The Challenge of Restorative Retelling Following a Violent Death:
A Conversation with Edward Rynearson, MD
by Robert Zucker
Edward K. Rynearson, MD is Clinical Professor of Psychiatry at the University of Washington and Medical Director of the Homicide Support Project at the Virginia Mason Medical Center in Seattle, Washington. He brings thirty years of experience in research and clinical practice in helping grief-stricken family members. Rynearson is the author of Retelling Violent Death (Brunner Routledge, 2001), a groundbreaking new book that has already contributed significantly to the development of new treatment strategies for traumatized grievers. The book is brilliantly written - instructive, challenging, engaging and from the heart. It was a great experience to speak with Dr. Rynearson over the phone from his office in Seattle. Here is some of our conversation.
Zucker: You write that when we "avoid" following a traumatic death, our retelling can not begin, and when we become "possessed" by the trauma, our retelling cannot stop. These normal trauma-related reactions, you suggest, are somehow juxtaposed with our need and desire to reminisce and collect stories following the death of a loved one. While very often clinicians think of trauma work as a necessary precedent to grief work, your notion of trauma work in relationship to grieving seems to be richer, and perhaps more complicated.
Rynearson: I'm glad you had a chance to read my book because that means I have a chance to be a bit more pointed. I think I write primarily as a clinician. What I wanted to highlight in my book were some of the really difficult interchanges that you get into when somebody is not accommodating to the violent death of a loved one or family member.
When seeing somebody in the office for the first time, I'm not just being clinical, in terms of coming up with a diagnosis, because that doesn't help anybody. It doesn't help the family member and it certainly doesn't help the therapist. I think the only thing that gets satisfied is managed mental health. None of these DSM-IV R models have really much utility when you are dealing with this combination of trauma and grief, and the combination of trauma and grief is particularly intense after a violent death. With a PTSD reaction, the person in your office is struggling with something that's happened to them directly - something very aversive and irrational and something that needs to be denied and separated from. This is totally different because they're not only, at an identificatory level, going through an experience that's violent and aversive and needs to be denied, but in the same act, they've lost somebody that's terribly precious to them who they need to remain close to. So there's this push-pull going on dynamically after a violent death that doesn't go on when somebody's been raped or assaulted - unless its been by a trusted sort of figure or within the family. Do you see what I'm getting at?
The dynamics are much different, because they're not only dealing with a traumatic act, but they're dealing with a very vulnerable loss of someone they so desperately needed and who is connected to them. I think it is the attachment that is so pivotal in all of this.
Zucker: You write about the "calming therapeutic alliance;" the importance of fostering resilience; helping the client recall positive memories that preceded the death; helping the client interrupt unwelcome intrusive thoughts; and teaching relaxation skills. All of this seems geared towards helping the client regain a sense of control as well as to normalize very intense trauma responses. I sense that for some people, that work, in of itself, might be enough. Therapy might end there.
Rynearson: That's true.
I think there are abundant opportunities to do restorative work within the community - not nearly as much as there used to be. I think that probably a hundred years ago, when death and dying was much more a part of the fabric of our culture, there were a lot more opportunities to commemorate and to restore yourself, and much stronger belief systems too - even with a violent death. But I think in our contemporary socio-cultural matrix which is very fast-paced, and more ego-centric and more related to action and to the present, and not nearly as much oriented to belief systems that connect us with something more ultimate - it's much more difficult for contemporary families to retell this experience.
As you know, the vast majority of people never even come in and asks for help. Probably 90% or 95% of family members are able to work that out, and not just spontaneously. They also may have the support of other family members, spiritual beliefs, the ability to get re-engaged in an affirmative sort of way with their work, and they can celebrate some of these values of trust, intimacy, hope and confidence in the future. Then they are able to retell it.
Zucker: What brings that other 5% or 10% into therapy?
Rynearson: I think the thing that brings people into therapy is an internalized struggle with this unfinished narrative and imagery going on within them. My book tries to clarify what I think needs to be addressed with people that can't begin to tell the experience, and who can't stop telling themselves the experience. I think there is something bipolar about non-accommodation.
Most of the people that come in to see clinicians either can't stop telling themselves the primary reenactment narrative of the dying or they can't stop telling the secondary narrative of being remorseful, enraged or retaliatory. Or else they need to protect everyone around them or themselves. Those sorts of narratives, as I see it, are more primarily associated with the internalized presence of the person. They can't revise the sort of distorted relationship that they are forced to assume with that internalized presence.
This is not the time to get into a lot of past problems - examining where these vulnerabilities are coming from. Initially, you've got to help people accommodate and eventually they might come back and do that sort of (historic) work. But it is nothing to address at first. Most people who are coming in and asking for help are so traumatized in terms of these (trauma) images that it is like there is a war going on inside of them and they don't have enough energy to do a lot of the sort of therapy that most clinicians are used to doing.
Unfortunately, they often get involved with a therapist who begins to register on the traumatic aspect of the dying too quickly. They're going to resist this. They are going to avoid this. They are going to get up and walk out because they're not ready for it. With these vulnerable people, I think it is more important to be restorative and commemorative before you begin to get into either the dying imagery itself or their secondary relationship with the dying - feeling that they are all at fault or they somehow have to retaliate.
Zucker: You write about what you call "mutual retelling," a revising of the dying story that is essential to your work. That would, I would think, take traumatic grief to a different dimension. Your clinical work in this area grew out of your own grieving process following your wife's suicide twenty years ago. You write about your daughter's hope, at the time, that her mom would magically come back, and you describe how her restorative narrative eventually contributed to your own revising of the story of your wife's death.
Rynearson: That's right.
Zucker: Describe how you learned to work, as you write, "improvisationally," to help others discover their unique restorative process.
Rynearson: It has to be their story. They've got to retell it. You can't guide too much. You can't come up with rigid sort of protocols or assumptions that this or that is going on underneath this particular story and that they have to go in a particular sort of direction. That begins to go on, I think, as you (their therapist) become a part of the story, but it is always different. The only absolute in this sort of work is to get comfortable with ambiguity and not to assume that this has to go in a certain direction. Instead, I think the therapist needs to maintain engagement and at the same time a healthy sort of distance in order to be reassuring and normalizing. I think the therapist needs to be able to instill hope that there is something purposeful about all this, and that we are going to be able to, maybe not make sense out of the reenactment imagery, but be able to change each other as we're retelling the story together. The goal isn't to change the story. The goal is to retell ourselves as we retell it - in terms of changing our perspective and our role in it.
Zucker: When working with someone who has not yet revised their dying story, do you ever talk to them about what others have done to reshape their stories?
Rynearson: Yes. It is very important when you're working with someone who is highly traumatized to come up with clarifying sorts of thoughts and principles. Another thing that I often do is to begin asking projective questions that include the voice of the person who has died - as a helpful sort of presence. For instance, "How would ‘Ralph' help us at a time like this?" "What would ‘Ralph' think that you needed?" " How would ‘Ralph' feel about the sort of work we're doing?" So that you're not all alone with the person in terms of the retelling.
You want to become a spiritualist. We end up doing a kind of primitive work, assuming the role of a shaman to some extent. This isn't just trauma work in terms of dealing with the aversive experience. It is also restoring the soul of the person who has died. This kind of work has gone on for tens of thousands of years in families that have lost somebody violently. It is the people who have died violently who are the unhappy ghosts and they are the ones that come back to haunt us. Shakespeare and others have written about this, but even before things were written, they must have existed in the form of flashbacks and hearing their voices. It must have been, I assume, interpreted at a spiritual sort of level - as if to say, "I can't be quiet with my own spirit, because the soul of the spirit that has died violently is not at peace and is robbing me of my spirit." So spiritualists would, through use of mask or dance, reconnect with the spirit. And this still goes on in contemporary society. There are still spiritualists that families will call on at times like this to try to contact the soul of a dead person.
I don't believe in spirits, but I do believe that there is something going on in the sense of projection about all of this, and I believe in the importance of dealing with the projection in a positive way. If people have strong spiritual beliefs, I certainly don't discourage that. When they can reframe what is going on spiritually, and invoke the presence of the person that has died, people become able to restore themselves in the retelling. Children do this naturally.
Zucker: So often childhood magical thinking is viewed as something to correct and to get beyond as quickly as possible, but I think that what you're saying is that this is where the core work might begin - a child's natural inclination towards magical thinking can facilitate restorative work.
Rynearson: Exactly. It is focusing on that magical thought and internalizing it. And then, I think, as you're able to share that and to retell it, it begins to subside - it is no longer so magical or intense, because you've incorporated it at some sort of level. It has served a purpose. It is not the sort of thing that we need to take away from children or to pathologize.
Sitting-in on presentations with Bob Pynoos and Kathleen Nader and others who have done a tremendous amount of work with kids after a violent death, they always show the drawings that the children made and they are absolutely wonderful. So what I've ended up doing with adults is having them make drawings of their imagery and bring it in to treatment. Often they can't express what's going on in words - it's beyond words -so we often look at the imagery together as we do the retelling.
Zucker: I worked with a little boy who believed that he caused his brother's stomach cancer because he had once had kicked him in the stomach. I tried to help him understand that kicking his brother didn't make the cancer. But there is something, perhaps, that one might do to consider his wish for control and his longing to save his brother.
Rynearson: Then ask him: "How would your brother feel about my interpretation? Would he agree with what I'm suggesting?" Do you see what I'm saying?
Zucker: So after teaching the child what we know about what causes cancer, then I might ask him what his brother might say to him now about his worrying.
Rynearson: What a natural way for a child to reprocess this - in the story form - by invoking the other voice - even as you are working with this other material. I do the same thing with adults when they arrive at some sort of an impasse. "We're going too fast. We need to pull back from this. It's too threatening. (I think we) don't have to get into this until you can have more control over this or until we've done more commemorative work. But how would ‘Fred' feel about this impasse that we're at? What does he think is going on? Why does he think the story is so painful? How could he help us to retell it in a different way?"
So you do some shamanic, magical sort of work, recognizing all the while that it represents all of these strong sorts of projections that are going on. I listen to them and try to work with the projections in a positive way.
Zucker: You write: "If you're going to swim in the ocean, it is more important to know how to float than to swim." A through-line in your book seems to be use of the "water" metaphor. Do you find this to be a universal metaphor?
Rynearson: I think it is. I was just out rowing this morning. (laughter) I do it every day I can. How to stay on the surface... I think water is invoked in any kind of healing ceremony. All sorts of rituals involve water. It is a powerful sort of intermediary, I think... It is a powerful sort of boundary, also... it is something that allows you to dissolve things. There is something very magical about it. And that's how I feel when I'm in it, or on top of it ... I think that's one of the reasons it is so sustaining for me.