Ellie shared the pain she felt with her therapist. “I’m the reason he died,” she whispered, eyes filled with guilt. As she clutched her own arm, it was clear that the weight of her husband’s recent death from a heart attack pressed heavily upon her. She believed that if she’d brought him to the hospital 20 minutes earlier, he’d still be alive. “I should’ve forced him into the car sooner, but he kept insisting the discomfort was nothing—that it was just something he ate.”
Ellie is stuck in what I call a prevention mindset, which is characterized by the belief that you can do something—or many things—to change a negative outcome. Because she continued revisiting a past that had already happened as if she’d failed to do the things that might have changed it, she was unable to move out of guilt and grief.
If Ellie had said to a friend what she’d said to her therapist, we’d be mortified if that friend had responded, “Well, yes, you should’ve gotten him in the car sooner. It’s your fault. You clearly caused his death.” In essence, this was what her own mind was doing to her in the midst of her grief. If you asked her how many times a day this happens, she’d probably pause, unsure about whether to reveal an embarrassing secret. Then, she’d have answered something like, “Thousands of times. People tell me not to blame myself, but I still do.”
Over the course of many years as a grief specialist, I’ve seen this agonizing mix of guilt and self-blame in countless clients. In fact, if a client has experienced the loss of a loved one, with or without trauma, I’d say there’s a 50 to 75 percent chance they’re assigning blame to themselves and ruminating about actions they took—or failed to take—before the loss. They’re wondering why they failed to pick up on details that seem, in retrospect, like glaring red flags, why they weren’t more proactive, didn’t trust their gut, call an ambulance, a hotline, a friend.
Now, imagine that Ellie’s well-meaning therapist unwittingly amplifies her looping guilt and emotional pain, not realizing how high the stakes are in a situation where a client is already blaming herself relentlessly. She does this by telling Ellie, in an attempt to be reassuring, “You did the best you could. We’ll never know if you could’ve saved him, so it’s not helpful to think that way.”
Perhaps the therapist comes from a family of medical practitioners and grew up hearing the mantra that getting to the hospital as soon as possible does save lives. From this prevention mindset, she might’ve said, “Look, Ellie, we’re all human, and humans make mistakes,” inadvertently reinforcing Ellie’s belief that her reaction to her husband’s complaints of discomfort did cause his death. Her seeming words of comfort would’ve normalized Ellie’s guilt as an accurate, appropriate reflection of reality. And if they continued to process the loss of Ellie’s husband from a prevention mindset, Ellie might live with excruciating, torturous guilt for far longer than she should, suffering needlessly over a loss she wasn’t responsible for.
Ellie’s therapist is genuinely trying to be helpful to her client, saying what sound like “normal,” rational things. And yet anything said to a client from a prevention mindset when they’re no longer in a prevention context won’t help. At worse, it will do harm, because the client is no longer able to prevent what happened.
What does Ellie’s therapist need to do to be genuinely helpful? She needs to shift out of a prevention mindset and have conversations from a postvention mindset.
Making the Shift
We’re all familiar with prevention language: Get to the hospital ASAP. Check in on your friends who may have self-harming thoughts. Get help for people struggling with addiction. Check your body for abnormalities that may be a sign of cancer. Test the batteries in the fire alarm.
But after a painful event, disaster, or death, we’ve left the context of prevention. We need a different language, a different approach. Postvention isn’t an intervention. It’s a radically different headspace focused on moving through what’s happened that can no longer be prevented or changed.
Joan, a therapist and client of mine, recently shared her struggle around suicide awareness month. Her son had died by suicide two years ago, and while she wanted to help other people avoid the devastation she was experiencing, she hated September and all the awareness campaigns that came with it. It made her feel confused and guilty. “How can I be upset about helping others?” she asked.
Suicide awareness month is a prevention context, I told her. In postvention, a person locates themselves psychologically and emotionally after an event has happened. It’s common for people in postvention to feel annoyed with prevention campaigns because, while they send an empowering message to those in a prevention space, they unknowingly send a message that’s often received as critical and blaming to those in a postvention mindset. It was a relief for Joan to hear me say this, as it released her from the guilt she felt for dreading what was clearly helpful for others.
Another client shared how guilty they’d felt about being angry at a fundraiser for cancer. They’d attended the event because their sister had given birth to a healthy baby boy a year ago and died of cancer six months later. My client had thought it would assuage some of their grief to attend a meaningful event that would help others. Yet they sat in the audience gritting their teeth as they heard one story after another from young mothers who’d been diagnosed with cancer and beat it. “I hated every single moment of that experience,” my client said. “My sister died while all these other young mothers lived. I was seething. I felt like a bad person.”
The cancer fundraiser was all about prevention. But my client was living in a postvention context. Breathing itself can feel different in postvention. Seeing, feeling, thinking—it’s all subtly but fundamentally different. The way you frame the past, present, and future as it relates to a loss becomes far more about surrender and acceptance than about sleuthing, heroism, determination, or taking initiative.
Understandably, people have a hard time making this shift. It is, after all, akin to a shift in the way we breathe. It doesn’t help that we live in a culture obsessed with prevention, which is perceived as a guarantee to save lives. Prevention, of course, is critical, but if it’s our sole focus, it can give us a false sense of control, which then comes crashing down on us when we enter a postvention context, and there’s no longer anything we can do to prevent a tragedy or a loss.
In our “just do it” culture, a postvention mindset is very uncomfortable. It requires vulnerability and deep humility. Many of us prefer to believe that if we can just do the right things, we’ll always avoid harm. But after a loss happens, discussions that draw on prevention principles and prevention language can interfere with healing. When I explain the importance of transitioning mindsets to my clients, and they begin to make the shift, they’re able to move into acceptance versus staying bogged down in guilt.
Good Postvention Helps Prevention
The mind consumed by trauma will always prefer feeling guilty to feeling helpless.
Our minds tend to grab onto anything to maintain the illusion of control. When we hear that someone died in a car accident, we immediately ask if they were wearing a seatbelt. That’s our mind, trying to make us feel better by thinking that if we always wear our seatbelts, we’ll always be okay. Of course, people who wear seatbelts die in car accidents too.
When I work with people experiencing guilt in the face of traumatic grief, I help them understand that guilt is a result of their mind grasping for a sense of control or power: “I could’ve prevented someone’s death.” In prevention, this sense of control can fuel someone to take protective, life-saving actions. Get a second opinion. Make sure your loved one takes their medication. Do all you can to ensure they show up to their doctor’s appointments. Encourage them to go to their 12-step meetings. But after a loss occurs, it’s time to think differently. That list of necessary actions no longer motivates, inspires, empowers, or helps. It keeps them stuck.
Framed like this, we can see how the language of postvention doesn’t undermine the need for prevention. In fact, good postvention helps prevention. My client Joan, having moved into a postvention mindset about her son’s death and thereby releasing her guilt, was able to volunteer for a local teen crisis center.
As humans, we’re mortal and vulnerable, we can’t control everything, nothing is guaranteed. As therapists, when we can segue between the prevention and postvention mindsets, one before a loss and one after, we can help more people.
Let’s go back to Ellie—only now, she’s with a therapist educated on postvention.
“I’m the reason he died,” Ellie whispered, eyes filled with guilt.
“Oh Ellie, I get how you might think that in our prevention culture,” her therapist responded. “That’s the message we all get—that we can somehow prevent all the bad events that happen in our lives and save the people we love. But this idea is an effort, a desire, a hope—not a guarantee. Let’s play out this alternate scenario together for a moment. What if you’d gotten your husband to the ER 20 minutes earlier? Would that have guaranteed his survival? My guess is we both know people who’ve made it to the ER on time and still died. And remember, you offered to take him, you encouraged him to go to the hospital. We’re not in charge of our spouses’ bodies or of their decisions. Your husband had a responsibility in this, too. That doesn’t mean what happened is his fault either. It’s not about blaming anyone. He thought he had indigestion. We can’t always know everything in every moment.”
Ellie looked thoughtful and said, “Everyone’s been telling me to move on because guilty thinking won’t bring him back. But the way you put it… my guilt doesn’t really make sense and it wasn’t helping anything.”
We hold separate prevention and postvention conversations all the time. We might tell someone, “It’s not a great idea to go to the ATM in the evening.” We’re talking prevention here. But if someone ends up going to the ATM late one night because they need cash and they’re assaulted, no decent person would ever say to them, “Well, it’s clearly your fault because you went to the ATM at night.” We’d switch to a postvention mindset and say, “I’m so angry this happened to you, my heart is aching, how can I help you?” If we don’t move into the language of postvention after something bad happens, we risk blaming the victim. Postvention avoids victim blaming because it relinquishes the illusion of power and control that characterizes prevention thinking. If you’ve moved into a postvention mindset, it becomes clear why saying to a mourner, “It’s such a shame he didn’t get to the hospital sooner,” is a terrible idea.
All of us stand to benefit from improving our ability to distinguish between prevention and postvention—and the types of conversations our clients need to have with us to move through grief. After an assault, many victims are told they were in the wrong place at the wrong time, when in fact, in postvention language, their perpetrator was in the wrong place at the wrong time, doing the wrong thing. In the case of a loved one who’s died, we no longer focus on alternate past realities, actions that weren’t taken, unsuccessful actions that were taken, or interventions that failed. This way, we can help clients move beyond guilt and self-blame and continue processing their loss and trauma in a healthy way.
ILLUSTRATION © PHOTOGRANARY
David Kessler, MA, RN, FACHE, is one of the world’s foremost experts on healing and loss. He’s the author of six bestselling books. His newest is Finding Meaning: The Sixth Stage of Grief. He coauthored two bestsellers with Elisabeth Kübler-Ross.