[acb-hsp] Helping Bereaved Children

[J.Rayl]

Helping Bereaved Children

and Adolescents: Strategies and Implications for Counselors.

by James P. Morgan , Jesse E. Roberts

This article provides an overview of how loss affects young people of different ages

and describes methods for helping bereaved children

and adolescents. Case examples demonstrate the use of drawings to elucidate the

inner experiences of young people who are grieving and to facilitate the

counseling

process. A format for a bereavement support group is detailed, and guidelines are

provided for the use of bibliotherapy. Cultural, ethical, and counselor competency

issues are also considered. The importance of counselors' awareness of the impact

of their own loss experiences is also discussed.

One of the greatest challenges we may ever face as adults is to provide support to

a grieving child. This process is particularly difficult because we naturally try

to protect

children

from emotional pain, we may have our own anxieties about death, and we may feel

at a loss as to how we can be helpful to a child who is grieving (Webb, 2005). The

words of the poet William Wordsworth, written over 200 years ago in "Now We Are Seven,"

ring as true today as then: "A simple child/that lightly draws its breath/and feels

its life in every limb/what should it know of death?" (cited in Webb, p. 3).

Children at different developmental levels perceive death differently. An understanding

of these differences is essential if we are to effectively help

children understand and cope with their grief. As Webb (2005) notes, by the age of

7 or 8 most children

achieve the knowledge about death that we as adults have come to know: death is

"irreversible, inevitable, and universal" (p. 4). However, from the preschool years

through adolescence, there are significant developmental differences in how

children

experience grief. Because of these differences, counselors who work with bereaved

children

and adolescents need to use a variety of approaches in their efforts to meet their

needs. To that end, this article reviews developmental factors associated with bereavement

in

children

and adolescents and describes an approach to working with bereaved young people

that integrates drawings, bereavement support groups, and bibliotherapy. We also

discuss cultural concerns related to grief in young people, and the implications

of ethical issues and their own grief experiences for mental health counselors who

work with bereaved

children

and adolescents.

DEVELOPMENTAL FACTORS

Preschool Children

While their conception of grief is different from that of older children, young children

are capable of experiencing sadness and therefore grieve in their own way when a

loved one dies. Young

children

typically do not comprehend the permanence of death and may ask repeatedly when

the deceased loved one is coming home (Fitzgerald, 1992). Young

children

are also prone to magical and egocentric thinking, as Piaget and Inhelder (1969)

suggest, and may think that they somehow caused the death because of their inability

to differentiate between thoughts and deeds (Webb, 2005). For example, a young girl

whose brother has died may think that her past anger toward him caused his death.

Often young children

also think that a deceased person's biological functions continue even after burial

(Bering & Bjorklund, 2004; Slaughter & Lyons, 2003): A young child may ask how a

deceased person can breathe or go to the bathroom after being buried. In the movie

My Girl (Grazer, Friendly, Gold, Carraciolo, & Zieff, 1998), which deals sensitively

with different types of loss throughout the life span, a little girl puts her best

friend's eyeglasses on him in the casket so that he will be able to see after he

is buried (Webb).

Preschoolers often consider death to be temporary and reversible (Nagy, 1948; Speece

& Brent, 1984). This belief was poignantly demonstrated by a 5-year-old girl whom

I (JM) saw for

counseling

. Her parents were going through a divorce, and she had recently returned from the

funeral of her aunt. When I asked her about her aunt's death, she told me in a matter-of-fact

way that her aunt was now "in a clock." Perplexed, I turned to her mother for clarification.

The child's mother explained that the aunt had been cremated and placed in a clock-urn

on the mantle! In our first session, I used the Freely Drawn Picture technique developed

by Gardner (1992), asking the child to draw a picture from her imagination and to

tell a story about it. Her picture was of a female figure in a long gown, holding

a bouquet of flowers in one hand and the hand of a male figure in her other hand.

Roses bordered the picture. The child's story nicely demonstrates her conception

of the reversibility of death:

A woman and a man. They had a fire. The woman was still sleeping.

The man got out. She got killed. Then the hospital came. The

fireman got the lady out. The hospital fixed her up. She was in the

hospital 40 days. And then a few days after 40 days, she got

married.

School-Aged Children School-aged children

7 to 11 begin to appreciate the permanence of death but generally see it as removed

from them, something that primarily happens to the old and weak and can be beaten

if only one is fast or strong enough (Webb, 2005).

Children

this age may feel guilty when someone close to them dies because they believe that

they should have done something to prevent it. For this reason, whenever

children

lose someone it is important to reassure them that it was not their fault, even

if they do not verbalize guilt. Interestingly, among

children

in this age range, death often assumes external forms, such as skeletons, ghosts,

or bogeymen, which are sometimes manifested in dreams. In the video What About Me?

Kids & Grief (Film Ideas, Inc., 1992), a boy describes a dream after his younger

sister died in which bogeymen shoot her with guns.

Prepubertal children

between 9 and 12 begin to think of death in more abstract terms because of changes

in their cognitive development. Their artwork reflects this change. Lonetto (1980)

found that

children

around this age used black crayon, which they described as "darkness," in their

artistic representations of death. However, while prepubertal

children

begin to think of death in more mature ways and experience increasing awareness

of their own mortality, they still tend to view death as far removed from themselves.

Adolescents

For teenagers, death can become an area of fascination; for some it is even a romantic

concept. Much to the chagrin of adults, teenagers may flirt with death by engaging

in dangerous activities, such as fast driving, experimenting with drugs, or taking

other unnecessary risks. Teenagers may even wonder who would come to their funerals

and what those people would feel. Yet at the same time, they may not be fully aware

of the finality of death (Webb, 2005). Adolescence can be a turbulent time marked

by paradoxes (Corey and Corey, 2006). We encourage adolescents to be responsible

and accept reality at a time in their lives when they are confronted with a variety

of temptations and avenues of escape. Teenagers are also expected to act as mature

adults before they are ready for full autonomy. And they are encouraged to think

of the future even as they have a strong desire to live for the moment. This paradoxical

context in which they live can easily give rise to confusion, isolation, and loneliness.

Superimpose on this scenario a significant loss, and teenagers become vulnerable

to a personal crisis that may not be readily apparent to the adults in their lives.

They are not prepared for the conundrum of emotions that accompany a personal loss.

Moreover, teenagers coping with death often struggle with the same philosophical

issues that adults do, though they may lack the conceptual framework for doing so

(Noppe & Noppe, 1987). Questions about fairness, the nature of life and death, and

the meaning of life become personal issues to be grappled with after a significant

loss.

This struggle was brought home to me (JM) in a very personal way during a meeting

with a 14-year-old girl who had recently lost her best friend in a drowning accident.

After an unsuccessful attempt to help the girl talk with me about her feelings about

the loss, I asked her if she would mind drawing a picture about them. She immediately

put pencil to paper, drawing a picture of an outstretched hand reaching for a heart.

The wrist was encircled by a chain that extended downward. She explained:

That's love and complete happiness [pointing to heart]. I go to

reach for it. I always get pulled back. Sometimes, when I feel

happy, I don't get to enjoy it for long because something bad

happens. When my friend died, something bad happened, and it

started tugging me down.

We were then able to have a meaningful therapeutic discussion about the impact of

her tragic loss, which gave her the opportunity to better understand and express

her grief. Since adolescents often give the outward appearance that everything is

okay and hold adults at arm's length emotionally, the adults may assume wrongly that

adolescents who have experienced a personal loss need less emotional support than

younger

children

. We may be concerned that we will invade their privacy and not respect their independence

if we try to engage a grieving adolescent. However, just as younger

children need help with understanding and expressing their grief, so do adolescents.

DRAWINGS

Often when young clients have difficulty finding words to express their thoughts

and feelings, they are able to do so through drawings. Goodman (2005) described a

14-year-old boy who had lost his father to suicide. Goodman explained how the boy's

drawings resulted in the "externalizing of significant memories" which became "a

bridge for discussing unarticulated thoughts and feelings about death" (p. 301).

Goodman suggested that the use of drawings can be easily adapted to the approach

of a particular counselor" When taking a nondirective approach, counselors can follow

their client's lead and allow for "a more open-ended unfolding of issues" (p. 301).

A directive approach can be taken when drawings are structured around "particular

themes" (p. 301).

Webb (2005) presented the case of a 9-year-old girl who lost her friend to a traumatic

death. With this client, Webb used another drawing approach, the Squiggle Technique

(pp. 182-184) developed by Winnicott (1971). The counselor first makes a squiggle

mark on a page; the client is then invited to make another mark. Counselor and client

take turns with this process until the drawing is completed. This method can strengthen

rapport between counselor and client while at the same time facilitating the exploration

of important themes. Use of the Squiggle Technique helped Webb's client to explore

her fear of death and gain some closure regarding the traumatic loss of her friend.

Sagara-Rosenmeyer and Davies (2007) reported on a study in which they used interviews

and drawings to explore Japanese

children

's views of death and afterlife. In their study,

children

aged 6-12 "perceived life as an evolving process that leads to death, and regarded

death as a transitional point to an afterlife" (p. 223). Worden (1996) described

how drawings can be used in groups as well as individual

counseling

. In a group setting, he suggested,

children might initially share their drawing with another child or a couple of children

before sharing it with the entire group.

BEREAVEMENT SUPPORT GROUPS

One way of assisting bereaved children

and adolescents is to give them the opportunity to come together with other grieving

young people and help them to learn about and share their grief (Haasl & Marnocha,

2000). This can be accomplished using a support group format. In collaboration with

a hospice program, I (JM) developed a support group format for use with

children

and adolescents. The group met for two hours weekly for six weeks. The first week

was for the parents only; during the remaining five weeks parents met in their own

support group at the same time their

children were meeting. The children

were divided into three groups based on age: 5 to 8, 9 to 13, and 14 to 18. Age

ranges for each group were meant to be guidelines only; a younger or older child

might be appropriate for a particular group depending on the child's developmental

level, the makeup of the group, and the number and ages of the other

children

. Optimum group size was 6 to 8 members. Each group had two co-leaders. Most participants

had lost a parent, sibling, or grandparent.

The basic philosophy was that the support group was designed to provide bereaved

young people with a safe place where they could better understand, express, and cope

with their grief. Group activities were designed to normalize the grieving process,

encourage sharing with other

children, and instill hope. The support group was not therapy; it was not designed

to help children

work on personal problems or make behavioral changes. Rather, it was intended to

give bereaved young people and their parents support and encouragement.

During the first meeting, parents were given information on child and adolescent

bereavement and an overview of the program. We then discussed the loss that had occurred

in each family and learned about each parent's concerns and expectations. Thereafter,

the parents met to share feelings and concerns and learn from each other. Parents

then joined their

children

for the second half of the final session, during which they discussed what they

had gained from participation in the bereavement support group. The activities and

discussion for each of the five meetings for

children

and adolescents revolved around a different theme: 1--Introduction and Discussion

of Death/Grief; 2--Feelings; 3--Memories; 4--The Funeral Process; 5--Coping Skills/Saying

Goodbye. Ideas for the content and structure of each group meeting were gathered

from a variety of sources, including publications on

children

's bereavement groups by Beckman (1990), Davis (1995), Haasl and Marnocha, (2000),

Johnson, (1995), Sandier et al. (2003), Wolfe (1995), and Wolfe and Senta (1995).

Each session followed the same format. We began with a warm-up exercise that encouraged

group interaction. For example, in the first session for parents as well as

children

, the group broke up into pairs who were asked to get to know their partners and

then introduce them to the group. In another warm up-exercise, we passed out index

cards with different feelings written on them and asked participants to talk about

a time when they experienced that feeling. We found that such warm-up exercises provided

an excellent means of helping group members to feel comfortable and encouraged open

sharing.

We then provided structured group experiences involving art, writing, and sharing

to help participants better understand and express their grief. For the session dealing

with memories, we asked participants to bring in pictures and other objects that

reminded them of their deceased loved one to share with the group. We took a field

trip to a funeral home for the session dealing with the funeral process. There participants

had the opportunity to learn what happens from the time of death until burial, to

ask questions of the funeral director, and to share feelings and memories of their

own experiences at funerals. In our final session, each group created a mural of

ways of coping with grief. Also, in that session, as a way of saying goodbye to each

other, participants each designed a greeting card from construction paper that all

other group members signed. At the final session, participants received a certificate

of completion.

While we did not collect outcome data on the children

's bereavement support groups, the feedback from parents and young people who completed

the group was uniformly positive. Parents often reported that they had acquired a

better understanding of their

children

and were therefore able to be more supportive, and young people often commented

on how the group helped them to better understand and express their grief and not

to feel so alone. Few studies have examined the efficacy of bereavement support groups

(Tremblay & Israel, 1998). Sandler et al. (1992), in an empirical investigation of

the effectiveness of a support group with bereaved young people and their parents,

reported improved family communication about grief, increased family support, and

decreased conduct problems and depression for adolescents, but not for younger

children

. Subsequently Sandier et al. (2003) completed an experimental study of a bereavement

support group that led to improvements in both parents and

children: enhanced parenting, better coping in both children

and parents, increased caregiver well-being, and reduced stress.

We have examined two approaches to helping bereaved young people and their families

deal more effectively with their grief: drawings and bereavement support groups.

These approaches are valuable tools counselors can use to facilitate the

counseling

process and promote healthy grieving. Bibliotherapy also holds promise for counselors

in their work with bereaved young people.

BIBLIOTHERAPY

Bibliotherapy is the practice of using books and stories as part of the counseling

process (Jones, 2001). Although many people are not familiar with the practice,

the term was coined as far back as 1916 by Samuel Carothers (Cohen, 1987). Literature

can sometimes help

children

better understand concepts that may not otherwise be clear to them. "Therapeutic

reading," as it is sometimes called, is an effective way to stimulate conversation

about topics that

children

may not be comfortable discussing openly, such as death, sex, or abuse. When a child

experiences a loss, bibliotherapy can be used to both help the child to better understand

death and clear a path for open conversation about it. As noted by Malchiodi (2008),

bibliotherapy also reassures

children that they are not alone and often answers questions they may have. As a

result, children

who are traumatized experience decreased isolation when they realize that others

share their situation (Webb, 2005).

When considering bibliotherapy, there are many factors to take into account, such

as CANS: cognitive ability, age, needs, and situation. Counselors need to choose

the literature carefully, keeping in mind the client's specific situation, age and

cognitive ability, and needs related to the situation experienced. Bibliotherapy

that does not match the developmental age and needs of the child will probably have

no significant impact.

The counselor also needs to read all books before recommending them. It is necessary

to consider the relevance of the book or story to the child's current situation and

individual development (Malchiodi, 2008). Also, the vocabulary must be appropriate

for the child. When choosing literature, it is also important to know the relationship

of the child to the person who died, how the individual died, the age of the child

at the time of the loss, and how the child learned about the death (Malchiodi). Counselors

will also find it beneficial to inquire about the child's cultural or religious background

so that they can choose literature that is

culturally relevant for the child (Malchiodi).

Books chosen should provide comfort and reassurance, along with explanation and insight,

and be realistic. Rather than being frightening, the book should be a source of comfort.

The books chosen should help

children

gain a better understanding of the feelings they are experiencing and be realistic

in the sense that the child can relate to what is happening. Once you have chosen

a book, explain why it is relevant and why you think the child should read it, to

help the child relate the story to personal experience (Malchiodi, 2008).

As the child reads the book, the counselor can stimulate discussion by asking specific

questions to tie the story to the child's situation. Malchiodi (2008, p. 182) suggests

the following questions to help

children explore a story and its characters and how they relate to the reader:

* Are you like any of the story's characters?

* Do any of the characters remind you of someone?

* Who would you like to be in the story?

* Is there anything you would like to change about the story?

* How would you change the characters, what happened, or how the story ended?

* What is your favorite part of the story?

* Did anything in the story ever happen to you?

* What do you think will happen to the characters in this story tomorrow, in a few

weeks, or a year from now?

Bibliotherapy is a wonderful tool when it is used correctly. It can benefit children

by helping them to understand their emotions, realize that they are not alone, and

answer their questions. However, it is important for counselors to keep in mind that

every child is unique and that bibliotherapy may not be appropriate for every person

or situation. Berns (2003) and Goldman (2000) provided helpful lists of bibliotherapy

resources for use with bereaved young people, but we have not found any studies that

systematically examined the effectiveness of bibliotherapy as an intervention with

bereaved

children and adolescents. This is an area in need of further research.

CULTURAL INFLUENCES

Any discussion of bereavement in childhood and adolescence needs to take into account

cultural influences on the bereavement process. Counselors working with this population

need to be mindful of how their own cultural experiences have shaped their views

of death and the grieving process and how each client is similarly affected (Brinson,

1996; Florian & Kravitz, 1985; Sagara-Rosenmeyer & Davis, 2007). Families vary greatly

in their views and customs related to death, and counselors need to respect these

diverse

perspectives in working with bereaved young people and their families (Webb, 2005).

One example of the influence of cultural factors is the question of whether a young

child should attend the funeral. While many counselors who work with bereaved

children

and their families would probably agree on the advantages of including the child

in the family's mourning rituals (e.g., Shapiro, 1994), some families may have strong

feelings against this practice rooted in their cultural traditions. Counselors need

to be sensitive to this, attempt to understand how cultural factors may exert an

influence, and work respectfully with families within the context of their religious

and cultural beliefs.

PROFESSIONAL IMPLICATIONS

Counselors working with bereaved young people and their families need to be mindful

of the ethical issues that arise in providing services to them. They also need to

be aware of how their own grief experiences affect their work. The ethical guidelines

of the American

Counseling

Association (ACA, 2005) and the American Mental Health Counselors Association (AMHCA,

2010) are explicit in emphasizing the importance of gaining competence in the areas

of

counseling they offer. They also emphasize the importance of cultural sensitivity.

While work with bereaved

children

and adolescents and their families requires general skills that any competent mental

health counselor would be expected to possess, there are additional areas of knowledge

and skill that are necessary for effective work with this population, among them

(a) child and adolescent development as it relates to the process of bereavement;

(b) cultural variations in beliefs about death and mourning practices; and (c) specific

interventions to help bereaved young people and their families. Hopefully, articles

like this will be of help to counselors interested in working with this population.

In addition, the Association of Death Education and

Counseling

(http://www.adec.org/) provides continuing education opportunities and certification

of professionals as experts in death and bereavement.

To work effectively with bereaved clients, counselors need to be aware of how they

have been affected by their own loss experiences (Morgan, 1994). Many adults, including

counselors, have lost someone at a tender age but did not have anyone to talk with

about their loss. James (2008) emphasized the importance of counselors' self-care

concerning their own grief experiences before they attempt to help bereaved clients.

Rando (1984) cautioned that counselors who have not worked through their own grief

run the risk of reliving their losses in ways that could undermine the

counseling

process. He suggested that counselors need to deal effectively with their own losses

so that they can use those experiences to enhance their effectiveness with bereaved

clients.

The experience of losing someone in childhood but not having the opportunity to grieve

was poignantly described in Albom's 1997 book, Tuesdays with Morrie, in which Albom

shared his weekly conversations with his former college professor, Morrie Schwartz,

who was dying. His description could apply to any adult who has lost a loved one

at a tender age. Morrie's story can help us as counselors to become more aware of

how we and our clients can be affected by early loss experiences. Albom described

an interview that Morrie had with Ted Koppel on the television program Nightline,

in which Morrie related his experience of losing his mother at a young age. After

receiving a letter from a schoolteacher in Pennsylvania who taught a class of nine

children

in which every child had experienced the death of a parent, Morrie wrote back to

tell the teacher about his loss.

"I lost my mother when I was a child ... and it was quite a blow to me... I wish

I'd had a group like yours where I would have been able to talk about my sorrows.

I would have joined your group because.." His voice cracked. "Because I was so lonely..."

"Morrie," Koppel said, "that was 70 years ago your mother died. The pain still goes

on?" "You bet," Morrie whispered (pp. 71-72). Hopefully, self-aware counselors who

have encountered significant losses can experience growth and use those experiences

to develop deeper empathy for their clients.

CONCLUSION

We have described developmental variations in how young people of different ages

experience loss and approaches that can be useful to counselors who work with bereaved

young people and their families. We have emphasized the importance of considering

the developmental level of the child, the family context, and cultural factors that

may affect the bereavement process. Moreover, we have encouraged the use of an integrative

counseling approach that includes the use of drawings, support groups, and bibliotherapy,

which can be combined with other

counseling

techniques and tailored to the needs of a particular client. We have also raised

ethical issues that need to be considered in working with bereaved

children

and adolescents and their families, and we have highlighted the relevance of the

counselor's own personal experience with grief.

As counselors become more knowledgeable about bereavement resources and counseling

approaches, they will be in a better position to assist grieving young people and

their families. Articles like this one can provide mental health counselors with

information and encouragement to develop their own bereavement services for individuals

in need. However, more outcome studies are needed to determine the best approaches

to take with young people who have suffered loss.

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Author Note: We would like to express our appreciation to hospice workers everywhere

who tirelessly care for those who are dying and for those who mourn. We also gratefully

acknowledge June Hobbs, Gardner-Webb University, who supported this project with

an undergraduate research grant, and David Carscaddon, Gardner-Webb University, for

his helpful review of our paper

James P. Morgan and Jesse E. Roberts are affiliated with Gardner-Webb University.

Correspondence concerning this article should be addressed to James P. Morgan, School

of Psychology and

Counseling

, Gardner-Webb University, PO Box 7344, Boiling Springs, NC 28017. E-mail: jmorgan at gardner-webb.edu.

Questia, a part of Gale, Cengage Learning. www.questia.com

Publication Information:

Article Title: Helping Bereaved Children and Adolescents: Strategies and Implications

for Counselors. Contributors: James P. Morgan - author, Jesse E. Roberts - author.

Journal Title: Journal of Mental Health Counseling. Volume: 32. Issue: 3. Publication

Year: 2010. Page Number: 206+. COPYRIGHT 2010 American Mental Health Counselors Association;

COPYRIGHT 2010 Gale, Cengage Learning

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