UC
University
of the
Cumberlands
Department of
Education
Presented by Dr. Susan R. Rose
March 2, 2011
UC
University
of the
Cumberlands

Department of
Education
Introductions

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
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
Your name
Your title and your school/organization
Educational Goals
What brought you to this session? To the conference?
Something of interest about yourself that you haven’t already
mentioned
 Favorite vacation
 Hobbies
 Foreign languages
UC
University
of the
Cumberlands
Department of
Education
Purpose of Grief
…this is not a process which can be rushed.
It is about integrating the changed circumstances
into the survivor’s ongoing life.


Related Quotes & Thoughts
While I thought I was learning how to live, I was learning how to
die. - Leonardo da Vinci
Life is measured not by its length, but by its depth. – Mary Fisher
UC
University
of the
Cumberlands
Department of
Education
Level 1: Defining the Loss Experiences
That Generate Grief Reactions
Grief knits two hearts
in closer bonds than
happiness ever can;
and common
sufferings are far
stronger links than
common joys.
-Alphonse de Lamartine
(French writer, poet, and politician, 1790-1869)
School Counseling Program
University
UC
of the
Cumberlands
Department of
Education
The Experience of Loss

Bereavement: The objective event of loss
 Disrupts survivor’s life
 “Shorn off or torn up” / “Being robbed”
 A normal event in human experience

Grief: The Reaction to Loss
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
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

Thoughts (mental distress)
Feelings (emotions)
Physical responses
Behavioral responses
Spiritual responses
Mourning
 Process by which a bereaved person integrates a loss into his or her
ongoing life
 Determined partly by social and cultural norms for expressing grief
UC
University
of the
Cumberlands
Department of
Education
Basic Facts about Loss and Grief

Every year, two million people die in the U. S.

Chronic illnesses such as cancer, heart disease, and diabetes account for
two of every three deaths. These illnesses create many losses before
death is anticipated.

Accidents are the leading cause of death children under age eighteen.
Accidents are also the cause of many disabling injuries, creating loss of
mobility, fine motor skills, and cognitive functions.

In 1999, the most recent year for which statistics are published by the
U.S. Dept. of Health and Human Services, 568,000 children were
removed from their biological families to live in foster care. These
children, their biological and foster parents, siblings, teachers, and
counselors/social workers are all affected by loss and grief.
 If each of these deaths affects just five people, at least ten million people are
affected each year.
School Counseling Program
UC
University
of the
Cumberlands
Department of
Education
Basic Facts about Loss and Grief cont.

According to predictions based on the U.S. census,
approximately 43% of marriages in the U.S. will end in
divorce.
 Some parents and children who experience divorce consider adjusting
to the losses associated with it to be as challenging as the losses
associated with death.

The tragic events of September 11, 2001 immediately affected
people all over the world.
 Traumatic losses associated with these terrorist attacks, along with
other tragedies such as the Columbine High School shootings, have an
impact on individuals and communities far beyond what can currently
be understood.
School Counseling Program
UC
University
of the
Cumberlands
Department of
Education
If you’re wondering what you should gain from this
workshop, you should ask yourself:

How comfortable and confident am I in my own ability to deal with grief and loss?

How well do I understand the impact of death on people of different ages,
genders, cultures and spiritual orientations?

How familiar am I with other life events and losses that can cause grief reactions?

Am I confident that I can identify when an individual or family is expressing
normal grief or when their grief may be complicated?

How prepared am I to respond effectively to those around me who are grieving?

Do I know how to acknowledge grief and make a referral to an appropriate
resource when necessary?
School Counseling Program
UC
University
Department of
Education
of the
Cumberlands
More Insight into the Purpose of this Workshop
The Keeper
http://www.counselingtoday.com/FreeStuff.html
School Counseling Program
UC
University
of the
Cumberlands
Department of
Education
Symbolic (Psychological) Loss
Divorce/The end of a relationship without one of the
partners dying
 Foster care placement
 Children leaving home for independent living (The “empty
nest”)
 Unemployment or Job demotion
 Changes in health status
 Moving, Selling a childhood home, etc.
 Parents whose children have been diagnosed with a
disabling medical or mental condition
 Moving parents into a nursing home
 Loss of independence
 Miscarriage/Infertility
 Death of a pet

School Counseling Program
University
UC
of the
Cumberlands
Department of
Education
Loss and Grief in Different Contexts

Crisis Counseling


We can’t “cure” grief, but we can offer help and care.
Trauma Therapy/Counseling
 Becoming attuned to grief issues helps identify and assist with loss
and grief associated with these problems.

Unacknowledged Grief – For example:




Losing a parent symbolically due to substance abuse
Refugees fleeing their homeland
Empty Nest (High School Counseling)
Loss of Health
School Counseling Program
UC
University
of the
Cumberlands
Department of
Education
Loss and Grief in Different Contexts cont.

The “Tough” Kid
 14-year-old girl place in therapeutic home for adolescents
 Mother died in a car accident when she was a toddler
 Father was incarcerated at the time, so she and her sister were
moved from family member to family member as well as to foster
homes where she was sexually and physically abused.
 Frequent expression of anger and poor behavior resulted in
residential placement, outside of the city in which she has spent her
childhood and separate from her sister.
What do you think happened next?
School Counseling Program
UC
University
of the
Cumberlands
Department of
Education
Small Group Exercise (3 – 4 members)

Divide a sheet of paper into two columns. In the first
column, write down the types of losses, both actual and
symbolic, that students are likely to experience.

In the second column, write the emotions someone
experiencing each loss is likely to experience.

Discuss your thoughts about how you might observe
these losses and the feelings related to them. (For
example, a school counselor leading a group for children
whose parents are divorcing might observe academic
problems with some of the children.)
School Counseling Program
UC
University
Department of
Education
of the
Cumberlands
Share out in Large Group
Although the
world is full of
suffering, it is full
also of the
overcoming of it.
- Helen Keller
School Counseling Program
UC
University
of the
Cumberlands
Department of
Education
Level 2: Self-Preparation - Preparing Yourself
to Help Others Encountering Loss and Grief
Everything that
happens to you is
your teacher. The
secret is to sit at the
feet of your own life
and be taught by it.
Polly B. Berends
(Author & Editor
of Children’s book)
-
What is of greatest
importance in a
person’s life is not
just the nature and
extent of his or her
experiences but what
has been learned
from them.
-Norman Cousins
School Counseling Program
UC
University
of the
Cumberlands
Department of
Education
Reviewing Our Own Experiences and Attitudes
Related to Grief

Experiences with death or loss significantly influence the way we react to
the losses of other, both consciously and unconsciously.

Take a few moments now to think about the following questions.
 What was your earliest experience with death or loss? How old were you when it
occurred? Where were you when you learned of the loss? Who did it involve?
 What were the physical, emotional, and cognitive reactions you were aware of in
yourself following the loss?
 How did the people around you respond to the loss? How did they respond to your
reactions?
 How did your cultural and/or spiritual background influence your responses?
 What about the loss makes you feel vulnerable now?
 Based on what you have learned since, what do you think can help you to cope
more easily with death or loss now and in the future?
 How do you think your own feelings and reactions to loss may impact your work
with others who are experiencing loss or trauma?
School Counseling Program
UC
University
of the
Cumberlands
Department of
Education
Assessing and Enhancing Readiness to Address Grief
in Our Work

How do we know if we are ready to help others with their
grief?
 Self-Assessment/Self-Awareness

Working with individuals and families facing loss inevitably
brings up emotions and memories for every professional.

Establishing competence in providing care to those who are
grieving.

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
Support clients in their expression of emotional needs
Actively listen
Refer to support groups, peer support programs, and professional experts
Ask open-ended questions such as, “How are you doing?”
School Counseling Program
UC
University
of the
Cumberlands
Department of
Education
Supervision, Consultation, and Collaboration with
other Professionals

Especially important when exposure to distress of others is
prolonged, frequent, or intense.
 Vicarious/Secondary trauma: a common reaction in professionals who
work closely with individuals or groups who directly experienced trauma.
 Supervisors, peers and consultants can help us to recognize when our own
reactions may be distressed.

Interdisciplinary/Multidisciplinary Team


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

Counselors
Teachers
Attendance Specialists/Clerks
Disciplinary Staff
Administrative Personnel
School Counseling Program
UC
University
of the
Cumberlands
Department of
Education
Questions, Comments, Concerns
UC
University
of the
Cumberlands
Department of
Education
School Counseling Program
UC
University
Department of
Education
of the
Cumberlands
Childhood
Factors that influence a child’s a child’ cognitive,
emotional, and behavioral reactions to death:




Chronological age
Earlier experiences with death
Reactions of adults and other children around them
Child’s own unique personality and coping style
School Counseling Program
UC
University
of the
Cumberlands
Department of
Education
Infants


Key developmental issues for infants are dependency and attachment.
Developmental Factors

Understanding of death

Reactions to loss

What can help?
 Dependence on caregivers for all basic needs
 Limited object constancy – the understanding that person or object exists, even if not physically
present.
 Limited ability to verbalize.
 Few coping strategies to regulate tension.
 Do not recognize
 Experience feelings of loss in reaction to separation that are part of developing an awareness
of death
 Emotional: Sluggish, quiet, unresponsive to a smile or a coo; may also cry and appear
inconsolable
 Physical: Weight loss, less active, sleep less
 Maintaining normal routines of care giving and familiar surroundings
 Providing a consistent caregiver who can give frequent and lengthy periods of love and
attention, including holding and hugging
 Providing consistent, gentle, physical and verbal reassurance and comfort
 Expressing confidence in the child and the world
School Counseling Program
University
UC
of the
Cumberlands
Department of
Education
Ages 2 – 3 (Toddlers)

Like infants, key developmental issues for toddlers are dependency and
attachment.

Great variation in cognitive and emotional development

Developmental Factors

Understanding of death

Reactions to loss

What can help?
 Ambivalence about independence
 Increasing comprehension and articulation of language
 Learning by mimicking and following the examples of others
 Generally cannot cognitively understand death
 Cannot differentiate absence for a short time from a long time
 Can sense loss of change but often cannot verbally explain or discuss it
 Emotional: Express discomfort or insecurity through frequent crying or protest; Express distress or
sadness through withdrawal, loss of interest in usual activities, and changes in eating and sleeping
patterns.
 Physical: May show regression through clinging or screaming when a caregiver tries to leave; May
express distress through regression, often giving up previously acquired skills such as speaking
clearly, toileting, and self-soothing at bedtime
 Same as infant +
 Providing simple, understandable verbal explanations for changes
 Naming feelings expressed by the child and those the child observes being expressed by others, such
as, “Daddy feels sad; that is why he is crying.”
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Ages 3 - 6

Children at this stage are still thinking concretely and may perceive death as a
kind of sleep


Department of
Education
Concept of death may involve magical thinking
Developmental Factors




Developing a fuller mastery of language
Learning to read
Expressing feelings through art and play
Acquiring social skills through interactions and observing others

Understanding of death

Reactions to loss

What can help?
 Cannot quite comprehend the difference between life and death
 Emotional: May be very anxious that something could happen to them or someone else upon whom
they are dependent; May exhibit searching behaviors
 Physical: May have trouble eating, sleeping, and controlling bladder and bowel functions
 Explaining death in simple and direct terms, including only as much detail as the child is able to
understand.
 Answering a child’s questions honestly and directly, making sure that the child understands the
explanations provided.
 Reassuring children about their own security and explaining that they will continue to be loved and
cared for (They often worry that their surviving parent or caregiver will go away)
 Encouraging master of age appropriate skills while allowing for regression
 Expressing confidence in the child and the world.
School Counseling Program
University
UC
of the
Cumberlands
Department of
Education
Ages 6 – 9

Children in this age are commonly curious about death and may ask questions
about what happens to one’s body when a person dies.


Children beginning in this age benefit from being invited to contribute to memorial
ceremonies or activities.
Developmental Factors



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Relationships with peers and adults are important
Striving for mastery of information and tasks
Superego and a sense of responsibility are developing
Cognitively, they are still thinking concretely.

Understanding of death

Reactions to loss

What can help?
 Children’s questions often indicate their efforts to understand death fully.
 Can become afraid of going to school or have difficulty concentrating, may behave aggressively,
become overly concerned about their own health, or withdraw from others.
 Discussions of death that include proper words, such as ‘died” and ‘death”
 Providing opportunities for children to ask questions freely and to express their feelings directly or
through creative activities
 Providing reassurances that the child’s thoughts, feelings, and behavior did not cause death
 Reading aloud stories or books that deal with death and allowing the child to share their reactions or
questions
 Inviting children to share memories and participate in ceremonies or remembrance activities
School Counseling Program
UC
University
of the
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The Sandpiper
http://www.counselingtoday.com/FreeStuff.html
School Counseling Program
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University
of the
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Department of
Education
What is
your Joy?
School Counseling Program
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Ages 9 – 12

Child is developing an increasing grasp of abstract concepts


By the time a child is 12, death is seen as final and something that happens to
everyone
Developmental Factors




Interest in and capacity to understand biological processes
Heightened sensitivity to others’ emotions
Increased awareness of vulnerability
Regressive and impulsive behaviors indicate stress

Understanding of death

Reactions to loss

What can help?
 Death is usually known to be unavoidable and is not seen as punishment
 Greater risk for symptoms of depression, withdrawal, anxiety, conduct problems, changes in school
performance, and low self-esteem
 Capable of empathy





Talking about death can help children learn effective ways to cope with loss
Providing an opportunity to explore and discuss spiritual and cultural beliefs related to loss
Providing physical outlets for strong emotions
Encouraging expression of feelings through different media including art, music, dance, and writing.
Letting children know they are not alone and that others experience loss and the feelings related to
it.
 Modeling direct and constructive expression of feelings naturally associated with loss such as anger
and sadness.
School Counseling Program
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UC
of the
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Department of
Education
Adolescence

Adolescents may view death in the family as making them appear different from
their peers


May perceive death has placed greater demands on their own development
Developmental Factors




Searching for identity
Peer relationships are very important
Exposure to maladaptive responses to stress
Abstract thinking

Understanding of death

Reactions to loss

 Adolescents comprehend that death is permanent, irreversible, and affects everyone.

At risk for exposure to maladaptive coping strategies; May also be at risk for parentification
What can help?
 Talking openly about death, indicating that the subject is not off-limits
 Verbal or written explanations that tears, sadness, anger, guilt, and confusion are all part of normal
grief
 Providing opportunities for adolescents to hear from and talk with peers who have also experience
loss
 Inviting the adolescent to help plan or participate in memorial or remembrance activities in the way
that feels most comfortable to them
 Connecting adolescents to peers who have similar experiences to reduce isolation
 Encouraging journal writing or using other methods to express thoughts and feelings
 Constructing memorials, memory books, boxes, or quilts, or providing other tangible ways to
memorialize significant relationships
School Counseling Program
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UC
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Young Adulthood
Multiple demands of life may deter ability to devote time and
energy to grief.
 Developmental Factors

 Expected to be self-sufficient (economically, if not emotionally)
 Developing career and life plans
 Expanding their range of roles and coping strategies

Understanding of death

Fully comprehend and are also capable of comprehending the complex range of
responses of different people to different types of losses

Reactions to loss

What can help?
 Vulnerable to the emergence of anxiety, depression, and other disorders that
stress related to loss can exacerbate
 Acknowledge the multiple impacts of loss and the normalcy of grief reactions
 Encouraging individuals to take time to attend to their own feelings as well as
those of others
 Acknowledging or providing opportunities for expression and discussion of
conflicting feelings
 Promoting social connections through peer support and group activities
 Referring young adults to credible Internet sources for information and peer
support
School Counseling Program
University
UC
of the
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Department of
Education
Middle Adulthood


“Sandwich” generation
Developmental Factors



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Re-examination, renewal, and /or reintegration of identity
Multiple roles and responsibilities
Long-established patterns may be difficult to change
Increased vulnerability to physical disorders

Reactions to loss

What can help?
 “Pile-up” of losses
 Maladaptive patterns may make the process of grieving complicated

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Empathic listening and support
Release time from work or school to meet family obligations and process grief
Bereavement support groups
Tangible expressions of support or caring
Pastoral care or connection with a religious or spiritual community
Identification of risk factors and offering intervention for complicated grief
Opportunities for respite and renewal
Opportunities to assist others
School Counseling Program
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UC
of the
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Department of
Education
Late Adulthood


Textbooks define this as 65 and older 
Developmental Factors

Reactions to loss

What can help?
 Poor health or disabling medical conditions may have significant impact as biological
aging progresses
 Serenity and wisdom may be sought
 Changes in identity related to work and family occur
 Adaptation to changes in information processing and memory is required to maintain
maximum functioning
 Multiple losses require continuing adaptation; May be difficult to differentiate
between grief and depression




Acknowledgement of symbolic losses as well as losses through death
Maintaining or augmenting social supports
Provision of income supports or economic assistance, when needed
Identifying new activities, roles, and relationships to augment or replace those that
have been lost
 Conducting informal and formal life review, with emphasis on strengths and
contributions
School Counseling Program
UC
University
Department of
Education
of the
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Conducting informal and formal life review, with emphasis
on strengths and contributions
A Life Well-Lived
http://www.counselingtoday.com/FreeStuff.html
School Counseling Program
UC
University
of the
Cumberlands
Department of
Education
Advanced Age

Textbooks define this as 80 and older

Developmental Factors
 Vulnerability to social isolation, disabling medical conditions, and
memory loss
 Adaptation to multiple losses, both symbolic and through deaths
 Change in sense of time
 A sense of consummation and conclusion in life

Reactions to loss
 Anticipate own death; Reminiscence is common and often
brings a positive sense of closure and fulfillment
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Advanced Age cont.

What can help?
 Reminiscence through sharing of memories, with individuals and
groups
 “Make memories, Little Buddy, because when you get older, that’s
all you’ll have.”
Thank You for Your Time , http://www.counselingtoday.com/FreeStuff.html
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Advanced Age – What can help? cont.

What can help?
 Reminiscence through sharing of memories, with individuals and
groups
 Providing concrete supports to allow expenditures of time and
energy on satisfying activities and relationship (helping with
household maintenance or bill paying)
 Acknowledging losses as well as strengths and coping capacities
 Encouraging completion of advance directives
 Providing opportunities to open discuss ideas, values, feelings,
and fear related to dying and death
 Just Be There
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Just Be There
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Questions, Comments, Concerns
UC
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Level 4:
Normal and
Complicated
Grief Reactions
School Counseling Program
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And can it be that in a
world so full and busy
the loss of one creature
makes a void in any
heart so wide and deep
that nothing but the
width and depth of
eternity can fill it up!
- Charles Dickens
School Counseling Program
UC
University
of the
Cumberlands
Department of
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Theories That Inform Our Understanding of Grief

Sigmund Freud’s Mourning and Melancholia (1917)

John Bowlby elaborated on Freud’s ideas (1973)
 Every human infant develops attachments to significant people (whom he referred
to as “objects”) through the process of Cathexis.
 Cathexis: process of attaching emotionally
 Decathexis: process of letting go of an attachment as an adaptive response to loss
of a significant “object”
 Proposed that attachment behavior helps infants establish an maintain a sense of
security throughout their life.
 According to Bowlby’s theory, grief reaction of the bereaved to the loss of a
significant other is a similar process.
 Bereaved must cease investing their emotional energy (referred to as libido in both
Freud and Bowlby) in the deceased in order to reinvest it in other relatioship

Both believed that with the passage of time grieving individuals
could achieve decathexis
 Failure to do this results in depression
School Counseling Program
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Theories That Inform Our Understanding of Grief
 Eric Lindemann became interested in grief reactions
after a major tragedy in Boston, the Coconut Grove
nightclub fire, took the lives of 492 people in
November 1942.

Lindeman studied the grieving survivors and found common reactions of:






Physical or Bodily Distress
Preoccupations with the image of the person who had died
Anger or hostility
Guilt
Impaired functioning in work or family roles
He also identified task that grievers completed that resulted in a
diminishment of these symptoms.



Acknowledging the reality of the death
Adjusting to life without the deceased person
Forming new relationships
School Counseling Program
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UC
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Theories That Inform Our Understanding of Grief

Elizabeth Kubler-Ross, a physician who worked with dying
patients, made major contributions to our understanding of
Anticipatory Grief.
Pioneering Publications in the 1960’s and 1970’s described her stage
model

1.
2.
3.
4.
5.

Denial and Isolation
Bargaining
Anger
Sadness/Depression
Acceptance
Parkes (1998) identified related stages in the grieving process




Shock or numbness
Yearning and pining (anger & guilt)
Disorganisation
Beginning to pull life back together
School Counseling Program
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UC
of the
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Theories That Inform Our Understanding of Grief

More recently, grief counselors Therese Rando and William
Worden have expanded on earlier theories
 Worden (2005) concentrates on tasks of grieving that have to be
worked through (‘grief work’) if resolution of grief is to take place:




To accept the reality of the loss
To work through or experience the pain of grief
To adjust to a changed environment in which the deceased is missing
To emotionally relocate the deceased and move on with life and capacity
to love others.
 Rando’s 6 R’s/ The Tasks of Mourning






Recognize the loss
React to the separation
Recollect the deceased and the relationship
Relinquish old attachments to the deceased
Readjust adaptively into a new world without forgetting the old
Reinvest
University
UC
of the
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Common Reactions in Normal Grief

Highly variable and individualistic

Grief reactions vary across a wide spectrum according to:










Cultural Backgrounds
Social Support Networks
Gender
Socioeconomic Status
Psychological Health
Circumstances of Loss
Complex, evolving process
Multiple dimensions
Signs of grief may appear immediately after the death or
may be delayed or even absent
No predetermined timetable for “completion”

Most often, the social and emotional support provided by family and
friends is enough
School Counseling Program
University
UC
of the
Cumberlands
Department of
Education
Normal Grieving Behaviors

Thoughts (Mental Distress)
 Confusion, inability to concentrate or remember details, disbelief, anxiety;
Sense of disorganization; Depression; Sensory responses undependable
and erratic; and auditory or visual experiences that mimic hallucinations –
such as seeing an image of the deceased person or hearing their voice – are
not uncommon following a loss

Feelings (Emotions)


Physical (Somatic) Sensations


Sadness, Longing, Loneliness, Sorrow and Anguish, Guilt, Frustration at being
unable to control events, Anger and outrage at injustice of the loss, Anxiety,
Fatigue, Helplessness, Numbness, Shock, and even Relief
Tightness in the chest or throat, choking, shortness of breath; Lack of energy;
Feeling of emptiness in the abdomen and stomach; Frequent sighing; Sleep
disruptions (e.g., insomnia); Changes in appetite; Chills, tremors, hyperactivity
Behavioral Responses
 Crying; Searching for the deceased; Incessant talk about the deceased and
circumstances of death; Avoidance of talk about the deceased;
Restlessness, irritability, hostility
School Counseling Program
University
UC
of the
Cumberlands
Department of
Education
Expressions of Mourning



The bereaved are “different” for a time
Abstaining from social occasions
Visual Symbols




Black armbands
National flag at half-mast
Seclusion
Cutting long hair short (Native Americans)
University
UC
of the
Cumberlands
Department of
Education
The Course of Grief
(Summarizing Normal Grief)

Initial phase: Shock, numbness, disbelief, denial
Middle phase: Anxiety, despair, volatile emotions,
yearning for deceased, feelings of abandonment

Last phase: Sense of resolution, reintegration, and
transformation; turmoil subsides; balance regained

University
UC
of the
Cumberlands
Department of
Education
Complicated Grief

Complicated Grief/Complicated Mourning: difficulty coping with loss;
prolonged distress long after the loss has occurred.

Failure to complete the tasks of grief/mourning results in several types of
complicated mourning:







Delayed grief: when a loss is insufficiently mourned
Masked grief: when grief is absent immediately after a loss but appears
later in the form of a medical or psychiatric problem
Exaggerated grief: when a normal grief reaction, such as depressed mood
or anxiousness, goes beyond normal grief to a clinical level of depression
or anxiety
Chronic grief: when the mourner is stuck, sometimes for many years, in
the grief process
Anomic grief: where there is an absence of standards or guidance on how
to grieve. The person does not know what to do, doesn’t know how to
deal with the loss, change in circumstances.
Forbidden grief: when others deny the person has suffered any loss.
Time-limited grief: the idea is that you should get back to normal,
especially emotional normality, as soon as possible.
School Counseling Program
UC
University
of the
Cumberlands
Department of
Education
Who is at risk for complicated grief?

Perceived lack of social support


High Profile Losses


Examples: Execution of a prisoner, loss associated with AIDS, death of a drunk driver, suicide
Unique losses that produce intense grief reactions for a long time






Reduced income or unexpected financial debt
Loss of important roles
Loss of a job or health insurance
Disenfranchised loss: losses accompanied by stigma resulting in loss of support or
acknowledgment for grieving survivors


Lack of privacy; frequent inquiries about and exposure to the details of the loss make
it difficult to obtain respite
Multiple Stressors




Examples: Suicide, older adults who have already sustained the loss of many members
of their primary support network, Children placed in foster care
Examples: Loss of a child, Parents whose children have been removed by CPS or how have
relinquished the role of parent through adoption
Sudden, unanticipated loss (especially when traumatic, violent, mutilating, or random)
Bereaved’s perception that the death was preventable
Death from overly lengthy illness
Relationship that was markedly angry, ambivalent, or dependent
Mental health problems or unaccommodated losses
School Counseling Program
UC
University
of the
Cumberlands
Department of
Education
Danger of “Medicalizing” Grief
Because circumstances and personalities differ, what is a
pathological response for one mourner may be an
appropriate response for another mourner
 Many of the criteria suggested for making a diagnosis of
traumatic grief appear virtually indistinguishable from the
signs of normal grief
 Label of “dysfunctionality” may be applied to normal
expressions of grief and mourning.
 No direct cause-effect link established between bereavement
and onset of disease.
 Higher incidence of some chronic diseases in recently
bereaved individuals

 Mortality/Morbidity of Grief: Studies Reported...
 Diminished immune response has been found among widowers
during first months following bereavement
 Death rate during first year of bereavement nearly seven times that
of general population (small community in Wales)
University
UC
of the
Cumberlands
Variables Influencing Grief





Survivor’s model of the world




Personality
Cultural context and social roles
Perceived relationship with the deceased
Values and beliefs
Mode of death





Anticipated
Sudden
Suicide
Homicide
Disaster
Multiple losses and bereavement burnout
Social support and disenfranchised grief
Unfinished business
Department of
Education
UC
University
of the
Cumberlands
Department of
Education
Interventions for Normal and Complicated Grief
 Why and how can a referral to a mental health
professional or grief therapist help?
 According to the DSM-IV, bereavement is considered to be
complicated by a major depressive episode if the normal
depressive symptoms are accompanied by:
 Morbid preoccupation with worthlessness, suicidal ideation
 Marked functional impairment or psychomotor retardation of
prolonged duration
School Counseling Program
UC
University
of the
Department of
Education
Cumberlands
Interventions for Normal and Complicated Grief
 Preventive Interventions
 Anticipatory grieving
 Education
 Emotional support

Monitoring, with social support

Support groups
 Face-to-face
 Online
 Telephone (Skype, etc.)
School Counseling Program
University
UC
of the
Cumberlands
Department of
Education
Interventions for Normal and Complicated Grief

Maintaining Bonds
 Rather than severing ties with the deceased, the bereaved
person incorporates the loss of a loved one into his or her
ongoing life
 Maintain “inner representation” of the deceased
 Bonds sustained through memories and linking objects
 The “ties that bind” are maintained by “threads of
connectedness”
UC
University
of the
Cumberlands
Department of
Education
Interventions for Normal and Complicated Grief cont.

Brief supportive or bereavement counseling

Grief therapy

Psychiatric referral and use of psychotropic medication

Innovative Interventions
 Individual
 Couples
 Family Therapy





Daylong workshops
Annual memorial workshops held at hospitals or hospices
Retreat programs/Camp Programs
Bibliotherapy
Using music in counseling
School Counseling Program
UC
University
of the
Cumberlands
Department of
Education
Exercise: Identifying Signs of Normal and Complicated Grief

Think of someone you know who has experienced a loss.
Using the normal emotions of grief as a checklist, note
whether the person showed signs of sadness, anger or guilt
that are a part of normal grief. Describe your observations

Discuss whether you saw signs of complicated grief.
Describe the type of complicated grief the individual
evidenced and the interventions that may have been helpful
to them to complete the tasks of grieving.
School Counseling Program
UC
University
of the
Cumberlands
Department of
Education
Share out in Large Group
Only people who
avoid love avoid
grief. The point is to
learn from it and
remain vulnerable to
love.
- John Brantner
School Counseling Program
UC
University
of the
Cumberlands
Department of
Education
Cultural and Spiritual Influences
We must accept
finite
disappointment,
but never lose
infinite hope.
- Martin Luther King, Jr.
School Counseling Program
UC
University
of the
Cumberlands
Department of
Education
Grief and Loss
 Grief and loss can be said to be part of every human
life although the meaning of this experience and
responses to it are unique.
 Each of us will grieve in our own unique way for the
unique loss that we have suffered. There is no right
or wrong way to grieve.
 Each person’s unique feelings of grief and loss will
be influenced by the culture and society in which
they live.
University
UC
of the
Cumberlands
Department of
Education
Influence of Culture in Coping with Loss and Grief

Culture: the integrated pattern of human that includes
thoughts, communications, actions, beliefs, values, and
institutions of a racial, ethnic, religious, or social group.



Often referred to as the totality of ways that are passed down from one generation to
another (NASW, 2005)
Cultural Sensitivity: an awareness of, and appreciation for,
the differences in values, beliefs, and norms of people from
different cultural and spiritual backgrounds.
Cultural Competence: professionals practice of cultural
sensitivity as well as the ability to engage and interact
effectively with people from diverse cultural backgrounds.
School Counseling Program
UC
University
of the
Cumberlands
Department of
Education
Lack of Awareness of different cultural
groups’ responses can lead us to:
Misinterpret an individual’s or family’s reactions
Fail to offer support or assistance that might be
perceived as helpful
 Offend the grieving person(s) and create a barrier
to their receiving care and support


School Counseling Program
UC
University
of the
Cumberlands
Department of
Education
Group vs. the Individual

Knowledge of a particular group does not
necessarily equip someone to adequately
understand in individual, who may not subscribe to
the beliefs or norms of the group.
 Differing Spiritual Practices within the group
 Differing Norms based on:
 Socioeconomic Status
 Multiple Group Memberships
 Individual Ideology
Sharing Stories of Differing Cultural
Experiences
School Counseling Program
UC
University
of the
Cumberlands
Department of
Education
Gender and Grief
 In American culture, men are taught not to show
emotions such as sadness, loneliness, or depression.
 Causes some men to be unable to cope with
the
feelings they are experiencing.
 They may not have health outlets to express their emotions
School Counseling Program
UC
University
of the
Cumberlands
Department of
Education
The Transmission of Cultural Messages


Family communication or interaction
Mass Media
Vicarious Experiences
 Makes us all “Instantaneous”
survivors
 Contributes to “Grief Denying”
culture
 Famous are front page news,
while the average Joe or Jill is
buried in death notices deep in
“Section G”

School Counseling Program
UC
University
of the
Cumberlands
Department of
Education
The Transmission of Cultural Messages

Culture of Poverty and Violence
 “Waking up and living another day, facing an endless
accumulation of losses”
 Area where much work is needed
 Let’s Brainstorm
School Counseling Program
UC
University
of the
Cumberlands
Department of
Education
Influence of Spirituality in Coping with Loss and Grief
Spirituality: that which gives meaning to one’s life
and draws one to transcend oneself

 Expressions of Spirituality




Prayer
Meditation
Interactions with others or nature
Relationship with God or a higher power
Religion: communal or institutional expression or
practice of faith.

School Counseling Program
UC
University
of the
Cumberlands
Department of
Education
Assessing importance of Spirituality in
People’s Lives

Pulchalski (1999) developed a user tool:




F: Faith or beliefs
I: Importance and influence
C: Community
A: Address
School Counseling Program
UC
University
of the
Cumberlands
Department of
Education
Exercise
1.
Of the stories that we discussed earlier or other
experiences that you have had, discuss the funeral
rituals or mourning behavior you have observed.
2. What aspects of these rituals are similar to the practices
of your own cultural or religious groups?
3. What aspects are different?
4. Of the rituals, practices or behaviors you have observed
in your own life, which ones do you feel would be
particularly helpful for those who have experienced a
loss?
School Counseling Program
UC
University
Department of
Education
of the
Cumberlands
Share out in Large Group
While we are
mourning the loss of
our friend, others are
rejoicing to meet him
behind the veil.
~John Taylor
School Counseling Program
UC
University
of the
Cumberlands
Department of
Education
Level 6: Counseling the Individual What Can We Do To Help?
One of the most
beautiful
compensations of
this life is that no
man can sincerely
try to help another
without helping
himself.
- Ralph Waldo Emerson
School Counseling Program
UC
University
of the
Cumberlands
Department of
Education
Grief
“No one ever told me that grief felt so like fear. I am
not afraid, but the sensation is like being afraid. The
same fluttering, the same restlessness, yawning. I
keep on swallowing. At other times it feels like being
mildly drunk, or concussed. There is a sort of invisible
blanket between the world and me. I find it hard to
take in what anyone says. Or perhaps, hard to want
to take it in; it is so uninteresting. Yet I want the
others to be about me. I dread the moments when
the house is empty. If only they would talk to one
another and not to me”
C.S. Lewis, A Grief Observed
UC
University
of the
Cumberlands
Department of
Education
Misconceptions of Grief
1.
Time heals all wounds.
2.
People find it too painful to talk about their loss.
3.
Crying indicates that someone is not coping well.
4.
The grieving process should last about one year.
5.
Quickly putting grieving behind will speed the
process of healing.
School Counseling Program
UC
University
of the
Cumberlands
Department of
Education
Empathic Communication

Active Listening






S= Sit up straight
L= Lean forward (Attentive body language)
A= Activate your thinking
N= Note key ideas (Verbal following)
T= Track the talker (Appropriate eye contact)
Communication Facilitation





Reflection of feeling
Paraphrasing
Use of minimal encouragers
Use of open-ended questions
Therapeutic silence
School Counseling Program
UC
University
of the
Cumberlands
Department of
Education
Empathic Communication

Avoid:
 Saying “I know how you feel” or “I understand.”
 Talking about your own losses (me-too-ism)
 Parroting or repeating the speaker’s exact words. Try, instead
to respond to the actual content expressed.
 Thinking about or planning your own responses instead of
listening to what is being said.
 Giving unsolicited advice.
 Breaking silences too quickly or filling in before the speaker has
finished speaking.
 Challenging the other person’s perception of their situation or
feelings.
School Counseling Program
UC
University
of the
Cumberlands
Department of
Education
Utilizing Information and Resources
Identify key experts in your own community and obtain
their contact information
 Internet
 National Organizations

 Compassionate Friends: support organization for parents who have
lost a child
 COPS (Concerns of Police Survivors): organization assisting survivors
of police who die in the line of duty
 The Dougy Center: National Center for Grieving Children and Families
 Cancer Care
 KET: Kentucky Educational Television
 Examples: Before It’s Too Late – Preventing Teen Suicide, http:
www.ket.org/health/before-its-too-late.htm ; The Forgetting - A Portrait
of Alzheimers, http://www.ket.org/forgetting/
 PBS: Public Broadcasting System
School Counseling Program
UC
University
of the
Cumberlands
Department of
Education
Collaborating with Others

Core functions related to goal attainment:
 Completing a thorough assessment
 Contributing to the development of a comprehensive
educational/treatment plan
 Participating as a member of the interdisciplinary team
 Implementing the components of the educational/treatment
plan
 Evaluating progress
 Advocating
School Counseling Program
UC
University
of the
Cumberlands
Department of
Education
Functions of Team Members

Counselors contribute an understanding of:

Counselors help other professionals cope effectively
with the demands of their work.
 Compassion Fatigue: the reactions that professional caregivers
sometimes experience in the process of helping others with grief, loss,
and trauma.
 Secondary trauma/Vicarious trauma: trauma that professional
caregivers can experience through listening to the details of trauma
that others have experienced.
 Expressing feelings to others who can listen empathetically and
provide support
 Using stress management techniques
 Making sure there is a balance in our lives
School Counseling Program
UC
University
of the
Cumberlands
Department of
Education
Books About Death, Loss, Illness, and Hope
for Children and their Caregivers
http://www.counselingtoday.com/
FreeStuff.html
UC
University
Department of
Education
of the
Cumberlands
Songs about Grief
http://www.recover-fromgrief.com/songs-about-grief.html
UC
University
Department of
Education
of the
Cumberlands
Visual Art & Grief

Materials









Paper: Letter, Legal, Butcher, Bulletin Board, etc.
Colorful Copy Paper
Construction Paper
Ribbon
Yarn
Glue Sticks and/or Tape
Coloring Pencils and/or Crayons
Pencils and/Pens (Depending on age)
Any other Art supplies you have on hand
 Beads, glitter, sequins, etc.
UC
University
Department of
Education
of the
Cumberlands
Grief Box

Your Grief Box for Counseling
 Books
 CD’s with songs
 Visual Art supplies

Student’s Grief Box





Decorated Cardboard Box (Shoe Box, Shirt Box, etc.)
Hand-made frames (Child can place pictures later)
Quotes, Phrases, Scripture verses, etc.
Journal (Notebook tied together with ribbon will suffice)
Any other memories
UC
University
of the
Cumberlands
Department of
Education
Questions , Comments, Concerns
UC
University
of the
Cumberlands
Department of
Education
Level 7: When Organizations and
Communities Grieve
As the sun
illuminates the
moon and stars
so let us
illuminate each
other.
- Master Lui
School Counseling Program
UC
University
of the
Cumberlands
Department of
Education
Counselors can make a significant difference
through a variety of helpful responses:
Practicing empathic communication (Chapter 6)
Referring a client to a support group, a
bereavement counselor, or another community
provider (Chapter 4)
 Attending a funeral or planning a memorial service
can serve as an expression of support
 Offering to be present with those who are grieving
 Taking a Leadership Role


School Counseling Program
UC
University
of the
Cumberlands
Department of
Education
Establishing a Bereavement Protocol:
Interdisciplinary Collaboration
Communicate the news to all the members of the
school community who knew the deceased.
2. Provide concrete ways for people to express their
caring and concern.
3. Acknowledge the loss in meetings and classes.
4. Obtain consultation or support for staff who are
providing grief counseling to others, if needed.
1.
School Counseling Program
UC
University
of the
Cumberlands
Department of
Education
Creating Remembrances and Memorials
 Memorial cookbook for an avid cook
 Memorial Walk accompanied by a “Concrete”
Memorial
 Honorary Trees/Bushes
 Donate organs as a “living” tribute
 Foundations to collect $ to find a cure for a disease
that took the loved one
 Scholarships or Memorial funds
 Memorial Events
 Basketball Games, Dances, etc.
School Counseling Program
UC
University
of the
Cumberlands
Never doubt that a
small group of
thoughtful, committed
citizens can change
the world. Indeed, it
is the only that ever
has.
Department of
Education
Discuss the Charles
Schulz Philosophy
- Margaret Mead
http://www.counselingtoday.com/FreeStuff.html
School Counseling Program
UC
University
of the
Cumberlands
Department of
Education
Questions , Comments, Concerns
UC
University
of the
Cumberlands
Department of
Education
Level 8: Self-Care – Sustaining Hope, Helpfulness,
and Competence in Working with Grief
Look well into
thyself. There is a
source of strength
which will always
spring up if thou will
always look there.
- Marcus Aurelius Antoninus
School Counseling Program
UC
University
of the
Cumberlands
Department of
Education
Continuing Education
You have taken the first step in taking care of
yourself. You are here!
School Counseling Program
UC
University
of the
Cumberlands
Department of
Education
Self-Care Strategies

Avoid compassion fatigue
 Take regular time off
 Vacation
 Mental health days
 Creative Expressions
 Art
 Music
 Dance
 Peer Support
 Debriefing
 Supervisor who can balance employee’s need for empathy and
protection with the need to feel competent and to continue work
School Counseling Program
UC
University
of the
Cumberlands
Informal Self-Care Strategies











Department of
Education
Spend more time with family and friends
Enjoy evenings full of laughter, ice cream and good times
Exercise regularly
Write a journal
Eat healthy food
Take a bubble bath
Take time for appreciating or creating art
Watch a sunset
Read for leisure
Gardening
Yoga (active relaxation)
School Counseling Program
UC
University
of the
Cumberlands
Department of
Education
Informal Self-Care Strategies
Hug someone
Listen to music (singing along with the radio in the
car works wonders)
 Watch movies (Save the heavy dramas for when life
isn’t already full of dramas)
 Go for a walk
 Dance
 Get a good night’s sleep
 Eat one piece of chocolate
 Reduce clutter/Get more organized so that the details
of everyday life don’t add to stress
 Take a weekend retreat or a day trip
 Take a vacation


School Counseling Program
UC
University
of the
Cumberlands
Department of
Education
Informal Self-Care Strategies


Listen to soft music in combination with deep breathing
exercises
Listen to a guided imagery tape
Meditate
Take at least 1 – 2 hours every week to do
something you want to do
Get a massage
Begin the day with gratitude and continue
to practice it throughout the day
Practice mindfulness
Pray

Enjoy the Ride: http://www.lshs64.com/enjoytheride.html






School Counseling Program
UC
University
of the
Cumberlands
Department of
Education
Professional Support Systems

Seeking help for ourselves
 Warning signs that trigger that we need to seek help:
 Use of maladaptive strategies




Overworking
Avoiding others
Using substances
Shutting down our emotions
 Options for Self-Care





Same organizations and resources we provide to clients
Same methods of individual or group counseling we use with clients
Trusted supervisor or colleague can help with referral
Effective models of Professional Development
Retreats for Professionals coping with grief
School Counseling Program
University
UC
of the
Cumberlands
Department of
Education
One Last Thing

We need to take a proactive role in preventing
burnout and managing stress related to
professional caregiving.

Philosophy for Old Age
 http://www.authorstream.com/Presentation/aSGuest40
411-347103-philosophyforoldage-entertainment-pptpowerpoint/
School Counseling Program
UC
University
of the
Cumberlands
Department of
Education
Exercise
Ask yourself the following questions:
Why am I drawn to the work I do?
2. What feelings are you aware of as you think about more
in-depth work with others experiencing grief?
3. What plans do you have to sustain yourself in your work
with grieving clients in the future? What strategies and
methods to you plan to use personally to prevent burnout and compassion and fatigue, and to maintain a
balance in your personal and professional life?
1.
School Counseling Program
UC
University
of the
Cumberlands
Department of
Education
Share out in Large Group
There are things that we
don't want to happen
but have to accept,
things we don't want to
know but have to learn,
and people we can't live
without but have to let
go.
~Author Unknown
School Counseling Program
UC
University
of the
Cumberlands
Department of
Education
Questions , Comments, Concerns
UC
University
of the
Cumberlands
Department of
Education
CURRENT, UPDATED BIBLIOGRAPHY
Adams-Greenly, M. and Moynihan, R.T. (1983). Helping the children of fatally parents. American Journal of Orthopsychiatry, 53, 219-229.
Aguilera, D.C. (1998). Crisis intervention. St. Louis, MO: Mosby-Year.
Albom, Mitch. (2002). Tuesdays with Morrie: An old man, a young man, and life’s greatest lesson. New York, NY: Random House.
Allen, J. (2002). Using literature to help troubled teenagers cope with end-of-life issues. Westport, Conn.: Greenwood Press.
Barnes, G.E. and Prosen, H. (1985). Parent death and depression. Journal of Abnormal Psychology, 94, 64-69.
Becvar, D. (2001). In the presence of grief. New York, NY: Guildford.
Bendikson, R. and Fulton, R. (1975). Childhood bereavement and later behavioral disorders. Psychiatric Annals, 16, 276-280.
Benner, D.G. (1991). Counseling as a spiritual process. Oxford, UK: Clinical Theology Association.
Biegel, D.E., Sales, E., and Schulz, R. (1991). Family caregiving in chronic illness: Alzheimer’s disease, cancer, heart disease, mental illness and
stroke. Newbury Park, CA: Sage Publications.
Boyd-Webb, N. (2002). Helping Bereaved Children, 2nd Ed. New York, NY: Guildford.
Bragdon, E. (1990). The call of spiritual emergency: From personal crisis to personal transformation. San Francisco, CA: Harper & Row.
Brock, S.E., Lazarus, P.J. and Jimerson, S.R. (Eds.) (2002). Best practice in school crisis prevention and intervention. Bethesda, MD: National
Association of School Psychologist.
Brunhofer, M.O. (1997). Mourning and loss: A life cycle perspective. In J.R. Brandell (Ed.), Theory and Practice in Clinical Social Work. (pp.
662-688). New York, NY: The Free Press.
Burke, M.T. & Miranti, J.G. (Eds.) (1995). Counseling: The spiritual dimension. Alexandria, VA: American Counseling Association.
Corr, C.A. and McNeil, J.N. (1986). Adolescence and death. New York, NY: Pergammon Press.
Doka, K.J. (1989). Disenfranchised grief: recognizing hidden sorrow. Lexington, MA: Lexington Books.
Doka, K. and Davidson, J. (1998). Living with grief: Who we are and how we grieve. Philadephia, PA: Taylor Francis.
Eliade, M. (1987). The Encyclopedia of Religion. New York, NY: MacMillan Press.
Ernswiler, J. and Ernswiler, M. (2000). Guiding your child through grief. New York, NY: Bantam/Random House.
Freeman, S.J. (2005). Grief and loss: Understanding the journey. Belmont, CA: Thomson, Brooks/Cole.
Freud, S. (1917). Mourning and Melancholia. Standard Edition, 14: 237-258. London: Hogarth Press.
Gilbert, K.R. (1996). “We’ve had the same loss, why don’t we have the same grief?: Loss and differential grief in families. Death Studies, 20,
269-283.
Gluhoski, V.L. (1995). A cognitive perspective on bereavement: Mechanism and treatment. Journal of Cognitive Psychotherapy, (9)2, 75-84.
International Work Group on Death, Dying, and Bereavement. (1992). "A Statement of Assumptions and Principles Concerning Education
about Death, Dying, and Bereavement." Death Studies, 16:59–65.
Worden, W. (2001). Children and Grief, 2nd ed. New York, NY: Guildford.
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Irish, D.P., Lundquist, K.F., and Nelson, V.J. (1993). Ethnic variations in Dying, Death and Grief. Washington, DC: Taylor and Francis.
James, R. and Gilliland, B. (2005). Crisis Intervention Strategies. 5th Ed. Belmont, CA: Brooks/Cole Publishing
Jamison, K.R. (1999). Night falls fast: Understanding suicide. New York, NY: Knopf.
Johnson, C.J. and McGee, M.G. (Eds.). (2002). How different religions view death and afterlife. Philadelphia, PA: The Charles Press.
Johnson, S.W. and Maile, L.J. (1987). Suicide and the schools: A handbook for prevention, intervention, and rehabilitation. Springfield, IL:
Thomas Press.
Kamerman, J.B. (1988). Death in the midst of life: Social and cultural influences on death, grief and mourning. Englewood Cliffs, NJ: PrenticeHall.
Lindemann, E. (1944). The symptomatology and management of acute grief. American Journal of psychiatry, 101, 141-148.
Matsunami, K. (1998). International handbook of funeral customs. Westport, CT: Greenwood Press.
McGovern, M. and Barry, M. (2000). Death education: Knowledge, attitudes, and perspectives of Irish parents and teachers. Death Studies,
24(4), 325-333.
Parkes, M. Loringani, C. and Young, B. (1997). Death and bereavement across cultures. New York, NY: Routlage.
Rando, T.A. (1984). Grief, dying and death: Clinical interventions for caregivers. Champaign, IL: Research Press.
Rando, T.A. (1993). Treatment of Complicated Mourning. Champaign, IL: Research Press.
Rothschild, Babette. (2000). The Body Remembers. New York, NY: W.W. Norton Publishing
Rowling, L. (2003). Grief in school communities: Effective support strategies. Philadelphia, PA: Open University.
Shapiro, E. (1996). Grief as a family process. New York, NY: Guildford.
Silverman, P. (2000). Never too young to know. New York, NY: Oxford Press.
Soricelli, J. and Utech, C.L. (1985). Mourning the death of a child: The family and group process. Social Work, 30, 429-434.
Sprang, G. and McNeil, J. (1995). The many faces of bereavement: The nature and treatment of natural, traumatic, and stigmatized grief.
New York, NY: Brunner/Mazel.
Stroebe, M. and Schut, H. (1999). The dual process model of coping with bereavement: Rationale and description. Death Studies, 23, 197224.
Stroebe, M., Gergen, K., and Stroebe, W. (1992). Broken hearts or broken bonds: Love and death in historical perspective. American
Psychologist, 37, 1205-1212.
Valeriote, S and Fine, M. (1987). Bereavement following the death of a child: Implications for family therapy. Contemporary Family Therapy:
An International Journal, 9, 209-217.
Volkan, V.D. and Zind, E. (1993). Life after loss: The lessons of grief. New York, NY: MacMillan Publishing Co.
Walker, R. and Pomeroy, E. (1996). Depression or grief? The experience of caregivers of people with dementia. Health and Social Work, 21 ,
247-254.
Walsh, F. and McGoldrick, M. (Eds.). (1991). Living beyond loss. New York, NY: W.W. Norton.
Webb, N.B. (2002). Helping bereaved children: A handbook for practioners. New York, NY: Guildford Press.