Understanding Children’s Grief: An Overview for Counselors

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Transcript of Understanding Children’s Grief: An Overview for Counselors

Front Matter TemplateThe Report Committee for Jessica Leigh Swope
Certifies that this is the approved version of the following report:
Understanding Children’s Grief: An Overview for Counselors
APPROVED BY
SUPERVISING COMMITTEE:
Deborah Tharinger
Allyson Jervey
by
The University of Texas at Austin
in Partial Fulfillment
of the Requirements
May 2011
by
Supervisor: Deborah Tharinger
ABSTRACT
The current report reviews the literature on grief manifestations in children.
Definitions of grief terminology and current models of adult grief are covered to give the
reader a foundational knowledge on grief. Unique manifestations of grief, developmental
needs, and tasks for reconciliation with children are explored. Finally, a sampling of
current interventions used with bereaved children is included.
iv
Kubler-Ross: Stages of Grief ..........................................................................9
Shattered Assumptions..................................................................................15
Reactions to Loss ..........................................................................................18
Key Elements of Grief Intervention ..............................................................26
Narrative Therapy .........................................................................................26
Expressive Therapies ....................................................................................29
Music Therapy .....................................................................................29
Conclusion .............................................................................................................38
References ..............................................................................................................39
vi
1
INTRODUCTION
It is important for counselors to have a thorough understanding of grief to
adequately conduct therapy with children. The topic of death can make many adults
uncomfortable, causing them not to discuss the issue with children. Not allowing children
to process their reactions may lead to unhealthy coping mechanisms (Farber & Sabatino,
2007; Heath et al., 2008). Counselors should become educated in the manifestations and
progression of grief in adults and children and research interventions that can be used
with children struggling with their bereavement.
Grief is a person’s thoughts and feelings associated with the loss of a loved one
(Bonanno & Kaltman, 2001; Heath, et al., 2008). Grief manifests itself in a variety of
subtle or more obvious ways. These can include physical reactions such as aches and
pains, affective manifestations including anger and guilt, cognitive manifestations such as
depersonalization, spiritual manifestations such as struggling with one’s faith, and
behavioral manifestations like crying or withdrawing (Cohen & Mannarino, 2004;
Kastenbaum et al., 2002). Many mourners receive assistance in working through their
losses by turning to grief counseling. This counseling method can be provided
individually or in a group format by psychologists, clergy, counselors, or social workers
(Higgins, 2009; Wolfe, 2002).
A person who has suffered the loss of a loved one may experience a wide variety
of symptoms. He or she may have feelings of sadness, anxiety, anger, loneliness, guilt,
relief, isolation, confusion, or numbness (Kastenbaum, et al., 2002; Wolfe, 2002). The
person may express all or only some of these feelings. After a loss the person may
2
become disorganized, feel tired, have trouble concentrating, endure sleep problems, have
appetite changes, encounter vivid dreams, and/or daydreams about the loved one (Pakes,
2008; Wolfe).
In understanding significant losses from a theoretical perspective, the leading
experts tend to subscribe to particular models of grief. Kubler-Ross’s stages of grief are
popular among counselors and the general public. This model was revised during the
Yale Bereavement Study (Maciejewski, Zhang, Block, & Prigerson, 2007). Psychologist
Rando created another model of understanding grief: the six “R” processes that a
mourner must complete to achieve healthy mourning (Rando, 2002; Solomon & Rando,
2007). The Dual Process Model was created to explain the bereaved’s struggle with their
past identity and their new identity (Swan & Scott, 2009). The Shattered Assumptions
Model expounds upon many models by describing the sense of traumatic confusion felt
by many grievers. These models are discussed in detail within this paper.
Some researchers believe that children hold unrealistic ideas about death and have
more complicated forms of grief than adults (Auman, 2007). Since children are not fully
cognitively developed, experts suggest that as children grow older and reach higher levels
of functioning, they need to reprocess their grief (Kraus & Monroe, 2005; Selekman,
Busch, & Kimble, 2001). As a result, children may be in counseling to assist in healing
wounds from a death that may have occurred years earlier.
Significantly, children have their own unique response to experiencing loss
(Coleman, 2009; Robson, 2008). Depending upon their developmental stage, their
understanding and expression will be different (Eppler, 2008; Kraus & Monroe, 2005). It
3
is important for counselors to become familiar with developmentally appropriate
responses to grief, which are discussed in a later chapter.
A grief reaction can be elicited in a child by a wide range of events. A child can
have intense grief reactions to the loss of a loved one or pet, a disruption of familiar
living situations, or traumatic events (Betz & Thorngren, 2006; Cohen & Mannarino,
2004). A disruption of familiar living situations can include divorce, family financial
difficulties, or frequent moves (Heath, et al., 2008). These disruptions are sometimes
caused by a death. For example, the death a parent can result in the depletion of
monetary resources and/or the relocation of the surviving family members. This can
compound the grief experienced by the child (Heath, et al.). Clearly, grief can be
brought on by many events. For the purposes of this paper, the grief following the death
of a loved one will be focused upon.
There are multiple approaches to grief counseling with children. Narrative
therapy is used to help children to restructure their stories (Degges-White & Davis,
2010). Therapists help children externalize their anxieties surrounding the loss and create
alternative narratives (Betz & Thorngren, 2006; Salloum, Garside, Irwin, Anderson, &
Francois, 2009). Counselors work with bereaved children in support groups that allow
for the expression of emotions through a variety of methods (Heath, et al., 2008). Group
therapy can also be delivered as a camp based intervention where longer sessions can be
conducted in close succession. Research has been conducted on expressive therapies,
which have evidence of being an adequate alternative to talk therapy (Dalton & Krout,
2005; Williams & Lent, 2008). A few examples include, but are not limited to, music
4
therapy, scrapbooking therapy, art therapy, and play therapy. In chapter 4, this paper
dissects these in order to give counselors a better understanding of interventions available
to grieving children.
Counselors using grief therapies developed for children, aim for specific
outcomes. Counselors facilitate children’s struggle to accomplish reconciliation
(Wolfelt, 1995). By working through tasks, this paper later describes, children come to
accept the reality of the loss, redefine themselves without their loved one, and build and
strengthen new and existing supportive relationships (Cohen & Mannarino, 2004). When
working with children, counselors may use a variety of activities that allow them to
experience their emotions, highlight their support systems, and memorialize the missing
loved one (Cohen & Mannarino; F. B. Wood, 2008).
This report will look at grief counseling from multiple perspectives. First, a brief
overview of the grief literature to explain and define grief terms and concepts is
presented. The content subsequently transitions to focusing on adult models of grief. A
review of the ways in which children experience grief and the stages they experience,
including the relevant research that has been conducted follows. Finally, a sampling of
different grief therapy techniques and approaches used with today’s children is provided.
This paper intends to educate counselors on grief in an effort to make this topic more
comfortable for them to broach while working with children.
5
Chapter One: Grief Overview
Many terms are important to understand and clarify when discussing grief.
Within the literature there are discrepancies regarding word definitions. The definitions
for the purposes of this report are defined and described below. In addition to defining
specific terms, this chapter provides an overview of the concept of grief.
Grief and bereavement are used interchangeably to describe a person’s reaction to
the loss of a loved one (Cohen & Mannarino, 2004). Grief can affect a bereaved person’s
thoughts, behaviors, and emotions (F. B. Wood, 2008). Each person’s experience of grief
is unique. Someone grieving may become disorganized, feel tired, have trouble
concentrating, experience trouble sleeping, or daydream about the deceased
(Kastenbaum, et al., 2002; Pakes, 2008; Wolfe, 2002). Individuals can feel a variety of
emotions that include but are not limited to sadness, anxiety, anger, loneliness, guilt,
isolation, helplessness, relief, confusion, and numbness (Kastenbaum, et al.; Wolfe).
Grief can aggravate or even bring about new health impairments (Irwin & Pike, 1993;
Kastenbaum, et al.). Examples of compounded or precipitated health concerns may
include: osteoarthritis, colitis, migraine, asthma, bronchitis, ulcerative colitis, spastic
colon, urticaria, and rheumatoid arthritis (Gentry, Kennedy, Paul, & Hill, 1995).
Grief can also throw a person into a state of traumatic confusion (Gentry, et al.,
1995). People can lose the ability to accomplish many tasks, impairing their daily lives.
Many times grievers find themselves between two stages of life: who they were before
their loss and their new identity without the loved one. One example would be a wife
who becomes a widow. These people are referred to as being liminal people (Gentry, et
6
al.). This means those experiencing grief may also be experiencing a conflict of self. In
an attempt to find balance between their past and future, they may simultaneously hold
their pre-loss and post-loss identities.
In contrast to mourning is a person’s way of expressing grief through religious
and cultural rituals (Cohen & Mannarino, 2004). These are often public displays that can
include attending funerals, wearing black, putting up memorials, and participating in
wakes. Mourning enables grievers to accommodate the loss of their loved one by
undoing their ties to the deceased, internally adapting to their new life without the loved
one, and reinvesting themselves to the world (Rando, 2002). Mourning practices are
shaped by an individual’s understanding of the nature of grief. This understanding has
been learned from the societal messages they have encountered (Balk, 2003) and is
dependent on cultural influences (Kastenbaum, et al., 2002).
Frequently following mourning bereaved achieve reconciliation, a term that refers
to a person’s adjustment and acceptance of their new life without their lost loved one
(Cohen & Mannarino, 2004). A person never reaches a time when they are completely
unaffected by the loss, but most people can find a healthy way to process their grief and
reintegrate themselves into society. When a person has achieved reconciliation they are
usually accepting the loss as being real, are experiencing and expressing all of their
emotions, are finding their place in the world without their loved one, integrating the
memory of their loved one into their life, and are finding meaning in the loved one’s
death (Cohen & Mannarino).
7
However, reconciliation does not happen for all mourners. A small number of
grieving individuals become stuck in their grieving which results in complicated grief
(Zhang, El-Jawahri, & Prigerson, 2006). Typically, the bereaved experience mourning as
a series of processes, which can become complicated (Rando, 1993). This means that the
mourner experiences disbelief about the death, anger, bitterness, yearning, longing, lack
of trust, lack of perceived meaning in life, and preoccupation with the deceased (Hensley,
Slonimski, Uhlenhuth, & Clayton, 2009; Johnson et al., 2009; Maccallum & Bryant,
2010). These symptoms are more intense and longer lasting than normal grief
expressions (Zhang, et al.). According to Bonanno and Kaltman’s longitudinal study
only a small amount of bereaved individuals, 10-15% (Bonanno & Kaltman, 2001) or 10-
20% (Hensley, et al.), will experience complicated grief.
Further deviations from normative grieving may occur when a loss is not
universally accepted as a cause for grief. These instances are labeled ambiguous loss and
can include, but are not limited to, the ending of a romantic partnership, the loss of a job,
the diagnosis of a child with a mental or physical disability, moving, or sexual abuse
(Betz & Thorngren, 2006). Often ambiguous loss is separated into two categories: either
a loss where the person is psychologically present but not physically there or when a
person is psychologically absent while being physically present (Ambiguous Loss, 2008;
Betz & Thorngren). Often times people experiencing ambiguous loss feel a lot of
uncertainty and do not have access to many of the supports nor are they able to
participate in the mourning rituals that people who experience unambiguous loss have
8
(Ambiguous Loss, 2008). If this grief is not dealt with the stress within the individual and
the family unit experiencing the loss can be exacerbated (Betz & Thorngren).
9
Chapter Two: Adult Grief Manifestations
A great deal of research has been conducted to study adults’ experiences of grief.
This research has been used as a foundation for counseling children and adolescents.
This chapter reviews the major adult theories before covering grief manifestations with
developing children in the next chapter.
Kubler-Ross: Stages of Grief
Kubler-Ross’s stages of grief are commonly referenced in scholarly journals and
popular media. Kubler-Ross interviewed terminally ill patients to collect their thoughts
regarding their impending death (Elisabeth Kübler-Ross, 2004). Five stages of dying
were created from the data that was collected. Later these stages were turned into the
five stages of grief (Bolden, 2007). The five stages of grief are: denial, anger, bargaining,
depression, and acceptance (Maciejewski, et al., 2007). These stages can be experienced
in any order and a person can return to stages they have already encountered (Schimmel
& Kornreich, 1993).
The first stage of grief is denial. People in this stage are in a state of emotional
shock where they are experiencing problems comprehending the implications of the death
(Friedman & James, 2008; Schimmel & Kornreich, 1993). Denial may be employed by
the person experiencing grief as a psychological defense in order to minimize the
seriousness of the event (Pakes, 2008). Bereaved individuals in the denial stage
cognitively understand that their loved one is dead, but facing the reality of the death is
complicated by this sentiment.
10
Denial is followed by anger, Kubler-Ross’s second stage of grief. The anger a
person is feeling in this stage may be directed inwardly, at the loved one that has passed
away, at others in the bereaved person’s life, or at a spiritual figure (Bolden, 2007;
Schimmel & Kornreich, 1993). Active manifestations of the anger stage can include
physical or verbal aggression. This stage can also manifest as passive-aggressive
behaviors (Pakes, 2008). Family members of the bereaved may distance themselves from
the bereaved during this stage due to the rage the bereaved may be expressing.
Following anger is bargaining, Kubler-Ross’s third stage of grief. Bargaining
includes going over the events of the death of their loved one. They obsess over the
small details that they believe could have facilitated a different outcome. Many times
grievers in this stage are mentally repeating phrases similar to “what if” and “if only”
(Bolden, 2007).
The next stage of grief, according to Kubler-Ross, is depression. This feeling is
typically present throughout the grieving process, but can intensify during this stage
(Pakes, 2008). People in this stage experience feelings of profound loss and sorrow
(Schimmel & Kornreich, 1993). Symptoms of this stage include difficulty concentrating,
disturbance of sleeping and eating patterns, high fluctuation of emotions, and low levels
of energy (Friedman & James, 2008). People in this stage are not considered clinically
depressed due to the normalcy of this manifestation of grief (Higgins, 2009).
Finally, Kubler-Ross’s fifth stage of acceptance is reached when a person
experiencing the loss of a loved one has attained reconciliation. This stage is
characterized by a griever’s ability to live their life without the missing loved one, but
11
still able to memorialize the person they have lost (Bolden, 2007). The name of this stage
is misleading in that it gives off the impression that the person is completely “healed” of
their grief. However, someone who has experienced the loss of a close loved one will
most likely be processing their loss on some level throughout their life (Friedman &
James, 2008; Matthews & Marwit, 2006; Moules, Simonson, Prins, Angus, & Bell,
2004).
Yale Bereavement Study
A study conducted at Yale University is believed to be the first empirical study of
Kubler-Ross’s stages of grief (Maciejewski, et al., 2007). The Yale Bereavement Study
(YBS) evaluated the grief manifestations of a sample of bereaved individuals (Johnson, et
al., 2009). The data was evaluated in order to rename and redefine a portion of Kubler-
Ross’s stages.
In contrast to Kubler-Ross’s denial, the first stage of grief was renamed
“disbelief”. The YBS renamed this stage to better illustrate how a person understands the
reality of the death but is experiencing difficulties accepting that reality (Friedman &
James, 2008). The study found that expressions of disbelief were highest immediately
following the loss and decreased after one month (Maciejewski, et al., 2007).
Kubler-Ross’s second stage, bargaining, was renamed “yearning” to reflect a
wider expression of grief (Friedman & James, 2008). People in the yearning stage are
longing for a reunion with their lost loved one. This stage is characterized by intense sad
feelings regarding the inability to reconnect with the deceased. YBS found that yearning
12
was the stage expressed by most of the study participants and was expressed the strongest
at four months after the loss (Maciejewski, et al., 2007).
Finally, the last stage of acceptance was reframed to be conceptualized as a level
that could increase and decrease within an individual. YBS asked participants to assess
their level of acceptance throughout their grieving process (Michalski, Vanderwerker, &
Prigerson, 2006). Bereaved individuals could be in the acceptance stage while still
processing their grief in another stage (Maciejewski, et al., 2007).
The YBS framework of grief processing is helpful in highlighting the uniqueness
of the stages of grief. Individuals can become concerned when they do not fit into
Kubler-Ross’s prescribed linear stages. Each person’s progression through grief will
manifest differently depending upon multiple factors, including the relationship to the
lost loved one, nature of the death, support during their time of grieving, and previously
instilled coping factors. Also, the reframe of acceptance as a gradient allows the bereaved
to build this within his or her own timeline.
Rando’s Six Processes of Mourning
In contrast to Kubler-Ross’s stages and YBS’s revisions, Rando distinguished six
specific processes that must be undergone to achieve healthy coping (see Table 1). The
six processes facilitate the reorientation of the bereaved on three different levels. The first
level focuses on reorienting the relationship the bereaved holds with the deceased
(Rando, 2002; Solomon & Rando, 2007). The bereaved must alter their ties with the lost
loved one (Solomon & Rando). The second level focuses on the bereaved’s personal
13
adaption to the loss, including their self-identity (Rando; Solomon & Rando). The last
level involves the bereaved discovering how to adapt to living in a world without their
lost loved one (Solomon & Rando).
People move through the following processes during uncomplicated mourning,
and processes may be revisited depending on the person’s unique grief process. The first
process that must be successfully completed is to recognize the loss of the loved one
(Rando, 2002; Solomon & Rando, 2007). The bereaved must be aware of the reality of
the loss of the loved one and understand the causes of the death (Rando; Solomon &
Rando). The person must acknowledge the reality of the death (Rando; Solomon &
Rando). The second process the bereaved should go through is reacting to the separation
(Rando; Solomon & Rando). The bereaved must experience the pain of the death
(Rando; Solomon & Rando). This includes feeling, identifying, accepting, and expressing
their thoughts and emotions (Solomon & Rando).
The third process a mourner should experience is recollecting and re-experiencing
the lost person and relationship (Rando, 2002; Solomon & Rando, 2007). To accomplish
healthy mourning the bereaved must realistically review and remember the relationship
(Rando; Solomon & Rando). The fourth process, according to Rando, for a person in
mourning is the relinquish phase. During this phase the person should give up the old
attachment to the lost loved one (Rando; Solomon & Rando). This includes their view of
the world that included them as a connected unit (Rando; Solomon & Rando).
Next, the bereaved should readjust to their new world post-loss without forgetting
their old world, when the deceased was alive (Rando, 2002; Solomon & Rando, 2007).
14
For this to be achieved, the mourner must develop a new relationship with the deceased,
create a new way of being in the world, and form a new identity (Rando; Solomon &
Rando). Finally, the last process is the reinvesting process. The mourner should take the
energy that they once put into the relationship with the deceased and find a place in their
new world (Rando). The mourner can put their energy into their relationships, life goals,
and other aspects of their life post-loss (Rando). If a bereaved person experiences
complications within one of the phases of mourning it can result in complicated
mourning (Rando, 1993).
Process Objectives
Understand the causes of the death
2 nd
Experience the pain of the loss of the loved one
3 rd
Recollect and
Form a new identity
Source: Rando 2002; Solomon & Rando, 2007
15
Kubler-Ross, Yale, and Rando’s theories have focused on the grief process in a
relatively linear way. However, new theories are being developed that look at the grief
process in a nonlinear format. The following two theories focus on how the bereaved
makes meaning after the death of a loved one.
Shattered Assumptions
According to the shattered assumptions model many people hold an unrealistic
view of the world (Swan & Scott, 2009). In order to maintain peace of mind, people tend
to block out the injustice and danger of the world. They believe that negative events
only happen to other people and that their family is safe from these occurrences.
According to this model, when a traumatic event happens, a person’s worldview is
shattered (Matthews & Marwit, 2006; Swan & Scott). This can lead to high levels of
insecurity or fear in the bereaved individual. Many will have to work to redefine their
beliefs in God or their spiritual beliefs (Matthews & Marwit). They may see the world as
a dangerous place in which their loved ones will never be safe.
Dual Process Model
Another nonlinear model that can be used in grief work is the Dual Process
Model. Strobe and Schut analyzed bereaved people’s coping mechanisms (M. S. Stroebe
& Schut, 2001). The researchers were attempting to discover how people who have lost a
loved one come to terms with their loss. The Dual Process Model provides a framework
for understanding a bereaved person’s adaptation techniques (M. S. Stroebe & Schut).
16
According to the Dual Process Model, many people who lose a loved one
experience two orientations of thinking. The first way of thinking is loss orientation
(Swan & Scott, 2009), which is when the bereaved focuses on the past: their life while
the deceased was alive. They experience distress and an urge to search and reconnect
with their lost loved one (M. Stroebe, Schut, & Boerner, 2010). The second way of
thinking is restoration orientation (Swan & Scott). The bereaved in this orientation look
forward to the future and make the transition from their old identity to their new identity.
They focus on secondary stressors that arise from the loss of a loved one, such as
changing one’s identity from a wife to a widow (M. Stroebe, et al.). According to this
model, people experience complicated grief when they do not oscillate between the two
models (Leighton, 2008). If people become stuck in one orientation they block the
memories of their lost loved one or do not confront their new life post-loss.
Summary
By understanding how adults react to grief and the processes they can experience,
counselors have a better foundation for understanding children’s expressions of grief.
Once a clear comprehension of adult grief is acquired, one can start to look at the
developmental aspects of children that may uniquely impact their grieving processes.
The following chapters explore much of the recent literature regarding children and grief.
17
Chapter Three: Children and Grief
Many adults avoid talking to children about peripheral losses such as distant
family members, acquaintances, and pets. Children are not always told about deaths and
may not be taken to funerals (Auman, 2007). Due to this and their cognitive limitations,
some of those children do not have a clear understanding of death (Auman; Oltjenbruns,
2001; Selekman, et al., 2001). This can result in a decrease in grieving ability (Auman).
Since children and adolescents are still cognitively developing, their expressions and
understanding of grief are dissimilar than adults’. According to much of the literature,
children will re-experience their grief as they develop (Hung & Rabin, 2009; Kraus &
Monroe, 2005; Leighton, 2008; Oltjenbruns). This means that not only will the child be
reminded of their lost loved one as important developmental landmarks are achieved, but
they will also re-grieve the loss from a more mature viewpoint (Oltjenbruns).
A variety of incidents can elicit a grief reaction within a child. Each child’s
expression of grief will be unique. The impact of a particular death on a child will most
likely be dependent upon three factors. The first thing a counselor should look at is the
child’s cognitive developmental level (Eppler, 2008; Webb, 2003). Next, one should
consider the nature of the relationship between the child and the deceased (Webb;
Williams & Lent, 2008). Finally, the story of the death that the family and the
community tell is important (Webb). One must remember that each child will have a
unique story, expression, and internalization. This chapter examines common
precipitators of grief, reactions to grief, developmental progression of understanding, and
reconciliation needs of children and adolescents.
18
Reactions to Loss
Like adults and regardless of developmental stage, children and adolescents may
display a wide variety of reactions to the loss of a loved one. These reactions can
manifest in children, regardless of their developmental level. Physical reactions may
include loss of appetite, overeating, stomach aches, and headaches (Heath, et al., 2008).
Children may become clingy, regress to thumb sucking, cry more often, and have
multiple nightmares (Farber & Sabatino, 2007; Tracey & Holland, 2008). Children may
even increase their hyperactivity or experience a lack of energy (Eppler, 2008; Robson,
2008). They may become more fidgety and involved in aggressive fighting (Cohen &
Mannarino, 2008). The physical manifestations of grief will be unique to each child.
Concern should arise when the behaviors last for an extended amount of time or are
exceptionally intense (Kraus & Monroe, 2005; Rowling, 2003).
In addition to diverse physical manifestations, bereaved children and adolescents
may experience a wide variety of emotions involving more than mere sadness (Eppler,
2008). These emotions include depression, guilt, anger, moodiness, embarrassment,
anxiety, hypersensitivity, hopelessness, helplessness, shock, numbness, and even relief
(Farber & Sabatino, 2007; Heath, et al., 2008; F. B. Wood, 2008). Children may go into
a state of emotional shock where they display a flat affect (Farber & Sabatino). Problems
occur when the child cuts off one or more of the emotions (Cohen & Mannarino, 2008;
Selekman, et al., 2001).
Further, when a child loses a loved one, they can experience cognitive grief
symptoms. They may become avoidant, inattentive, confused, or preoccupied with death
19
(Heath, et al., 2008). They can be in a state of denial about the incident (Cohen &
Mannarino, 2004). Many will be distractible and start to question their beliefs (Leighton,
2008). If the death was caused by a traumatic event they may develop distorted ideas
about the event (Cohen & Mannarino, 2008). They may also believe that they were to
blame for the death.
Finally, children may express their grief in their social interactions. They
sometimes withdraw from their peers, isolating themselves in their environments (Tracey
& Holland, 2008; F. B. Wood, 2008). Bereaved children may become argumentative
with adults and other children (Cohen & Mannarino, 2004). Teachers may find them
rebellious or oppositional (Auman, 2007; Heath, et al., 2008). They may display
attention-seeking behaviors within their social networks. The physical, emotional,
cognitive, and social reactions become problematic if they persist over time without
resolution (F. B. Wood).
Children can express grief through a variety of physical, emotional, cognitive, and
social manifestations. These expressions may present differently depending upon
cognitive development. Adults, such as counselors, in these children’s lives should
monitor the intensity and duration of these grief reactions. These grief reactions may
become less persistent if a child reconciles with the loss of their loved one (Heath, et al.,
2008).
Developmental Progression of Understanding
Even though many reactions are consistent throughout development, a child’s
ability to understand loss is dependent upon their development level. As a child matures,
20
their reactions manifest differently. Researchers separate developmental subgroups
several ways. For the purposes of this chapter, childhood development is sectioned into
five developmental stages. The sections are Preschool to Kindergarten (approximately 3
to 5 years in age), Early Primary (approximately 6 to 8 years in age), Late Primary
(approximately 9 to 11 years in age), Early Secondary (approximately 12 to 14 years in
age), and Late Secondary (approximately 15 to 17 years in age). This section will
examine each in detail.
Preschool to Kindergarten/Ages 3-5
At this stage of children’s development, children struggle greatly with assuming
an outsiders’ viewpoint (Rowling, 2003). They are not able to grasp the finality of death
(Kraus & Monroe, 2005; Selekman, et al., 2001). They do not understand that when a
loved one dies they are not going to “wake up”. Since this age has not developed abstract
thinking, they see heaven as being a place they can physically visit (Rowling).
Statements like, “they have gone to heaven”, can be very confusing to this age group.
Many grievers in this developmental stage will display sadness, aggression, and
regressive behaviors (Kraus & Monroe; Selekman, et al.). This age group may have
more intense, but shorter, reactions to grief in comparison to other age groups. Children
in this age group experiencing grief need help understanding death and dispelling their
fears.
21
As children move into this stage they have a better understanding of the finality of
death, but may still be misplacing blame on themselves for the death (Kraus & Monroe,
2005; Selekman, et al., 2001). Death is seen as an entity, like a boogie man or the Grim
Reaper, which can be tricked or avoided (Rowling, 2003). Children, between ages six
and eight, can become obsessed with outsmarting their physical manifestation of death.
If these children’s emotional needs are not met they may try to find ways to fill them with
food or other materials (Rowling). When processing their grief, bereaved children at this
developmental stage may display temper tantrums, increased anxiety, and clinginess
(Rowling; Selekman, et al.). These children can benefit from reassurance about life, clear
expectations about the funerals, and allowances to express their emotions through
nonverbal avenues (Rowling).
Late Primary/Ages 9-11
In contrast to the earlier stages, this age group is likely to seek detailed
information about the nature of the death (Kraus & Monroe, 2005; Rowling, 2003).
Some of these questions may be perceived as gruesome. Due to the increase in cognitive
ability, these bereaved children may be using more elaborate defenses (Rowling). These
defenses can include denial and repression of feelings. At this age children are also able
to compare their life pre- and post-loss, increasing their understanding of the
bereavement they experienced (Rowling). Children in the late primary stage can start to
identify with others, which can result in grief reactions to people outside their immediate
family (Rowling). Some of the behaviors this age exhibits include being defiant,
22
possessive, and aggressive (Selekman, et al., 2001). Their reactions may appear more
subdued than those of younger children (Kraus & Monroe).
Early Secondary/Ages 12-14
As children enter the early secondary stage they become aware of the personal
and social implications of the death (Rowling, 2003). They may see how the loss will
make them different from their peers, as in being outside the norm in losing a parent.
They may become avoidant towards information pertaining to the death and expressions
of grief displayed by their loved ones (Kraus & Monroe, 2005). These children may
display signs of low self-esteem (Rowling). They may also become withdrawn, anxious,
and depressed (Selekman, et al., 2001). Many times they will develop health problems
(Rowling). Children in this stage of development may have poor educational
performance due to their inability to concentrate (Kraus & Monroe; Rowling).
Late Secondary/Ages 15-17
Finally, children at the late secondary level have a more developed understanding
of the future implications of the loss of their loved one (Kraus & Monroe, 2005).
Adolescents may experience an initial stage of numbness. This numbness stage is often
followed by an array of emotions that can include: sadness, anger, bitterness, and
hopelessness (Kraus & Monroe; Selekman, et al., 2001). Many times these adolescents
can be overwhelmed by the various emotions they experience. To cope with these
emotions, adolescents in this stage of development will participate in reckless behavior.
These behaviors can include drug use, reckless driving, and unsafe promiscuous acts
23
(Rowling, 2003; Selekman, et al.). Grievers in this cognitive stage need help maintaining
their sense of control and should have their privacy respected (Rowling).
A child’s understanding and reaction to the death of a loved one will change as
they develop. As children mature, they may use more elaborate defense mechanisms to
cope with the grief they are experiencing. Even though many developmental coping
mechanisms exist, there are also grief reactions that are not completely bound to a child’s
maturity.
Needs of Children Who Grieve
In addition to understanding what grief can look like in children, counselors must
also understand what their needs are. A helpful model for this is Wolfelt’s Reconciliation
Tasks. The first task is to acknowledge that the death is a reality (Cohen & Mannarino,
2004; Heath, et al., 2008). This involves confronting the fact that the person is gone and
will not return (Wolfelt, 1995). Adults need to work with the grieving child to help make
the unreal real. Participation in the funeral can help children accomplish this task (Heath,
et al.).
After acknowledging the death, the second reconciliation task is to face the pain
of the loss with support (Cohen & Mannarino, 2004; Heath, et al., 2008). The pain and
emotional aspects of the death need to be experienced (Wolfelt, 1995). This task requires
the bereaved to express the wide range of thoughts and emotions that accompany grief.
The child needs to participate in memorializing activities so that they are better able to
face and share memories of the lost loved one (Heath, et al.).
24
Following facing the pain, Wolfelt’s third task is to reframe the child’s
relationship with the deceased. The bereaved needs to convert their relationship from a
connection in the present to a relationship with the memory of their lost loved one
(Wolfelt, 1995). The child should not be encouraged to give up all ties with the
deceased, but rather to find a healthy way to memorialize the loved one. According to
The Dual Process Model, they need to find a healthy way to oscillate between the loss
orientation and the restoration orientation (M. Stroebe, et al., 2010).
After reframing, the fourth task of mourning is to develop a new self-identity
without the lost loved one (Wolfelt, 1995). The child needs to redefine themselves in the
absence of the deceased (Heath, et al., 2008). The child may begin to question their self
worth (Wolfelt). They also may experience doubts about the future and their new
identity without the loved one.
Finally, Wolfelt’s last reconciliation task is to form meaning around the death
(Cohen & Mannarino, 2004). To complete this task the child needs to make sense of the
loss of the loved one and find new significance in their life after the death. When
attempting to complete this task, children may question their religious beliefs (Wolfelt,
1995). The counselor needs to be attentive to the children and be with them during this
time to help them discover meaning in their loss (Wolfelt). People find meaning by
believing a lost loved one has gone on to a better life, their suffering has ended, or their
death could bring about change.
The literature has taken Wolfelt’s five reconciliation tasks and added one more to
be used specifically with children. The added task is to build and strengthen new and
25
existing long-term supportive relationships (Cohen & Mannarino, 2004). Children need
to experience the comfort of a continuing or supportive adult presence in their life
(Heath, et al., 2008). The child can be gently questioned to discover the identity of their
confidants and with whom they would feel comfortable talking.
A counselor can assist children in acknowledging the reality of the death, face the
pain that results, reframe their relationship with the deceased, develop a new self-identity,
form meaning around the death, and strengthen their support network. By helping a child
successfully navigate the reconciliation tasks, a counselor can renew a child’s resources
for living (Wolfelt, 1995).
Summary
Children’s understanding and display of grief varies significantly from adults.
Counselors should be aware of the manifestations of grief that may be expressed through
emotional, physical, behavioral, or social outlets. There are specific needs that a
counselor can assist students in meeting to achieve reconciliation. The next chapter
samples interventions counselors can use to assist children in adequately coping with
their grief.
Key Elements of Grief Intervention
Many times adults avoid processing grief with children. Whether this is due to
their own fear of death, unresolved grief from their past, or some other reason, it can have
negative impacts on children who have experienced the loss of a loved one. Death should
be discussed with children in a developmentally appropriate, clear, and direct manner
(Coleman, 2009; Selekman, et al., 2001). Adults may feel that it is inappropriate to cry
when talking to children. However, Selekman, Bush, and Kimble (2001) assert that
adults’ grieving serves to give children permission to show their own emotions.
This chapter will sample grief counseling approaches used with children
experiencing grief. It is important for counselors to become familiar with a variety of
approaches that are available to use with bereaved children. The child’s developmental
needs and preferences of expression should be considered when choosing an intervention.
Narrative therapy, trauma- and grief-focused psychotherapy, group interventions, camp-
based interventions, music therapy, scrapbooking, and play therapy will all be discussed
in this chapter.
Narrative Therapy
A primary method is Narrative therapy. Narrative therapy encourages a child to
share their story, including their past, present, and future. This approach helps the child
work with the counselor to verbalize their reactions to the death and attempt to construct
meaning (Betz & Thorngren, 2006; Leighton, 2008; Salloum, et al., 2009). Afterwards,
27
the counselor reflects the child’s narrative to allow the child to restructure the story as
they see appropriate (Leighton). Counselors help clients externalize problems, elaborate
their story with rich descriptions, explore outcomes, and develop alternative narratives
(Degges-White & Davis, 2010; Salloum, et al.). Some researchers believe that clients
with shorter narratives may be blocking off memories of a trauma, such as a loss of a
loved one (Beaudreau, 2007).
One specific technique under narrative therapy is Biblionarrative. Biblionarrative
therapy is used with children to allow them to talk and write about dramatic life events
(Eppler & Carolan, 2005). To create a Biblionarrative, the counselor works with the
client to gather life information while highlighting strengths, such as successful coping
techniques, throughout the process. When working with bereaved children, the counselor
touches upon the basic circumstances surrounding the death during the interview. The
Biblionarrative includes a description of the relationship with the lost loved one. This
approach allows the child to have multiple options of expression (Pomerantz, 2007).
Eppler and Carolan (2005) found, when conducting a study on Biblionarratives, that 50
percent of their participants preferred writing, while 33 percent preferred talking. Each
child is going to have their preferred method of communicating, which expresses a
unique perspective and mode of expression that can reveal as much as the content of their
discourse.
28
In contrast to Narrative therapy, short-term Psychotherapy tends to focus on the
“here and now” by using techniques such as psycho-education, instead of using
externalizing approaches. Researchers have found that using short-term, trauma-focused
grief intervention lowered children’s experience of traumatic grief and the occurrence of
PTSD symptoms (McClatchey, Vonk, & Palardy, 2009; Saltzman, Pynoos, Layne,
Steinberg, & Aisenberg, 2001). The trauma- and grief-focused psychotherapy outline is
composed of psycho-education, skill-building, and process-oriented components. These
interventions focus on five areas, which include the traumatic experience, the trauma and
loss reminders, the posttraumatic adversities, the connection between the trauma and the
grief, and resuming cognitive development (McClatchey, et al.).
Saltzman, Pynoos, Steinberg, and Aisenberg (2001) conducted a study with the
goal of determining the results of a trauma and grief focused group psychotherapy
program conducted in a school. The program attempted to screen for students who had
experienced a severe trauma or loss that resulted in impairing distress. Once students
were accurately identified, the clinicians followed a psychotherapy manual that focused
on traumatic experiences, reminders of trauma and loss, the interplay of trauma and grief,
post-trauma adversities, and developmental progression (Denzine, 2008; Saltzman, et al.,
2001; Social Learning Theory, 2001). The treatment resulted in a significant decrease in
posttraumatic stress scores, no significant decrease in depressive symptoms, significant
decrease in complicated grief symptoms, and higher academic scores (Saltzman, et al.).
There have been additional studies conducted evaluating the impact of trauma/grief-
focused brief psychotherapy using the specific treatment model explained above
29
(Goenjian et al., 1997; Layne et al., 2001; Möhlen, Parzer, Resch, & Brunner, 2005).
This intervention is one of the most successfully researched one available (Rosner, Kruse,
& Hagl, 2010).
Expression Therapies
Younger children’s language abilities are still being developed and may prevent
them from fully benefitting from the interventions previously discussed. In order to meet
the needs of these children, counselors have attempted to create strategies that allow for
expression in alternate forms. Some alternative therapies utilize artistic expression, in
order to bridge the gap between adults and young children developing language skills. A
few of the therapies that utilize artistic expression are reviewed below.
Music Therapy
Music is one therapy that attempts to incorporate artistic expression into mental
healing. One study analyzed the results of a music therapy intervention that worked with
children to create songs to express their grief (Dalton & Krout, 2005). The therapy
focused on five grief process areas: understanding, feeling, remembering, integrating, and
growing (Dalton & Krout). The approach was grounded in the assumption that children
would need to understand the cause of the loss, then explore their feelings, remember the
good and bad memories of the lost loved one, begin to make a plan for their future
without the loved one, and then discover their own personal growth from the loss (Dalton
& Krout). The researchers found that the seven-week songwriting-based music therapy
treatment group resulted in noticeable decreases on a thirty point self-statement grief
30
process scale (Dalton & Krout). This study has been reviewed and found to be very
successful (Rosner, et al., 2010). More studies should be conducted to further support
this intervention.
Distinct from other expressive therapies, Scrapbooking utilizes objects that the
bereaved associate with the lost loved one. This intervention allows children to bring in
artifacts that serve as reminders of the loved one in order to engage in memorializing
activities (Williams & Lent, 2008). This intervention is also referred to in the research as
a memory book or collage (Buxbaum & Brant, 2001; Webb, 2003). The reminders the
children use are not required to be the actual artifact, but can be photographic in order to
prevent damage to the original objects. While the artifacts are added to the scrapbook,
the therapist engages the child in a dialogue regarding the object and its connection to the
lost loved one. The scrapbook can be used to facilitate dialogue between the child and
other family members. After the scrapbook is complete, the therapist can use it as a tool
to refer to during therapy (Williams & Lent).
Play Therapy
Many therapies, such as Narrative, assume that children will be able to articulate
their emotions, however many children’s typical form of communication is not
verbalization. The younger the child, the more likely they are to be more comfortable
communicating through play. In play therapy, the therapist joins the child in the
metaphors used to attempt to lower the child’s anxieties surrounding the topic of death
31
(Webb, 2003). Expressing emotions through play helps the child develop their
understanding of the loss (Glazer, 1998). This approach functions under the assumption
that the client will use play to explore their feelings in a displaced way (Webb).
Group Intervention
The interventions reviewed above are often used in an individual setting. While
individual counseling has the benefits of giving the child one-on-one attention, group
therapy can have its own therapeutic benefits. Group therapies can be especially
effective with bereaved children (Buxbaum & Brant, 2001; Heath, et al., 2008; Selekman,
et al., 2001). Facilitators should construct groups that include children that are
experiencing similar coping difficulties due to the loss of a loved one. Information
regarding the group members’ cultural beliefs about death, grief, and mourning need to
be gathered as well in order to incorporate those beliefs into the group (Heath, et al.;
Selekman, et al.).
Group therapy allows the members to share their experiences with others and
receive normalizing feedback (Buxbaum & Brant, 2001; Selekman, et al., 2001). Groups
also help facilitate the normalizing process by educating members on the grief process
(Buxbaum & Brant; Selekman, et al.). Members are provided with a safe environment in
which to express their feelings regarding the loss (Buxbaum & Brant). Children may
need opportunities to release energy while in the group through activities such as games,
walking, and drawing (Heath, et al., 2008).
32
Salloum (2008) conducted a study to evaluate the effectiveness of a school based,
time-limited grief and trauma group intervention for elementary aged children. The
group included survivors of homicide victims and children who had witnessed extreme
violence within their community (Salloum, 2008). Group members participated in group
therapy attempting to reduce traumatic symptoms. The goal of the therapy was to allow
the children to process their grief without complications stemming from the trauma of
their loss. Salloum (2008) found that the group members who had not witnessed the loss,
scored lower on a posttraumatic stress reaction index after treatment. Given this evidence,
there are inherent benefits to group counseling with bereaved children.
Camp-Based Intervention
Many child focused interventions are confined to traditional counseling settings
such as schools and private practices. In contrast, grief interventions conducted in a
camp environment have the unique ability to provide assistance for longer sessions and in
closer succession. The American Camping Association has conducted research that
supports the positive benefits of camping. They found that camping can increase a
child’s self confidence and self-esteem (Thurber, Scanlin, Scheuler, & Henderson, 2007).
Children develop and improve social skills. Camps help children become more
independent in addition to forming effective leadership skills (Directions: Youth
development outcomes of the camp experience, 2005). The environment has also shown
that children become more adventurous and increase their willingness to try new things
(Directions: Youth development outcomes of the camp experience).
33
Many grief therapy camp-based groups develop positive coping mechanisms
through the tenets of social learning and social norms theories (Farber & Sabatino, 2007).
Social learning theory is an approach that focuses on the interplay between an
individual’s personality and their environment (Denzine, 2008; Social Learning Theory,
2001). Social norms is a term that refers to the unspoken rules that dictate how
individuals are expected to act in different situations (Hagman, Clifford, & Noel, 2007).
Social learning theory posits that a person’s environment affects their thoughts and
actions (Social Learning Theory; P. B. Wood, Gove, Wilson, & Cochran, 1997).
According to this theory, the individual’s environment can be affected by the individual
(Social Learning Theory). The camp setting allows group members to learn from others
who are participating in the activities (Farber & Sabatino). The children use others to
construct meaning about the death they experienced and the acceptability of grief (Farber
& Sabatino).
intervention. The counselors used a mixture of structured therapeutic activities and play
activities to attempt to help the participants process their grief (McClatchey, et al., 2009).
The researchers screened camp members to discern those who were at risk of
experiencing grief or PTSD symptoms (McClatchey, et al.). The results of the studies
indicated that these participants were significantly less likely to experience extreme grief
or PTSD symptoms (McClatchey, et al.). In summary, this is a new, promising approach
to grief therapy that needs to be explored further.
Systems Approach
When counselors provide interventions with bereaved children they should not
overlook the child’s contextual factors. Many experts believe the attainability of healthy
mourning can be mitigated by the support structures surrounding the child (Cicchetti &
Rogosch, 1997; Saldinger, Porterfield, & Cain, 2004; Van Horn, 2010). A child could be
supported by important people in their life including, but not limited to, family,
neighbors, and community members. It is believed that a child needs the commitment of
at least one supportive, trusted adult (Cicchetti & Rogosch; Van Horn).
Research suggests that children will experience healthier adjustment to their loss
if they are engaged in a positive caregiver-child relationship (Wolchik, Yue, Tein,
Sandler, & Ayers, 2008). It is important for counselors to not only offer support to the
bereaved child, but also to their caregiver who may be experiencing their own grief. The
grieving caregiver may be less emotionally available to the child, lowering their ability to
convey hope (Saldinger, et al., 2004; Van Horn, 2010). These grief manifestations in the
caregiver can result in less stability in the child’s life, which can increase maladaptive
reactions to grief (Saldinger, et al.). Counselors can support caregivers to positively
impact children by communicating the child’s experience of the loss to the adult,
educating the caregiver of the developmental needs of the bereaved child, and connecting
the caregiver with assistance to help with daily problems (Van Horn).
Summary
Many interventions are available for use with bereaved children. The sampling of
grief interventions showed multiple approaches that have been researched for bereaved
35
children. Counselors should examine the system in which the child belongs to determine
if there are structures that need support. Because this was not an exhaustive review of the
research, other interventions that were not reviewed are currently being used.
36
Interventions
It should be noted that some scholars in the bereavement field have debated the
effectiveness of bereavement interventions. Some experts believe that grief work can
have detrimental consequences. Currier, Holland, & Neimeyer analyzed data collected
from thirteen grief therapy intervention studies (Currier, Holland, & Neimeyer, 2007).
The studies that they reviewed compared a group of children who received a group grief
therapy intervention with a group of children who received no treatment. Their results
found that, on average, children who participated in the group interventions did not show
a higher level of healthy adaption to bereavement (Currier, et al.). It should be noted that
the studies that attempted to select only children who were considered a higher-risk of
experiencing coping difficulties showed greater improvement (Currier, et al.).
In contrast to Currier, Holland, and Neimeyer’s (2007) findings, Rosner, Kruse,
and Hagl (2010) conducted a meta-analysis that found more promising results. The meta-
analysis studied twenty-seven interventions for bereaved children and adolescents. The
researchers found that the interventions had little to moderate treatment effects (Rosner,
et al., 2010). This is more promising than the findings listed from the previous study.
Although the studies reported little follow-up data, the data found suggested that
treatment effects were persistent over time (Rosner, et al.).
There are other issues inherent in the attempt to provide services for bereaved
children and adolescents. It has been argued that there are barriers to finding appropriate
participants for services (Saltzman, et al., 2001). Some researchers believe that many
37
studies use unproductive screening tools to identify students who could benefit from
interventions (Saltzman, et al.). Acquiring permission from the important adults in the
children’s lives has also been identified as a barrier (Saltzman, et al.). In order for more
conclusive data to be collected, a higher number of participants in research studies will be
required. Patient participation is directly influenced by parental approval. The
researchers need to find a way to appeal to the parents of grieving children so that further
progress can be made in this field.
38
Conclusion
Grief work with adults, adolescents, and children is pivotal to help facilitate
growth towards healing. Children are especially at a disadvantage due to their lower
levels of development and, consequently, require special attention. Counselors’ work
with children can benefit from having a clear understanding of adults’ reactions,
manifestations, and progression of grief. Understanding adult grief can bolster the
counselors understanding of the developmental progression of grief. This, in turn, helps
counselors become more attuned to the differing needs of children.
It is important for children to be given opportunities to express their grief. A wide
range of approaches such as narrative therapy, trauma- and grief-focused psychotherapy,
music therapy, scrapbooking, play therapy, group interventions, and camp-based
interventions may be used to help children reach reconciliation. Counselors can use these
approaches to create an environment conducive to healing while setting up interventions
for students who need more focused attention.
More research is required in order to determine the benefits of different
interventions. Adequate screening techniques should be developed to ensure that
children who will benefit from counseling are identified for services. A consensus within
the research community on the best approach to use with grieving children seems far-
fetched now. Hopefully, the publication of more quantitative studies can help to support
the approaches that are successful.
39
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