A discussion of coping methods and counseling techniques for children and adults dealing with grief and bereavement

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Slate, C. N., & Scott, D. A. (2009, March). A discussion of coping methods and counseling techniques for children and adults dealing with grief and bereavement. Paper based on a program presented at the American Counseling Association Annual Conference and Exposition, Charlotte, NC.

A Discussion of Coping Methods and Counseling Techniques for Children and Adults Dealing With Grief and Bereavement
Paper based on a program presented at the 2009 American Counseling Association Annual Conference and

Exposition, March 19-23, Charlotte, North Carolina.

Candice N. Slate and David A. Scott
Slate, Candice N. is currently a M.Ed. candidate in the Community Counseling Program at Clemson University. Her area of interest is grief and bereavement across the lifespan; particularly on techniques and skills most effective and well-received for those clients.
Scott, David A. is currently the Community Counseling Program Coordinator and Assistant Professor at Clemson University. His areas of interest include career and community counseling, identity development, and at-risk youth.
The Basics
What Do Grief and Bereavement Really Mean?

Most can agree with the simplistic definition provided by Webster that grief is “a keen mental suffering or distress over affliction or loss; sharp sorrow; painful regret” (Pickett, et al., 2005, p. 500). As we can see, grief is not too abstract a term for us to define, because to some degree we have all experienced grief or seen it displayed in others. Though it is not a hard term to wrap meaning around, it is however a complex entity in itself. It is presented differently in everyone through variances in intensity, complexity, duration, and the properties and stages that one experiences.

Webster also defines bereavement as the “state of sorrow over the death or departure of a loved one” (Pickett, et al., 2005, p. 106). This term also seems pretty simple and equates to the reactions one goes through after losing a loved one. Again, the terms may be simple, but the emotions attached to both are very complex.

Now that there is an established common understanding of the terms, one might raise the question, is there a difference between grief and bereavement? Yes. Most experts offer an explanation similar to the following: bereavement is a term specifically used to describe the effects experienced from the death of a significant other, whereas grief can describe any sort of loss not necessarily related to death, i.e.: loss of control, loss of money, divorce (National Institute for Trauma and Loss in Children, n.d.).

Stages of Grief

In 1969, Elisabeth Kubler-Ross (Kubler-Ross and Hobbing, 1997) published a model to explain the stages of grief. This model is not specific to bereavement or the death of someone; this model is used for grief associated with trauma and change. In the matter of grief associated with death, this model can be applied to anticipatory grief experienced by one who is facing their own death or to the loved ones who are preparing for the death of a significant one in addition to the bereavement experienced following the death of someone. She denotes that there are five stages (denial, anger, bargaining, depression and acceptance) and that the bereaved may not go through all five stages, nor follow the steps in sequence, and that one may experience a stage more than once. She does express that most individuals will experience at least two of the stages. The stages are not linear nor are they equal in the time one spends per stage. A person does not have to complete a stage in order to progress into another stage.

Goals of Grief Counseling & Grief Therapy

There is a difference in the goals of grief counseling and grief therapy. The term grief counseling is most often reserved for helping someone work through the process of grief via one-on-one counseling or through group work (Worden, 1991). The goals of grief counseling are to aide the individual through uncomplicated, normal grief to a healthy resolution of the tasks of grieving within a reasonable amount of time.

Goals of grief counseling typically include helping the bereaved move toward acceptance through guiding the individual to talk about the loss, who the person was to them, and the circumstances surrounding the death. In addition, it is important to help the bereaved label and describe their feelings and emotions encompassing the loss. Another important goal of grief counseling is to help the individual learn coping strategies for tough times, such as anniversaries, holidays, birthdays, and milestones. Letting the bereaved know that the emotions they are feeling are normal and expected is also a significant component of grief counseling. Two very critical constituents of grief counseling include helping the bereaved to understand their coping behavior and to identify coping mechanisms that are problematic or unhealthy for the individual. Without these basic principles, the person may continue these unhealthy patterns and may need more extensive treatment such as grief therapy.

Grief therapy is a term used for more serious or complicated grief reactions that usually fall under four main types including exaggerated grief, chronic grief, masked grief, and delayed grief (American Society of Clinical Oncology [ASCO], n.d.a).

The main goal of grief therapy is to identify and resolve the conflicts of separation that interfere with the completion of the tasks of mourning, such as the four complicated grief reactions mentioned above. Grief therapy entails talking about the loss and determining if there is minimal or exacerbated emotions surrounding the loss. Grief therapy is intended to allow the bereaved to see that negative, uncomfortable feelings and emotions do not preclude more positive ones, and vice versa (Slate and Scott, 2009).
Grief Across the Lifespan
Grief is unique for everyone, however there are some commonalities that can be shared within age groups. There are vast differences in the way that children and adults grieve, namely because children have not yet developed complex and abstract reasoning skills to express and understand their feelings and emotions.
Grief in Children

Exploring how grief is presented in children can best be explained by dividing up the developmental stages, as children attain abilities and refine them throughout their growth.

Infant- 3 years old.

Children from birth through the age of three are not able to understand death. However, they are aware of the absence of a caregiver. This can be displayed by the child through symptoms such as an increase in crying, seeming more lethargic and listless, and via noticeable changes in eating or sleeping habits (Fitzgerald, 1992). The child may also look about or seem to wait for the caregiver to return. A two or three year old may associate death with being asleep. Also, if a child sees a caregiver grieving or dwelling in sadness, the child will often mimic those emotions though they do not understand them or necessarily feel that way themselves (ASCO, n.d.b).

Approaches/Techniques. Although children at this age do not understand death, it is still important, as counselors, to explain to the child what happened in order to hopefully alleviate thoughts that they may have about being abandoned by their loved one. Using simple, but correct terminology is important. Saying “Grandma passed away” or “We lost him” is not helpful to the child for comprehension in the long run. A death occurring at this age for the child will be revisited as they arrive at further developmental stages, so setting the pace now will lessen the confusion for them when they become inquisitive later about the death.
3-6 year olds.

This age group is very curious about death. They may ask questions like “How does Mom breathe since he is dead?” because they are now able to understand that the person is not there with them anymore but believe that they are alive in some limited kind of way. They may be able to recognize the physical death as temporary or gradual, reversible and not final. The child may also experience ‘magical thinking’, in which they believe that their thoughts caused the action (i.e., being mad at the parent, misbehaving, saying “I hate you”, etc.; ASCO, n.d.b). They are very much egocentric and may feel that they caused the death. Children at this age often temporarily regress with symptoms such as bladder and bowel control, use baby talk, thumb sucking, want to sleep with a sibling or parent, and experience a change in eating and sleeping habits. They may also have worries of abandonment and fear that when others leave that they are not going to come back. Children at this age are also much more impressionable and are greatly influenced by the emotions that others are expressing, especially sadness.

Approaches/Techniques. At this age it is especially important to be honest and provide as much detail as can be comprehended by the child (Wolfelt, 1983). This should be done to lessen the confusion and provide as much clarity about the event as possible. Doing so will help the child to understand that their thoughts and actions did not influence the death of their loved one. Measures should be taken to assure the child that they will be cared for and that one’s leaving does not preclude them from ever coming back. Counselors need to encourage the child’s guardians to try and keep to the child’s regular routine and allow them to be their age. Children should be told what will take place at the memorial service and burial of the loved one and be given the option of attending.

Therapies that are especially helpful when working with grieving children include play, art, puppet, and storytelling. These therapies are beneficial because they allow expression without words to show how they feel. It is easier for a child this age to draw or use a figurine to act out feelings than it is for them to indentify those same emotions in a verbal format. Counselors can gain much insight through watching and listening to a child partaking in these therapies. The use of creative expression in a therapeutic environment can help a child to express emotion and process their own grief (Glazer, 1998).

6- 12 year olds.

Children at this age are typically able to understand the finality of death but do not view it as something that will happen to them until the latter part of this developmental stage. Children 10 and older seem to grasp the concept that they will die and may dwell over the idea of their own death (ASCO, n.d.b). The younger part of this age group may view death as a spirit, ghost, or angel. Boys often displace their grief as being aggressive and destructive whereas girls may become very clingy and attached. The range in emotions that are felt by this age group runs across a full gamut anywhere from guilt, sadness, and anger to anxious, shameful, or worried. They often have trouble putting words to the emotions that they are feeling, so being cued into their actions is most helpful. Some children will complain of physical ailments, like a stomachache, rather than being able to say that they feel afraid or sad.

Approaches/Techniques. Yet again, the most important approach is to be honest and open when talking to the child about the death of their loved one. Letting the child be a part of the planning for the service also seems to be helpful in the closure process for this age group (Slate and Scott, 2009). Techniques that would be beneficial to use with children of this age group include the use of sand trays, music, and recreation therapies in addition to utilizing play and art therapy.
Adolescents (13-18 years old).

This age group has the same capacity of understanding grief as an adult does. In fact, this age group views themselves as adults, however they are caught somewhere right in the middle developmentally. Pottmeyer and Scott (2008) contend that adolescents have trouble stopping “the developmental clock” to deal with the death of a loved one. Grief compounds and complicates the confusion that teenagers already face without an additional trauma. Teenagers are not children but are not yet adults, and when they are grieving the loss of a significant other they do not know which direction to take—the emotional dependence and sadness like a child, or the strong and brave approach of an adult. They will usually not reach out and embrace support from adults because that would make them appear childlike. Yet most will not seek solace in a peer for being afraid of looking weak. Many times, this creates the idea in them that they must face it alone and keep it together on the outside. The results of unresolved grief and bereavement can lead to ongoing mental health problems ranging from depression, social withdrawal, substance abuse, defiant behaviors, and academic problems (Pottmeyer and Scott, 2008). Caregivers and counselors for this age group can help by letting the teenager know that the confusion and emotional turbulence they are feeling is normal and that it is okay to cry or express those undesirable emotions. Remind the adolescent that they are available and will help in appropriate ways. Be aware that grief at this age challenges and contradicts the teenagers’ view of themselves as invincible and may create questions and doubt in their religious views and understanding of the world (ASCO, n.d.b). Counseling techniques to use for this age group can include relaxation/yoga, cinema, music, expressive (drama and projective arts), and narrative (journaling, creative writing, letter writing, poetry) therapy.

Grief in Adults

In an adult’s lifetime, one will likely experience grief in a number of different relationships, including, but not limited to, the loss of a parent, spouse, sibling, friend, family member, co-worker, or child. Many factors play into how an adult will grieve including what the nature of the relationship was with the deceased; grieving over the loss of a parent is likely much more intense than grieving over a neighbor. The cause of death is often times a large component in the depth of one’s grief; typically an anticipated death offers more comfort versus a sudden, unexpected death. If the bereaved has not effectively dealt with past losses, the grief process can be more complicated and multifaceted when facing another loss. The personality and typical response to change is also a component when an adult grieves; if one does not have a healthy reaction to loss or adjustment, they will not likely react in a healthful manner. One’s availability of support from friends and family also strongly impact how one will grieve. Religion and spiritual belief also plays an important role in the bereaved.

An adult who is grieving will likely review their own life and appraise their accomplishments, shortcomings, goals, and their meaningfulness in the world. One may also envision their own death. If the adult is grieving over a spouse, parent, or child, they are likely to experience many adjustments that influence grief; these may include a change in routine, responsibilities, priorities, relationships, goals, and activities.

Grief in adults is displayed uniquely from one person to the next. Emotions and feelings also run along a full scale and may vary in the individual over time. Many adults preoccupy themselves to avoid their feelings while others become fixated on the loss and are unable to function for a period of time as they once did.

Approaches/Techniques. One effective coping technique is to encourage a bereaved adult to attend a support group with people who are experiencing a loss similar to their own. Journaling and relaxation techniques are often times very therapeutic for a grieving adult. Encouraging eating well and getting adequate sleep and exercise are also important. It is also significant to remind the bereaved to take time making major decisions, such as moving, changing jobs, etc. Supporting the bereaved to find an outlet for comfort is beneficial through promoting one to review past hobbies or seek out activities to help fill their time and renew their joy.
Grief in the Elderly

Grief in the elderly is slightly different than the grief that an adult experiences because at this point in one’s life, many are more focused on dying than living. They are no longer looking forward to the future with anticipation of reaching milestones and goals. Instead, this time in their life is one of reflection. Loneliness, at least to some degree, is a central component in most elderly people, which intensifies exponentially when they experience the loss of a loved one.

Grief is presented in the elderly with an increased likelihood of having feelings of sadness, loneliness, and depression. The elderly will tend to ruminate over their loss especially if they have faced many losses in a short period of time (i.e., most of their friends or siblings have deceased).

Approaches/Techniques. The approaches and techniques for this age group are the same as those one would use with adults. One should also help the bereaved to secure additional help in doing tasks that their loved one was able to do. Also, helping the bereaved to establish a caregiver or helping them to find community support services is of great importance since many in this population do not know what services are available for them to help with tasks that they may not be able to take care of themselves.
Multicultural Component of Grief
Culture plays an important and critical role in understanding the manner in which one grieves. A person’s culture also aides in their concept of what happens to a loved one after death. One’s concept of the meaning of life and of death comes from one’s culture and beliefs, so therefore the emotions and grief that one experiences is linked directly to one’s cultural identity (ASCO, n.d.c). Every culture has its own rituals and customs that guide and shape the way the bereaved grieves.

It is essential to note that there is not a standard for how someone should grieve. What is “normal” grieving to one may be considered inappropriate to another. There are however some specific questions to keep in mind when working with a grieving client from a culture different than your own so that you can keep your perspective on what the client believes (Slate and Scott, 2009). Asking what the client and family’s belief surrounding death is very important in knowing how to appropriately go through their grieving process. Also, learning what emotions and behaviors are considered normal grief reactions in their culture is key (ASCO, n.d.c). In addition, asking the bereaved what special dates they know of that could be particularly difficult for them to face in the future is good to figure out so that you can help prepare them for those difficult times appropriately.

Grief and bereavement are natural emotions that we all will experience. Simply knowing the dictionary definition of grief and bereavement is not enough to effectively help clients. The key as counselors is to understand how grief and bereavement affect individuals differently and take notice in the variation of comprehension and grief presentation across different developmental groups. Knowledge of a client’s cultural beliefs and practices continues to be an important construct. Proper training in grief counseling techniques is critical to be an effective counselor in this field.
American Society of Clinical Oncology. (n.d.a). Help for when you are grieving. Retrieved September 10, 2008, from http://www.asco.org/patient/Coping/ Grief+and+Bereavement/Help+for+When+You+Are+Grieving

American Society of Clinical Oncology. (n.d.b). Helping a child or teenager who is grieving. Retrieved September 10, 2008, from http://www.asco.org/patient/ Coping/Grief+and+Bereavement/Helping+Grieving+Children+and+Teenagers

American Society of Clinical Oncology. (n.d.c). Understanding grief within a cultural context. Retrieved September 10, 2008, from http://www.asco.org/patient/Coping/ Grief+and+Bereavement/Grief+Among+Cultures

Fitzgerald, H. (1992). The grieving child: A parent’s guide. New York: Fireside.

Glazer, H. (1998). Expressions of children’s grief: A qualitative study. International Journal of Play Therapy, 7, 51-65.

Kubler-Ross, E., & Hobbing, E. (1997). On death and dying. New York: Simon & Schuster Adult Publishing Group.

The National Institute for Trauma and Loss in Children (n.d.). Grief and trauma: The confusion – the difference. Retrieved September 10, 2008, from http://www.tlcinst.org

Pickett, J., et al. (Eds.). (2005). Webster’s II New College Dictionary (3rd ed.). Boston: Houghton Mifflin

Pottmeyer, H. B., & Scott, D. A. (2008). Effects of bereavement and grief on adolescent development. Grief Digest, 5, (4), 24-25.

Slate, C. N., & Scott, D. A. (2009). Relevant concepts and techniques for school counselors working with children and adolescents dealing with grief and bereavement. New York State School Counseling Journal, 6, 44-52.

Wolfet, A. (1983). Helping children cope with grief. Muncie, IN: Accelerated Development.

Worden, J. (1991). Grief counseling and grief therapy. New York: Springer Publishing Company.
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