Working with the Grief of Children and Adolescents Idaho School Counselor Association Fall Conference – October 3rd, 2014 Coeur d’Alene Mark de St. Aubin, LCSW, FT College of Social Work, University of Utah Lorene de St. Aubin, Chaplain mark.lorene@gmail.com

Let’s talk about Grief Some essential concepts and terms: Grief - "a multi-faceted response to loss that includes psychological, behavioral and physical reactions combined with cognitive, emotional, behavioral, social, spiritual and somatic elements." Stroeb ,M, Stroeb, W and Schut, H. Bereavement - an objective state of having lost someone or something. The term is generally used to describe the state of having suffered a loss due to death. Mourning - the process by which people adapt to loss; the public expression of grief, which is shaped by social and cultural expectations. It is how a person tries to incorporate the loss into life and keep living.

First, let’s review what “normal grief” looks like Feelings Physical Sensations Cognitive Behavioral Spiritual

Feelings Anxiety Shock Helplessness Numbness Yearning Anger Emancipation Guilt and Self-reproach Relief Shock Numbness Anger Sadness Loneliness Fatigue Material adapted from William Worden, Grief Counseling and Grief Therapy: A Handbook for Mental Health Practitioner, 4th edition, pp. 18-31,Springer Publishing, 2009

Physical Sensations Sense of depersonalization Breathlessness Weakness in the muscles Lack of energy Dry mouth Hollowness in stomach Tightness in the chest Tightness in the throat Oversensitivity to noise

Cognitions Disbelief Confusion Preoccupation Sense of presence Hallucinations

Behaviors Sighing Restless hyperactivity Crying Visiting places or carrying objects that remind one of the deceased Treasuring objects that belonged to the deceased Sleep disturbances Appetite disturbances Absentminded behavior Social withdrawal Dreams of the deceased Avoiding reminders of the deceased Searching and calling out

Spiritual Can lead to a spiritual crisis. The tough questions – “Why did this happen?”; “Why did it happen this way?”; “How could God let this happen to me?” Causes us to question our beliefs (‘assumptive world’ ) which form our world view May bring feelings of emptiness, meaninglessness, disconnection from our source *Wolfelt, A. “The Journey Through Grief”, www.centerfor loss.com, 2007

Some examples of loss across the life span Childhood Death of a pet Abuse/abandonment/ Foster care/adoption Divorced parents Death of sibling or parent Moving/relocation Adolescent Death of a friend Abortion Unwanted pregnancy Adulthood Loss or death of child Miscarriage/SIDS baby Child with disability Chronic illness/health Death of friend or parents Divorce/death of partner Retirement/career transition Dementia/Alzheimer’s Loss of dreams/hopes/plans

How can we help others along their journey of grief?

One Model “The Four Tasks of Mourning” From Grief Counseling and Grief Therapy: A Handbook for Mental Health Practitioners, 4th Edition By J. William Worden, Springer Publishing Co., 2009

How do we heal from grief? THE FOUR TASKS OF ADAPTING TO LOSS - Just as healing is necessary in the physiological realm in order to bring the body back into physical health, a period of healing is likewise needed after a loss to return to a similar state of emotional well- being. There are four tasks of adapting to loss which are an essential part of the healing process. They do not always follow a specific order, but still must each be worked through during the time of grieving.

THE FOUR TASKS OF ADAPTING TO LOSS Task 1 - To Accept the Reality of Loss To come full face with the fact that your loss is real and will not return, i.e. that immediate reunion or regaining it is impossible, that the loss is permanent. Obstacles: Denying the facts of loss. Denying the meaning of the loss, e.g. It wasn’t a good job anyway, or I don’t miss him, or I’m just as healthy as I ever was. Minimizing the loss. Denying the fact that the loss is irreversible. Belief and disbelief alternate. Adaptive denial.

THE FOUR TASKS OF ADAPTING TO LOSS Task 2 – To Process the Pain of Grief It is impossible to lose something or someone you have been attached to without experiencing some level of pain. Society often feels uncomfortable when you show this pain, and often will give you the subtle message of “You don’t need to grieve”, or “Please don’t be so emotional around me.” They will often try and distract you from your feelings. Obstacles: Not allowing yourself to feel. Cutting off your feelings and denying that pain is present. Avoiding reminders of the loss – e.g., trying to find a ‘geographic cure’ by moving to another location, removing all pictures/reminders of the deceased.

THE FOUR TASKS OF ADAPTING TO LOSS Task 3 - To Adjust to a World Without the Lost Person, Ability, etc. Coming to terms with being without (maybe raising children alone, facing future unemployment or handicap, redefinition of self, etc.). This often requires the learning of new skills and functioning in a new set of roles. This adjustment may also include a redefining of some life goals. A. External Adjustments – how the loss affects your everyday functioning in the world B. Internal Adjustments – how the loss affects your sense of self C. Spiritual Adjustments – how the loss affects your beliefs, values and assumptions about the world Obstacles: Promoting your own helplessness. Not developing the skills you need to cope. Withdrawing from the world. Refusing to see yourself or the world differently.

THE FOUR TASKS OF ADAPTING TO LOSS Task 4 – To Find an Enduring Connection With the Deceased in the Midst of Embarking on a New Life To find a place for the deceased that will enable us to remain connected with them but in a way that will not keep you from going on with life. We come to realize that there are still areas in life left to become involved in or other people to be loved. Obstacles: Withdrawal from others and life. Not living. Holding onto the grief as a way to honor the deceased. Unwillingness to risk; making a vow to never love again. Holding on so tight to the past that you’re unable to form new relationships or develop new skills.

THE FOUR TASKS OF ADAPTING TO LOSS These tasks can be revisited and worked through again and again over time. Various tasks can also be worked on at the same time. When is grieving over? No time limit can be set. Mourning is finished when the tasks of mourning have been accomplished; when you are able to think of your loved one without fresh pain. This does not necessarily mean that the bereaved will no longer feel sad, it means that one is able to move on and continue living, even though they still may miss the deceased.

Grief Counseling Interventions - - Task 1 – Helping the survivor actualize the loss Have them tell their story – Tell me how your friend/family member died Tell me about the funeral Tell me about when you heard the news of his death Tell me about your visit to the grave of your loved one Then listen, listen, listen. You may have to hear the same story over and over again. That’s OK, they need to tell it. Having them review the events of the loss assists them in coming to grips with the reality of the death

Interventions – cont’d Task 2- Helping them identify and experience feelings related to the loss Helping the client express the feelings they are experiencing and give them permission to feel these feelings – sadness, anger, guilt, anxiety, loneliness, fear, etc Have them bring a photograph of their family member/friend and tell you about them, their relationship, their memories Educate them about what normal grief looks and feels like Use reflective and empathic listening skills Validate their feelings and experience. This will assist them in feeling safe to express and explore these feelings Perhaps ask them to write a letter to the deceased person to give voice to thoughts and feelings which may relate to ‘unfinished business’

Interventions - cont’d Task 3 – Assist them living without the deceased External adjustments – A problem-solving approach, education and modeling may be most helpful learning the new skills needed to adapt and take on new roles - the cook, decision maker, home repairman, etc. You may ask What roles did your loved one perform? What changes has this required of you? How have you been able to change or adapt in the past?

Task 3 interventions - cont’d Internal/spiritual adjustments – You may ask: How has this loss changed your view of the world? How are you different because of this loss? How do you make sense of this loss - why has it happened to you? At this time? In what ways has this loss challenged your faith, or how you see the world? Is it important to you to find good or value or something learned from this loss? What good, then, has come of this loss?

Interventions – cont’d Task 4 – To Assist in Emotional Relocation of the Deceased (shifting from a relationship of ‘presence’ to a relationship of ‘memory’) Reminisce - What memories do you have of the deceased? Which memories do you want to keep? How do you want to remember and honor him/her? What ways/practices can help you keep them in your life? In your mind? In your memory? What things can you do to remember them on special days – anniversaries, holidays, birthdays? How can you symbolize the completion of this time of grief and mourning? (a ceremony or ritual may be performed)

Things to remember in helping another in their grief Listen with your heart – allow yourself to be touched by their loss. Your shared humanity allows them to feel safe and understood. ‘Companion’ them, don’t try to ‘fix’ their grief. (see Wolfelt, A., The Handbook for Companioning the Mourner: Eleven Essential Principles, Companion Press, 2009) Avoid cliches – “They are in a better place.” “God needed them on the other side.” “At least you enjoyed 25 years of a good marriage with them.” These types of comments do not help the bereaved. Don’t try to ‘fix’ their grief so that they will ‘feel better’. Understand the uniqueness of grief – each person grieves in their own way and on their own time schedule. They will teach you what they need along the way, if you listen.

Things to remember when working with children in grief Answer the questions they ask, even the hard ones Be truthful and speak to their level of understanding. Children’s age and cognitive level affects their ability to understand death. Give the child choices whenever possible Do they want to be involved in the funeral? Choosing the casket? Clothing of their family member of friend? Talk with them about and remember the person who died Use the name of the deceased as you talk about the deceased. Talk about memories they have and things that matter to them If they do not wish to speak, use drawing , clay or play as ways of expression Respect differences in grieving styles Children grieve differently than their parents or siblings. Generally through play and through their behavior rather than through talk. *The Dougy Center: The National Center for Grieving Children and Families

Working with Children – cont’d Listen without judgment Simply reflect back to the child their feelings or experience without trying to judge, fix or direct them. Hold a memorial service and allow for saying goodbye Inform a child about the funeral and involve them, if they choose. If they don’t want to join you, invite them to create their own activity for saying goodbye – planting a flower or tree, holding a candle-lighting ceremony, drawing a picture Take a break from grief Children, like adults, need a break from grief. That’s OK. Having fun or laughing is not being disrespectful, this is how children process their feelings.

Things to remember when working with adolescents in grief The sense of being out of control that is often a part of grief may overwhelm or frighten some teens. It may be an experience some teens resist and reject. Helping them accept the reality they are grieving allows them to do their grief work and to progress in their grief journey. Each teen’s grieving experience is unique. Adults can best assist grieving teenagers by accompanying them on their journey in the role of listener and learner, allowing the teen to be the teacher. Invite the teen to try helpful ways of expressing their grief – talking with a trusted friend, journaling creating art, and expressing emotion rather than holding it inside. *The Dougy Center: The National Center for Grieving Children and Families

Working with teens – cont’d Teens may mourn differently at different times – for example through talking, crying, or withdrawal. This can cause a great deal of tension within the already stressed family. Each person’s responses to the death should be honored as his/her way of coping in that moment. And this may change from day to day or even from hour to hour. Other factors which may impact the teen include: Social support available Circumstances of the death – how, where and when death occurred Whether the teen unexpectedly found the body The nature of their relationship with the deceased- harmonious, abusive, conflictual, unfinished supportive The emotional and developmental age of the teen The teen’s previous experiences with death