with post-loss substance use. We also completed a Managing Reactions Worksheet that helped us identify specific, upsetting triggers and coping strategies relevant to managing cued distress. She reported that the most upsetting trigger was seeing the bridge where her son's car was found. Working collaboratively, she decided that, when emotionally or physically upset by seeing the bridge, she could physically touch an amethyst that she wore around her neck that reminded her of her son and say aloud to herself, “I want to be a better person like he was.”

Following our initial meeting, Ms. S's son's suicide was tragically confirmed when his body was recovered from a nearby waterway. In our second session, we continued to focus on skills for managing distressing reactions, and we specifically discussed the rationale for breathing retraining as a strategy for managing distressing reactions given that she was reporting increased physiological symptoms of anxiety. We practiced breathing retraining in session, and she was also provided with a handout describing the steps involved in calm breathing. Ms. S also noted in this session that her work as a tour guide generally helped her manage stress and so stated that she would like to begin working again on a limited basis within the month. Along with managing distressing reactions, Ms. S and I also discussed how individuals in her social support network were supportive following her son's death, and she reported that she had an extensive network of family and friends who had provided her with emotional support. She mentioned, however, that she wanted more grief-specific support from others who had lost loved ones to suicide, and, in line with the rebuilding social connections module, she was provided with information about an area suicide support group.

Because Ms. S reported that she would like to return to work but also expressed concern about her ability to function at work given her emotional distress, we decided to use problem-solving skills to help her identify the best strategy for returning to work without feeling too emotionally overwhelmed and, thus, primarily focused on teaching problem-solving skills in the two sessions that followed (sessions three and four). As we discussed her plan to return to work, Ms. S realized that many of her colleagues and friends in the community were unaware of her son's death and would casually ask about him in conversation. Moreover, others who were aware of her son's death occasionally made comments that Ms. S perceived as unhelpful and upsetting. To address this issue, Ms. S and I used a Problem-Solving Worksheet to brainstorm strategies for responding to others when they asked about her son and/or offered unhelpful, grief-related comments (problem definition). She recognized, however, that most unhelpful inquiries and comments from others were well-intentioned, and she wanted her responses to others to be respectful (goal). So, we brainstormed possible ways of responding to others' inquiries when she did not want to continue the conversation, and she decided that one possible way of responding respectfully (choosing a solution) could be to say, “We lost him. I'd prefer not to talk about it right now, but thank you for your support.”

During sessions three and four, additional Problem-Solving Worksheets focused on how to improve role functioning at work without using Xanax. As a solution, Ms. S decided to delay taking Xanax if she felt anxious at work and instead use coping skills discussed in sessions one and two (e.g., touching the amethyst she wore around her neck; engaging in positive self-talk; calm breathing) rather than take Xanax before work in anticipation of feeling anxious. By our fifth and final contact, she reported successfully working without taking any medications and reported that she was increasingly engaging in positive activities with family and friends, explaining that, after losing her son, she wanted to spend as much time with loved ones as possible. We reviewed skills discussed in previous sessions and wrote these down on a Preventing Setbacks Worksheet. Moving forward, Ms. S stated that she planned to continue attending a local suicide survivor support group, and she also expressed interest in individual, supportive counseling, and I provided her with a referral for supportive counseling. Overall, she reported that she felt better prepared to manage her grief, and her self-reported improvement was supported by decreases on all three symptom measures (see Figure 2; NSES: pre = 34, post = 29; BDI-II: pre = 13, post = 5; PG-13: pre = 27, post = 22).

Figure 2. Pre-post scores on measures of bereavement-related mental health problems.

Note: NSES = National Stressful Events PTSD Module; BDI-II = Beck Depression Inventory – II; PG-13 = Prolonged Grief 13 Scale.

Ms. Y

Ms. Y was a single African American female in her late 40s who was seen for early intervention six weeks after her niece and ex-sister-in-law were killed in a double murder/suicide by her niece's boyfriend. She worked at a school and had already returned to work in order to financially help provide for her niece's three children, who were in her care following their mother's death. She was also actively working towards a doctorate in education. As with Ms. S, her presentation was consistent with a diagnosis of Uncomplicated Bereavement, and she reported symptoms including recurrent reenactment imagery of her niece and sister-in-law's deaths (note, she was not present at the death scene but was familiar with details about their deaths because of media reports about the event). Ms. Y also reported that her niece's children were unaware of how their parents and grandmother died, and she reported secondary stress associated with concerns about how to talk with the children about the circumstances surrounding the deaths.

During our first session, we completed a SPR screening form to assess problem areas most important to Ms. Y. Although she reported concerns about emotional difficulties related to her loss, her primary concern was how to talk with the children about the nature of their mother and grandmother's deaths. Because she was unsure how to have this discussion with the children, we decided to use problem-solving skills to brainstorm how to have this conversation with the children. Thus, sessions one and two primarily focused on brainstorming ways to talk to the children about their parents' and grandmother's deaths using Problem-Solving Worksheets. Ms. Y was also provided with psychoeducational handouts on common grief reactions during our first session. Ms. Y brainstormed several strategies, including talking to the children individually or with her clinician as well as talking to the children with or without other family members present.

During our third session, Ms. Y reported successfully using problem-solving skills to help her decide how to best talk to the children about the deaths, but she also reported that talking about the deaths would likely trigger intense emotional distress for her given that she was experiencing recurrent reenactment imagery of the death scene. So, in addition to problem-solving skills, we decided to complete the managing reactions module to help her develop effective strategies for coping with distress associated with trauma-related imagery. In session, we discussed the rationale for calm breathing as a strategy for managing distress and practiced a calm breathing exercise together. We also discussed the potential benefits of writing about her thoughts and feelings related to the deaths, and she was provided with handouts describing the steps involved in calm breathing and suggestions for structuring writing exercises. We completed a Managing Reactions Worksheet to consider how these strategies may be helpful during specific stressful situations like talking with her niece's children about their parents' and grandmother's deaths.

We continued to review skills to help manage reactions during our fourth session, and she reported successfully using calm breathing in response to several stressful situations, including talking, along with other family members, to her niece's children about the deaths. As we discussed stressful situations, she mentioned that her birthday was later that week, and she anticipated that this would be an especially difficult trigger for her given that her niece would not be able to celebrate with her and her family. We discussed coping strategies that would be helpful if she experienced distress on her birthday, and we also discussed helpful thinking skills in the context of her anticipated distress. In discussing helpful thinking skills, we reviewed how thoughts influence feelings, worked to identify potentially unhelpful thoughts (i.e., “I know I will become upset.”), and collaboratively identified helpful thoughts to replace the unhelpful thoughts (i.e., “I will be with family and may actually enjoy my birthday,” “If I do get upset, I have skills to help me manage my distress.”).

In our final session, we reviewed skills practiced during previous sessions. While she reported some improvement in emotional difficulties related to her losses, she stated that she still occasionally felt “overwhelmed” trying to manage occupational, familial, and educational stressors. Because she reported feeling overwhelmed, we discussed the importance of trying to engage in personally relevant, pleasant activities to help her feel more relaxed. Her schedule and family responsibilities, however, left her with limited time to engage in many preferred activities, so we used problem-solving skills to brainstorm pleasant activities that could help her relax and fit into her schedule (e.g., listen to a favorite CD in the car on the way to work, call a cousin in the evenings for emotional support). We also completed a Preventing Setbacks Worksheet and identified warning signs and triggers of intensifying personal distress and reviewed specific skills that could be useful if she encountered these triggers. Improvement was noted on a self-report measure of grief symptoms (PG-13: pre = 30, post = 24) though symptoms were largely unchanged on measures of PTSD (NSES: pre = 35, post = 33) and depression (see Figure 2; BDI-II: pre = 14, post = 18). She attributed her depressive symptoms, however, to coping with educational stressors, as she was completing final exams at the time of her final session.

Discussion

This paper describes a brief, manualized early intervention – Skills for Psychological Recovery – and illustrates its applicability to survivors of violent loss. SPR is a skills-based intervention that aims to reduce ongoing distress by helping survivors utilize problem-solving skills to systematically solve trauma-related problems, develop coping skills to manage trauma-related distress, increase engagement in pleasant activities, promote helpful thinking, and increase social support. Skills are utilized as needed and, as such, the intervention is idiographic in the sense that it is tailored to the unique needs and circumstances of each survivor. The intervention draws on previous theoretical work on the development of early interventions for trauma and loss suggesting that secondary stress associated with post-trauma resource loss can inhibit natural recovery and exacerbate symptoms (e.g., Hobfoll et al., 2007) and, thus, is intended to help address secondary stressors and enhance natural coping. In this way, SPR can be distinguished from other early intervention models, such as Critical Incident Stress Debriefing (CISD; Mitchell & Everly, 1996), which has, in some cases, demonstrated harmful effects in trauma survivors (Bisson, McFarlane, Rose, Ruzek, & Watson, 2009). SPR is also different from CISD in that CISD is offered in a group format, which has drawn criticism from some clinicians and researchers who argue that group expectations regarding the disclosure of personal information in CISD sessions may leave trauma exposed individuals feeling pressured to disclose said information, potentially resulting in harmful consequences (Young & Gerrity, 1994). In contrast, SPR recognizes that disclosure of personal information related to a traumatic event may or may not be a priority for some survivors and is done so only once other, pressing needs are addressed or as prioritized by the survivor.

In addition to drawing on theoretical work on the development of early interventions for trauma, SPR reflects current conceptualizations of bereavement as a “dual-process” of loss and restoration (Stroebe & Schut, 1999). That is, coping with bereavement generally involves alternating between loss orientation where one focuses primarily on emotional aspects of the loss and/or the events that occurred before and at the time of death and restoration orientation where one focuses primarily on efforts to manage secondary stressors associated with the loss. Given that individuals may oscillate between loss and restoration-oriented coping at different times throughout the bereavement process, SPR allows providers to flexibly select skills relevant to a survivor's immediate orientation. Survivors actively confronting emotional responses to mental images of a loved one's death, for example, may benefit from writing exercises that aim to help them make sense of their feelings (an active component of the managing reactions module). On the other hand, those primarily focused on restoration-oriented processes, such as learning to manage the finances or independently care for school-age children, may benefit more from problem-solving or other restoration-oriented skills.

In the two cases presented, both individuals reported a positive response to the SPR intervention. Both survivors reported decreases in grief symptoms as evidenced by improvements on our measure of prolonged grief symptoms. In the case of Ms. S, improvements were observed on measures of PTSD and depressive symptoms as well, although, in the case of Ms. Y, scores on the PTSD measure were mostly unchanged with some slight increase in depressive symptoms. It is important to note, however, that Ms. Y attributed her increase in depressive symptoms to stress associated with attending graduate school. In the absence of a rigorously controlled randomized clinical trial, we certainly cannot conclude that any reported changes were the result of the intervention any more than the natural passage of time. Moreover, follow-up data was not available for these cases. These pre-post improvements are encouraging, though, and call for more rigorous research on the short and long-term impact of this promising early intervention model.

These cases also raise important questions for future study. Differences in response to the SPR intervention across observed symptom domains in these two cases may be the result of a number of different factors, but one question is whether the SPR intervention targets some symptoms (e.g., grief symptoms) more effectively than others (e.g., trauma symptoms). Furthermore, both Ms. S and Ms. Y reported some improvement in overall functioning while receiving the intervention. For example, Ms. S returned to work, and, indeed, improving occupational functioning was a specific intervention goal in the case of Ms. S. Thus, future research should also explore whether the SPR intervention helps improve health-related functioning in recently bereaved survivors. Because one goal of SPR is to link survivors to community-based services and providers to help improve mental and physical health functioning where such a need exists, future research should further evaluate whether SPR promotes more rapid utilization of community health services.

Another question is whether potential intervention effects are moderated by type of loss (i.e., homicide, suicide, accident). Here, Ms. S – a suicide survivor – reported improvements on all symptom measures although Ms. Y – a homicide survivor – reported improvements on the measure of prolonged grief symptoms only. While previous research suggests that type of loss does not appear to moderate treatment response, at least in the context of tertiary interventions for bereavement-related mental health problems (Rheingold et al., 2015), it is not clear whether a similar pattern of responding could also be expected in response to early intervention. Furthermore, other moderating factors observed in previous research with violent loss survivors (e.g., Rheingold et al.) worth investigating in future research on SPR and other early interventions include gender and relationship to the deceased (e.g., parental vs. non-parental bereavement).

In both cases described in this paper, the intervention was delivered by a licensed clinical psychologist. An advantage of the SPR intervention, though, is that it can be delivered by trained paraprofessionals who work directly with trauma survivors. Thus, future efforts to evaluate the effectiveness of early interventions like SPR should include paraprofessional interventionists to help determine the real-world applicability of these approaches.

In conclusion, SPR is a novel, early intervention for trauma survivors that can be easily tailored to the needs of violent loss survivors. These case examples represent an important first step in demonstrating the feasibility and acceptability of SPR for violently bereaved families. In building on this first step, we hope that the cases discussed herein encourage future efforts to explore these and other questions about the community effectiveness of SPR and early interventions for survivors of violent loss.