G505 Andrea Davasher Kassy Franchville Chris Kempf DEATH & GRIEF G505 Andrea Davasher Kassy Franchville Chris Kempf DSM category (v62.82 Bereavement http://ajp.psychiatryonline.org/cgi/content/abstract/154/7/904

What Is Grief? “Grief is the emotion people feel when they experience a loss. There are many different types of loss, and not all of them are related to death. For example, a person can also grieve over the breakup of an intimate relationship or after a parent moves away from home.” 1995-2007 The Nemours Foundation. http://www.kidshealth.org/teen/your_mind/emotions/someone_died.html http://www.kidshealth.org/teen/your_mind/emotions/someone_died.html 1995-2007 The Nemours Foundation.

“Grief is a natural reaction to the loss of someone important to you “Grief is a natural reaction to the loss of someone important to you. Grief is also the name for the healing process that a person goes through after someone close has died. The grieving process takes time, and the healing usually happens gradually.” 1995-2007 The Nemours Foundation. http://www.kidshealth.org/teen/your_mind/emotions/someone_died.html http://www.kidshealth.org/teen/your_mind/emotions/someone_died.html ｩ1995-2007 The Nemours Foundation.

*Depends on relationship with person. *“Although everyone experiences grief when they lose someone, grieving affects people in different ways.” *Depends on relationship with person. *Circumstances under which they died. 1995-2007 The Nemours Foundation. http://www.kidshealth.org/teen/your_mind/emotions/someone_died.html http://www.kidshealth.org/teen/your_mind/emotions/someone_died.html ｩ1995-2007 The Nemours Foundation. “How it affects you, partly depends on your situation and relationship with the person who died. The circumstances under which a person dies can influence grief feelings. For example, if someone has been sick for a long time or is very old, you may have expected that person's death.”

Cont. *Knowing someone is going to die can give us time to prepare. *If they were suffering, it can mean a sense of relief. *If the person that died was young, we may feel it was unfair. 1995-2007 The Nemours Foundation. http://www.kidshealth.org/teen/your_mind/emotions/someone_died.html http://www.kidshealth.org/teen/your_mind/emotions/someone_died.html ｩ1995-2007 The Nemours Foundation.

“Losing someone suddenly can be extremely traumatic, though, no matter how old that person is. Maybe someone you know died unexpectedly - as a result of violence or a car accident, for example. It can take a long time to overcome a sudden loss because you may feel caught off guard by the event and the intense feelings that are associated with it.” 1995-2007 The Nemours Foundation. http://www.kidshealth.org/teen/your_mind/emotions/someone_died.html http://www.kidshealth.org/teen/your_mind/emotions/someone_died.html ｩ1995-2007 The Nemours Foundation.

*Grief can make us feel guilty. *Some people might blame themselves or think they could have done something to stop the death. 1995-2007 The Nemours Foundation. http://www.kidshealth.org/teen/your_mind/emotions/someone_died.html http://www.kidshealth.org/teen/your_mind/emotions/someone_died.html ｩ1995-2007 The Nemours Foundation.

“Others might think if only they had been better people, than their loved ones might not have died. These things aren't true, of course - but sometimes feelings and ideas like this are just a way of trying to make sense of something that's difficult to understand.” 1995-2007 The Nemours Foundation. http://www.kidshealth.org/teen/your_mind/emotions/someone_died.html http://www.kidshealth.org/teen/your_mind/emotions/someone_died.html ｩ1995-2007 The Nemours Foundation.

Coping With Grief “The grieving process is very personal and individual - each person goes through his or her grief differently. Some people reach out for support from others and find comfort in good memories.” 1995-2007 The Nemours Foundation. http://www.kidshealth.org/teen/your_mind/emotions/someone_died.html http://www.kidshealth.org/teen/your_mind/emotions/someone_died.html ｩ1995-2007 The Nemours Foundation.

Coping cont. *Throw selves into activities to take mind off loss. *Become depressed and withdraw from activities, peers, family. *Everyone handles grief in different ways. 1995-2007 The Nemours Foundation. http://www.kidshealth.org/teen/your_mind/emotions/someone_died.html http://www.kidshealth.org/teen/your_mind/emotions/someone_died.html ｩ1995-2007 The Nemours Foundation.

“For some people, it may help to talk about the loss with others “For some people, it may help to talk about the loss with others. Some do this naturally and easily with friends and family, others talk to a professional therapist.” 1995-2007 The Nemours Foundation. http://www.kidshealth.org/teen/your_mind/emotions/someone_died.html http://www.kidshealth.org/teen/your_mind/emotions/someone_died.html ｩ1995-2007 The Nemours Foundation.

Do children experience grief? “Yes, if children are old enough to love, they are old enough to grieve. Many times in our society children are the forgotten grievers. For instance, when a parent dies, whom do we expect to help the child with their grief? The surviving parent. That parent not only has their own grief to deal with but they are learning for the first time how to be a single parent. They, like their child, can use support in their grieving.” Excerpt from David Kessler’s website “On Grief & Grieving” By Elisabeth Kübler-Ross & David Kessler http://www.davidkessler.org/html/qa_grief.html#9 DAVID KESSLER http://www.davidkessler.org/html/qa_grief.html#9 Excerpt from David Kessler’s website “On Grief & Grieving” By Elisabeth Kübler-Ross & David Kessler

Example “Joey's friends expected he'd be really upset at his mom's funeral, so they were surprised that he was smiling and talking with people as if nothing had happened. When they asked him about it, Joey said that seeing his friends at the funeral cheered him up because it reminded him that some things would still be the same. Joey was able to cry and talk about how he felt when he was alone with his dad after the funeral.” Reviewed by: D'Arcy Lyness, PhD
Date reviewed: April 2004 KIDS/TEEEN.ORG Reviewed by: D'Arcy Lyness, PhD
Date reviewed: April 2004 KIDS/TEEEN.ORG

Counselors should keep in mind: “Children don’t grieve the way we do. They don’t openly talk about how they are feeling. A death in their life usually causes them to feel even more different than usual.” Bereavement groups can be a helpful tool for children. KESSLER KESSLER

DSM IV V62.82 Bereavement along w/diagnosis of Major Depressive Disorder “This category can be used when the focus of clinical attention is a reaction to the death of a loved one.” Can be linked with a “Major Depressive Episode (e.g., feelings of sadness and associated symptoms such as insomnia, poor appetite, and weight loss).” Symptoms must still be present 2 months after loss. Can’t be considered “normal” grief reactions. DSM IV, p 740-741, V62.82 *Very limited information DSM IV, p 740-741, V62.82 *Very limited information

What are the Five Stages of Grief and Do They Always Occur in the Same Order?

Elisabeth Kübler-Ross The five stages: Denial Anger Bargaining Depression Acceptance Elisabeth Kübler-Ross Elisabeth Kübler-Ross

Youtube video clip Summer expresses her grieving for Marissa in five stages. From episode 4x04 "The Metamorphosis". http://www.youtube.com/watch?v=iIfg2wXv6vk http://www.youtube.com/watch?v=iIfg2wXv6vk

Stages (cont.) The stages are tools to help us frame and identify what we may be feeling. Different for everyone. Doesn’t always happen in exact order, may revert before moving forward. KESSLER KESSLER

Typical Physical Symptoms of Grief difficulty going to sleep, or waking in the middle of the night weight loss or gain; over- or under-eating low energy or fatigue headaches, chest pain, or racing heart upset stomach or digestive problems hair loss

Grief or Depression? Grief Depression Experienced in waves Diminishes in intensity over time Healthy self-image Hopelessness Response to support Overt expression of anger Preoccupation with deceased Depression Moods and feelings are static Consistent sense of depletion Sense of worthlessness and disturbed self-image Pervasive hopelessness Unresponsive to support Anger not as pronounced Preoccupation with self * Excerpts from Therese A. Rando (1993). Treatment of Complicated Mourning. Research Press, Champaign, IL.

There are many ways people who are grieving can help themselves: Attending support groups Therapy with a psychologist or other licensed mental health professional Journaling Eating Well Exercising Getting enough rest Antidepressants such as Zoloft, Paxil, Wellbutrin, Lexapro, Celexa, Prozac and can be very effective to those who become clinically depressed

(continued) Reading and learning about death-related grief responses Seeking comforting rituals Avoiding major changes in residence, jobs, or marital status Allowing emotions Seeking solace in the faith community

Factors that may hinder the healing process Avoiding or minimizing emotions Using alcohol or drugs to self-medicate Using work to avoid feelings

Gender Differences Women Men express their feelings early after loss reach out for social support are seen to express more sorrow, depression, and guilt more willing to talk about the loss of a child Men more likely to take on a managerial role intellectualize their emotions indicate that they feel more anger, fear, and loss of control use denial more more private about grief

Developmental Grief Responses Ages 2-4 Concept of Death Death seen as reversible Grief Response Intensive response but brief Very present oriented Most aware of changes in patterns of care Asking questions repeatedly

Developmental Grief Responses Ages 4-7 Concept of Death Death still seen as reversible Feeling of responsibility because of wishes and thoughts Grief Response More verbalization Great concern with process. How? Why? May act as though nothing has happened General distress and confusion

Developmental Grief Responses Ages 7-11 Concept of Death Still wanting to see death as reversible but beginning to see it as final Death seen as punishment Grief Response Specific questions Desire for complete detail What is the right way to respond? Starting to have ability to mourn and understand mourning                      

Developmental Grief Responses Ages 11-18 Concept of Death Ability to abstract Beginning to conceptualize death Grief Response Extreme sadness Denial Regression More often willing to talk to people outside of family and peer support Risk-taking

It's only when we truly know and understand that we have a limited time on earth -- and that we have no way of knowing when our time is up, we will then begin to live each day to the fullest, as if it was the only one we had. ~Dr. Elisabeth Kübler-Ross

Needs of the 2 – 5 year old Kind and understanding tone of voice and demeanor Encouragement to talk about how s/he feels in whatever way s/he can express it Permission to “play about” death and the events surrounding the experience Open and direct manner that says “I’m with you and you are with me. There are no secrets.”

Needs of the 2 – 5 year old (continued) Sharing of how you feel or felt when a similar thing happened Reassurance that remaining family members will take care of the child

Needs of the 5 – 9 year old Clear answers in simple terms to the questions that they ask, no matter how improbable their fears seem An accepting listener to the memories s/he has of the deceased Explanations to refute the magical beliefs that feed their fears Acceptance of play, artwork, songs, etc. about the events surrounding the death

Needs of the 9 – 12 year old To be taken seriously, no matter how shallow his/her concerns seem To be included in family discussions about the changes brought about by the death To have his/her ways of grieving accepted While this age-group may understand death intellectually, they may have great difficulty understanding it emotionally.

Needs of the Teenager To be included in planning & decision making To be informed of what to expect in terms of events, ceremonies, rituals, etc. To know what to expect from various relatives To know what is expected of them To witness adults grieving so they can learn adult ways to grieve

Needs of the Teenager (continued) To be encouraged to talk about what they think and feel and have their thoughts and feelings respected

What to Do Act natural Show genuine care and concern Make it clear that you are there to listen Talk openly and directly about the person who died Keep in mind that evenings, weekends, anniversaries, and holidays can be extra challenging times

What to Do Find a way to help children symbolize and represent the death Pay attention to the way a child plays; this is one of the main ways that children communicate Say that you are sorry about the loss Sit next to a child that wants closeness

What NOT to Do Try to shelter children from the reality of death; it can be a learning experience Give false or confusing messages (“Grandma is sleeping now.”) Tell a child to stop crying because others might get upset Try to cheer the person up or distract from the emotional intensity (“At least he’s no longer in pain.” “She’s in a better place now.”)

What NOT to Do Offer advice or quick solutions (“I know how you feel.” “Time heals all wounds.”) Pry into personal matters Ask questions about the circumstances of the death

Grief Groups By sharing feelings with one another, children find out that they are not alone and that others are also struggling to rebuild shattered lives. Grief groups help children feel understood, accepted, and supported.

How do you start a group? Open-ended: new kids can arrive at any time, and group introductions will need to be made often. The advantage is that children will have more time to work on their grief, especially after sudden, violent, or traumatic deaths. Walk-in: this format frees students from any commitment and fits into the busy routine of school life. The difficulty is not knowing who or how many kids will attend.

How do you start a group? 3. Time-limited: these groups work best in the school setting. School schedules often do not allow the flexibility for an on-going group. Students may also be more comfortable knowing there is a beginning and an end to the group. The number of sessions is usually 8 – 12, but shorter groups could be offered along with the opportunity for teens to request an additional session or sessions.

How do you select group members? Group leaders have to decide on the parameters of the group. Is this going to be limited to students who have had a parent die, or will it be more general? Are there enough students to do a group focusing on parent loss? This type of focused group may work best, but grief groups that are broader in nature work well too. Referrals may come from teachers, coaches, students, or parents. The school newsletter or website can be a good place to advertise the group.

Group Activities Writing or drawing spontaneously on mural paper taped to the wall Creating a collage using pictures and words cut from old magazines Writing a poem, eulogy, or song Constructing a book that can be used as a journal or a memory book Launching a balloon after writing messages to the person who died Going on a field trip to a funeral home, cemetery, etc.

Signs that Bereavement in Young People Needs Outside Intervention If a young person pretends that absolutely nothing has happened If school work takes a dramatic decline or the student develops a school phobia If a young person threatens suicide If a young person panics frequently If a young person becomes involved with alcohol or drugs If a young person begins committing serious socially delinquent acts

Signs that Bereavement in Young People Needs Outside Intervention If news of a death or other significant loss was kept from the young person for a long time or if the young person was told lies about the death If a young person frequently physically assaults others or is cruel to animals If a young person had a difficult relationship with the deceased or behaves poorly with family members If the young person is unwilling or unable to socialize with other young people