Transcript Bereavement

Children Coping With Death & Dying
Presented by Nora Gravois, LMSW-IPR
Bereavement Coordinator for The Hospice of East Texas
Objectives
• Clarify Definitions
• Distinguish normal vs complicated grief
• Acknowledge children’s grief process & needs of grieving children
• Identify effective communication to talk to children about death and dying
• Encourage professional self care
Bereavement
Bereavement is the state of
having suffered a loss.
Objective: Clarify definition
Objective: Clarify Definition
Grief
Process of
experiencing
the
psychological,
social, physical
and spiritual
reactions to
the perception
of loss.
Objective: Clarify definition
Anticipatory Grief
A normal mourning reaction
that allows emotional preparation for the loss.
Objective: Clarify definition
Mourning
Objective: Clarify definition
Conscious and unconscious processes
that help the mourner adapt to the loss.
Reinvestment/Accommodation
Reinvesting emotional energy into new constructive outlets.
Preparing to “embark”
Objective: Clarify definition
Children’s Grief
Should we discuss death and dying with Children?
Shielding a child from conversations about death and dying deprives them
•of their own right and need to grieve
•of their need to mourn
•of their need to feel and heal
•of their need to experience reinvestment
Children’s Grief
Why should we talk to children
about death and dying?
If we don’t
Conveys a message of avoidance
Avoidance lead to unhealthy feelings and emotions
Unresolved worry, fear
Increased anxiety, apprehension
Develops seeds for resentment and distrust
Opportunity for unhealthy lifelong coping patterns
Objective: Effective Communication with Children
Children’s Grief
Why should we talk to children
about death and dying?
If we do
We will discover what is known vs. not known
Clear up distorted thinking
Resolve fears, worries
Provide needed information
Demonstrate comfort, understanding
Promote growth, coping skills
Strengthen bond of supportive relationships
Assurance and security lead to healthy coping
Child learns to understand grief as part of life cycle
that will support throughout life
Objective: Effective Communication with Children
Children’s Normal Grief Reactions
May be emotional
Self blame
Guilt
Fears
Helplessness/Hopelessness
Anger
Withdrawn
Increased Anxiety
May be Spiritual
Challenges to belief system
Physical Confusion
A LOT of questions
“Why’s”
Where did he/she go?
What is “dead”?
Objective: Distinguish Normal vs Complicated Grief
Children’s Normal Grief Reactions
May be Physical / Behavioral
May be Cognitive
Reduced attention span
Increased distraction
Easily confused
Exaggeration
Magical thinking
Objective: Distinguish Normal vs. Complicated Grief
Changes in appetite
Sleep disturbances
Nightmares
Physical hurts
Hyperactivity
Aggressive reactions
Increased volume/tone in speech
Passive reactions
Limited conversations, introverted
Complicated Grief
DSMIV-TR
Prolonged, intense reactions that interfere
with daily function 6 months or longer
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Symptoms overlap with depression diagnosis
Refusal to accept loss
Continued sense of disbelief, anger
Recurrent painful emotions
Preoccupation with thoughts of loved one
Distressing intrusive thoughts related to death
Intense longing and yearning
Referred to as traumatic, altered, pathological,
dysfunctional, abnormal, absent, inhibited,
delayed, disenfranchised
NO SENSE OF RELIEF, REST OR SUPPORT
Objective: Distinguish Normal vs Complicated Grief
Complicated Grief Implications
•
Social interactions increase support and risk
•Tween & Teen individuation stretches adult-child relationships
•Increased possibility of unfinished business
•Increased possibility of anger, guilt, depression
Objective: Distinguish Normal vs Complicated Grief
Objective Assessment
Normal
Anticipatory
Complicated
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Tearfulness and general sadness
? Expression of emotions
? Physical Reactions
? Ability to Focus
? Desire & Motivation
? Ability to Function w/ daily activities
?
Objective: Distinguish Normal vs Complicated Grief
Children’s Grief Concepts 0-2 years
LM Aldrich, William Worden, Dan Schaefer, Christine Lyons
Understanding: Does not comprehend death
Aware of constant activity in home, others looking
“sad”, someone is “missing”
Reactions: Responds to emotions or feelings of adults
Crankiness, Crying, Vomiting
Regression in Toileting, Altered eating and sleeping
Clinging, Restless, Insecure, Scared
NEED: Reassurance
Wrap infant in soft blanket, maintain routine, physical assurance through
holding, quick attention to expressed reactions and needs
Objective: Acknowledge Needs of Grieving Children
Children’s Grief Concepts 2-5 years
LM Aldrich, William Worden, Dan Schaefer, Christine Lyons
Understanding: Mostly live in present tense
Curious about death and life; see it as temporary, reversible
Death mixed up with trips, sleep, happens to other people
Engage in Magical, exaggerated thinking
Wonder what deceased is doing “underground”
Reactions: Trying to “Figure it Out”
May show little concern or Regress to infantile behavior, Fear separation
Need to talk about the death over and over, Confused
NEED: Consistency
Short explanations with real terms, fact of death, no catchy sayings,
Consistent Expectations for behavior
Respond to security needs
Don’t punish, instead explain and teach with repetition
Let the child tell the story over again
Objective: Acknowledge Needs of Grieving Children
Children’s Grief Concepts 6-9 years
“This particular group
should be singled out for special concern.
They have insufficiently developed
social skills to enable them
to defend themselves.”
…William Worden
Objective: Acknowledge Needs of Grieving Children
Children’s Grief Concepts 6-9 years
LM Aldrich, William Worden, Dan Schaefer, Christine Lyons
Understanding: Clearer
Comprehending that they can die too; begin to question biology of death
Begins to fear Death; realize that death is final; people they love can
Reactions: Highly emotional
Crying, high anxiety, anger, cranky, aggression, hyperactivity
Decline in school performance, involvement
Greif reactions ebb and flow; less willing to talk about death
More fearful questions and thoughts about “what will happen if…”
NEED: Honesty
Refrain from using cliché's
Respond passionately; be responsive without judgment
Reassurances with clear expectations of appropriate behavior
Use of art and stories
Objective: Acknowledge Needs of Grieving Children
Children’s Grief Concepts 9 - 12 years
“This age concentrates on
the disruption death causes.”
“Do we have to move because daddy died?”
”Now grandpa won’t be able to take me fishing”.
…William Worden
Objective: Acknowledge Needs of Grieving Children
Children’s Grief Concepts 9 -12 years
LM Aldrich, William Worden, Dan Schaefer, Christine Lyons
Understanding: Death is very personal
A more realistic view of death; can differentiate between dead and alive
Increased curiosity / research about biological aspects of death
Begin to understand that death is “forever”
Reactions: Separation Anxiety
Fear, reluctant to leave safe adults or home
Boys may lose some manual skills; aggression appears hostile
Anger, Guilt, Distancing, Anxious, Worried, Isolated
Decline in performance, grades, involvement
NEED: Permission with appropriate expectations
Give compassionate answers, comfort, reassurance
Permission to vent feelings; provide honest explanation of death
Listen attentively, Use appropriate touch (with permission)
Include in discussion of ways to honor & remember loved one
Objective: Acknowledge Needs of Grieving Children
Children’s Grief Concepts Teen years
LM Aldrich, William Worden, Dan Schaefer, Christine Lyons
Understanding: More adult processes evident
Able to think abstractly; Understands implications of death
Talks about feelings of immortality; realize death is fragile
Reactions: Assumes the adult role
Fearful of future, preoccupied with thoughts of death
May need to protect or stay close to loved ones
Anger and aggression, May exhibit “risk-taking” behavior
Withdrawn, Quiet, Loud, Lonely, Sad, Worried
NEED: Communication & Connection
Encourage communication “when you can”
Physical touch very important, but ask permission
Engage in loving confrontation
Involve trusted friend
Provide professional help if necessary
Objective: Acknowledge Needs of Grieving Children
Common Misconceptions
“Children do not
understand death”
“Children don’t
grieve”
“Attending a
funeral is not
good for
Children”
“Talking
makes it worse”
“Children don’t really know
what’s going on”
“Silence means okay”
“Children will be scared
if they find out the truth”
“Child is young, won’t
remember”
“Children are just little adults”
“It’s best not to bring it up”
Objective: Acknowledge Needs of Grieving Children
Common Mistakes that Adults Make
Minimize
expressions of grief
Assume a child is
not grieving because
of laugher or play
Think all children
feel the same
Avoid the
Grieving PROCESS
Use cliché's like ‘God’s will’,
Or ‘God took her because
she was so good’
Objective: Acknowledge Needs of Grieving Children
Stop telling stories
Avoid opportunities
To allow expression
and understanding
of feelings
Not talk about their own grief, and
how support, strength is found
Use euphemisms like ‘he died in his sleep’,
‘crossed over’, or ‘we lost her”
Talking to Children about Death & Dying
Children need to feel safe and secure.
Try not to put up barriers
that may inhibit their attempts to talk.
Keep discussions
developmentally appropriate.
Be sensitive to their desire to talk when THEY are ready.
Objective: Acknowledge Needs of Grieving Children
Talking to Children about Death & Dying
Be ready for “spurts”…
when a child is ready
for more information,
questions will be asked.
Provide brief and simple answers that are appropriate to the
question asked; do not overwhelm with too much information.
Listen and accept feelings….
create an environment within the
family system that makes it okay to
talk; offer permission to feel & be.
Offer honest, simple, straightforward explanations.
Use concrete vocabulary, such as “die”, death, or “dying”.
Objective: Acknowledge Needs of Grieving Children
A Child’s Tasks of Mourning
Experiencing the Pain of Grief
•Provide a time and place to grieve
•Recognize that the first days are the most chaotic
•Provide opportunities for expression
•Anticipate critical times when intensity may be high
•Expect more difficulty 6-9 months later
Objective: Acknowledge Grief Process
A Child’s Tasks of Mourning
Accepting the Reality of Loss
•Acknowledge the loss each time it comes up
•Encourage to say aloud what is “missing” at that moment
•Talk about “new reality” in structured manner
•Stick to facts, what is known, or information learned
Objective: Acknowledge Grief Process
A Child’s Tasks of Mourning
Adjusting to an environment
•Talk about how things are different now
•Encourage to say aloud the things their loved one used to do
•Brainstorm who can do those things now (not replace, but embrace)
•Recognize the “empty space”
•Involve children in problem solving to handle reminders
•Plan events that honor presence in life and death
Objective: Acknowledge Grief Process
A Child’s Tasks of Mourning
Reinvesting emotional energy
•Resolution of loss is a focus on the meaning of the life, not the death
•Select memorial activities, events that honor the life
•Discover things “in common” that express honor
•Decrease attention on expressions of continual trauma reminders
•Increase attention on expressions of good life lived
•Validate efforts made by the child to embark on “new normal”
Heart Equation
T+T=H
T
Objective: Acknowledge Grief Process
KEEP IN MIND ~ Children Need
To feel safe in confusion
Routine, Order, and Stability
Designated Safe Place
Comfort
Do not reject their emotions or their efforts to comfort you
Permission
Do not tell them How to feel or How Not to feel
Assurance of being okay
Patience
They will ask questions over and over
Opportunities to say goodbye
Death is not contagious…be sure to differentiate.
Children tend to idolize the dead
Gently help children regain balance and perspective
Compassion Fatigue
May be manifested as anger, anxiety, blame, helplessness, guilt
May look cynical, or appear as decrease in tolerance or sensitivity
May feel difficult maintaining hope
May take the form of a chronic or delayed grief response
…no satisfactory conclusion.
Professional caregivers are distant mourners
Effects of professional grief are hidden & subtle
Professional losses accumulate
Is a significant cause of burnout
Objective: Self Care Skills
So What About YOU?
PRACTICE SELF-CARE
Be aware of professional boundaries
Maintain Balance with ongoing self monitoring
Learn to express professional grief in appropriate ways
Let others know what you need
Treasure relationships
Draw on support
Be patient with yourself
Manage Stress
Say Goodbye
Tend to Basic Health Needs
Sustain Family Support
Nurture Friendships
Relax, Rest, Rejuvenate
Laugh
Attend Peer Meetings
Be Nice to Yourself
Acknowledge your feelings, grief reactions, and
experiences of loss as part of your journey
Objective: Self Care Skills
Grief is a Journey
A little laugh
A little hope
A little promise
Nora Gravois, LMSW-IPR
Bereavement Coordinator
The Hospice of East Texas
4111 University Blvd.
Tyler, Texas 75701
www.hospiceofeasttexas.org
(903) 266-3447 direct line
Resources for Children Coping with Death & Dying
Karaban, Roslyn A. Ph.D: Complicated Losses, Difficult Deaths, 2000
Rando, Therese A, Grief, Dying and Death, 1984.
Schaefer, Dan, Ph.D., & Lyons, Christine: How Do We Tell the Children, 1986
DSMIV-TR
Numerous works of:
Elizabeth Kubler-Ross
Dale Larson
Alan Wolfelt
William Worden