CHILDHOOD TRAUMATIC GRIEF: A GROUP WORK CURRICULUM FOR
CHILDREN AND TEENS
Aja A. Michael
B.A., California State University, Sacramento, 2009
Laurie E. Thompson
B.A., California State University, Sacramento, 2009
PROJECT
Submitted in partial satisfaction of
the requirements for the degree of
MASTER OF SOCIAL WORK
at
CALIFORNIA STATE UNIVERSITY, SACRAMENTO
SPRING
2011
CHILDHOOD TRAUMATIC GRIEF: A GROUP WORK CURRICULUM FOR
CHILDREN AND TEENS
A Project
by
Aja A. Michael
Laurie E. Thompson
Approved by:
__________________________________, Committee Chair
Joyce Burris, Ph.D.
Date
ii
Aja A. Michael
Student: Laurie E. Thompson
I certify that these students have met the requirements for format contained in the
University format manual, and that this project is suitable for shelving in the Library and
credit is to be awarded for the project.
, Graduate Coordinator
Teiahsha Bankhead, Ph.D., L.C.S.W.
Date
Division of Social Work
iii
Abstract
of
CHILDHOOD TRAUMATIC GRIEF: A GROUP WORK CURRICULUM FOR
CHILDREN AND TEENS
by
Aja A. Michael
Laurie E. Thompson
This project was a collaborative effort and both researchers brought unique perspectives,
ideas, and strengths to the forefront of this project. Both researchers were responsible for
conducting surveys, collecting literature, and creating the project. The Childhood
Traumatic Grief Group (CTG) Work Curriculum for Children and Teens is intended for
use with those that have recently experienced the death of a loved one and are suffering
from symptoms of grief and trauma. CTG is a relatively new topic, so this study was
exploratory in nature. Information was gathered from texts, professional journals, art
therapy curriculums, and professional interviews as well as the writer’s personal
experiences working with grieving children.
Implications for social work and
recommendations for future grief curriculums are also discussed.
__________________________________, Committee Chair
Joyce Burris, Ph.D.
____________________________
Date
iv
TABLE OF CONTENTS
Page
Chapter
1. INTRODUCTION ...........................................................................................................1
The Problem .............................................................................................................1
Statement of Collaboration ......................................................................................3
Background of the Problem .....................................................................................3
Statement of the Research Problem .........................................................................4
Purpose of the Study ................................................................................................4
Personal Interest in the Problem ..............................................................................6
Theoretical Frameworks ..........................................................................................6
Grief Models ............................................................................................................9
Research Questions ................................................................................................11
Assumptions...........................................................................................................11
Justification ............................................................................................................12
Definition of Terms................................................................................................13
Delimitations ..........................................................................................................14
Summary ................................................................................................................15
2. LITERATURE REVIEW ..............................................................................................16
Introduction ............................................................................................................16
Theoretical Perspectives on Grief ..........................................................................18
v
Components Influencing Grief Processing ............................................................23
Children’s Grief .....................................................................................................34
Factors Influencing Children’s Responses to Grief ...............................................34
TF-CBT an Overview ............................................................................................40
Summary ................................................................................................................41
3. METHODS ....................................................................................................................45
Introduction ............................................................................................................45
Design ....................................................................................................................46
Research Questions ................................................................................................46
Participants .............................................................................................................47
Instrumentation ......................................................................................................48
Data Gathering Procedures ....................................................................................48
Protection of Human Subjects ...............................................................................48
Data Analysis .........................................................................................................49
Summary ................................................................................................................49
4. FINDINGS ....................................................................................................................51
Introduction ............................................................................................................51
Findings from Interviews .......................................................................................51
Childhood Traumatic Grief a Group Work Curriculum Guide for Children
and Teens ...............................................................................................................54
5. CONCLUSION AND IMPLICATIONS FOR SOCIAL WORK .................................83
Introduction ............................................................................................................83
vi
Review of the Findings and Relevance ..................................................................84
Implications............................................................................................................85
Recommendations for Further Research ................................................................85
Summary ................................................................................................................86
Appendix A. Interview Questions......................................................................................89
Appendix B. Consent to Participate in Research ...............................................................91
Appendix C. Relaxation/Breathing Exercise .....................................................................93
References ..........................................................................................................................94
vii
1
Chapter 1
INTRODUCTION
The Problem
On its own grief can be an incredibly challenging and horrific issue for a child to
deal with. When grief is combined with trauma it becomes an often overwhelming
experience far beyond a child’s scope of coping abilities. While many clinicians are well
trained in treating each of these issues separately, there has been recent acknowledgment
that it may be ineffective to treat one without addressing the other. Children who have
experienced these types of traumatic losses may become fixated on the trauma and unable
to process their grief. This can lead to serious disorders including depression and
anxiety, along with the presence of PTSD type symptoms. The presence of these
symptoms in conjunction with the experience of a traumatic loss has been defined as
Childhood Traumatic Grief (Cohen, Mannarino, & Deblinger, 2006). If left untreated
CTG can put children at risk for developing serious psychiatric conditions including
depression, substance abuse, and borderline personality disorder (Cohen et al., 2006).
The importance of distinguishing CTG from other forms of grief is a relatively
new idea in the field of social work. For this reason there is very little emphasis on how
to adequately treat the traumatic aspects of death addressed in the current grief
curriculums. The researchers of this project felt that in their professional experiences
many of the children being treated for grief had lost a loved one in an exceptionally
traumatic or gruesome circumstance. In most of these cases the experience was so severe
2
that it overwhelmed the children’s capacity to cope with the behavioral, cognitive,
emotional, and physical symptoms commonly observed in trauma situations. Brown and
Goodman (2005) describe the thoughts and images involved in CTG as being so violent
or disturbing that they prohibit the child from being able to think about the deceased. By
doing this they are unable to evoke positive memories of their loved one which is an
important part of the grieving process. These children appeared to be unable to process
their grief regardless of the treatments and resources that were available.
Grief is not a process that can be skipped over or ignored, even for children. The
task of grief takes a great deal of time and energy and must be processed in stages. When
trauma interferes with a child’s ability to appropriately resolve these tasks, they are at
risk of developing a variety of problems that can persist well into adult life. Properly
assessing and treating children who are at risk for Childhood Traumatic Grief is
becoming an essential skill for clinicians working with children or in the field of
bereavement. Although much of the research on this topic is preliminary, multiple
studies have found that a conjoint curriculum designed to treat the symptoms of trauma
while focusing on a grief model is an essential intervention when working with children
affected by CTG (Cohen, Mannarino, & Staron, 2006). Based on the negative affects,
Childhood Traumatic Grief can present for children’s health, safety, and overall well
being the authors of this project feel that the research and development of this project is
an important contribution to the field of Social Work.
3
Statement of Collaboration
Laurie Thompson and Aja Michael are co-authors of this project. We were
equally responsible for all aspects of the project including the research, writing, data
collection, and curriculum development.
Background of the Problem
Recent research has shown evidence that children who experience traumatic grief
that is untreated, continually exhibit unhealthy behaviors well in to their adult life
(Cohen, Mannarino, & Deblinger, 2006). These behaviors put them at risk for a variety
of mental health issues including anxiety, depression, and substance abuse. Children who
have experienced a traumatic loss are also shown to have higher incidences of suicide and
an increased risk of HIV infection (Cohen, Mannarino, Murray, & Igelman 2006).
Children who lose a parent or caregiver to a traumatic death, tend to experience similar
symptoms to those with PTSD, including numbing and avoidance. For this reason they
disassociate with positive memories of their parent and focus instead on the trauma of the
death itself. The inability to form attachments to healthy memories contributes to an
inability to process grief. Children who experience these issues may continue to act out
until they have had an opportunity to properly deal with their loss (Brown, 2005).
Recent research has indicated that it is increasingly important to differentiate
between CTG and typical bereavement in order to provide appropriate interventions. The
significance of this issue has brought to light the possible need for a new diagnostic
category specifying the trauma symptoms that are present with grief, while distinguishing
4
them form other diagnoses such as PTSD and depression. There have been complaints
that the current diagnostic system in relation to trauma symptoms for children and
adolescents is lacking diversity and leads to issues of no diagnosis, inaccurate diagnosis,
or inadequate diagnosis (van der Kolk & Pynoos, 2009). In 2009 a proposal was made to
include a Developmental Trauma Disorder diagnosis for children in the DSM-V based on
these complaints. The proposal indicated that the symptoms of trauma did generally not
independently exist but co-occurred with other issues including grief (van der Kolk &
Pynoos, 2009).
Statement of the Research Problem
The research problem involves taking the information gathered by these authors
on CTG and using it to create a curriculum guide for counselors that will address aspects
of grief as well as trauma. Children who are exposed to graphic scenes or details about a
death or experience loss in a situation that is considered to be unusually violent or
gruesome may have similar symptoms to PTSD that can last well into adulthood.
Purpose of the Study
The purpose of this research document is the development of a group work
curriculum for children and teens who are suffering from traumatic grief. This problem
is significant because without the proper treatment of grief, children may have difficulty
coping with all aspects of daily life. They may act out at home, in school, and in social
settings. Goodman, Morgan, Juriag, and Brown (2004) describes the factors that mark
traumatic grief as not being able to experience the reality and permanence of death
5
regardless of the child’s cognitive ability to do so, having difficulty coping with
emotional reactions surrounding death, being unable to adjust to changes in their lives or
identity, not developing new relationships or strengthening pre-existing ones, an inability
to maintain appropriate attachment to the person who died, and abnormalities in
continuing through the developmental stages of childhood and adolescence (Goodman et
al., 2004). Due to the increasing rates of violence in many communities, children are
experiencing violent and traumatic losses. There has also been a swell in the number of
children being treated for this problem because they have lost parents or caregivers who
are members of the military. The families and communities of these children often are
not aware of how to support them and without clinical interventions, they often suffer
untreated.
The development of a separate curriculum for dealing with traumatic grief is
necessary because many of the current curriculum guides for working with children and
loss do not address the trauma that can be involved. In these types of complicated loss, it
may be insufficient to address only the trauma or the loss separately. It is the intention of
this study to gather information from experts in literature as well as from personal
interviews to determine what aspects of curriculum will best facilitate treating the
symptoms of trauma and grief simultaneously.
Based on the information obtained in the research these authors will be
developing a curriculum guide to treat children and teens suffering from CTG in a group
setting. While many of the available treatment models are directed at individuals, the
6
authors of this project felt that it was important to develop a group intervention. Based
on limited resources many children are being treated for grief in group settings, including
support groups, art therapy models, and schools. A group curriculum for properly
addressing issues of CTG would be very beneficial in any of these settings.
Personal Interest in the Problem
The researchers involved in this project developed a personal interest in this
problem while they were working with children in their field placements. Many of these
children were experiencing horrific losses of multiple caregivers and there was not an
adequate resource to meet the needs of these experiences. Although there were multiple
interventions for grief, they appeared to be ineffective because they did not address any
of the trauma symptoms these children were experiencing. There were also resources to
manage the trauma issues but these did not revolve around themes of grief and loss. The
authors observed a gap in the ability to properly provide clinical interventions for
children who had both of these needs. The development of a group work curriculum was
conceptualized as a way to concentrate on this gap in services.
Theoretical Frameworks
The development of a curriculum for treating Childhood Traumatic Grief was
dependent on a wide variety of theoretical frameworks. The authors of this project looked
extensively at theory models of grief, attachment, child development, and trauma. Based
on this research it was determined that to understand CTG symptoms and interventions
there would be a focus on grief treatment as well as the developmental stages of children
7
in relation to their grief. There were three fundamental theories from which this
curriculum guide was developed: Jean Piaget’s Cognitive Development Theory (as cited
in Zastrow & Kirst-Ashman, 1997) and William Worden’s (1991) and Therese Rando’s
(1984) tasks of mourning.
A child’s ability to interpret and express grief is directly linked to her or his
developmental ability to understand death. One of the key theorists in children’s
development is Jean Piaget. Piaget’s cognitive development theory describes the
developmental stages children go through in relation to their age, which these authors see
as incredibly useful in understanding their ability to interpret the meaning of death
(National Child Traumatic Stress Network [NCTSN], 2010). The researchers of this
project used Piaget’s theory as a foundation for developing appropriate interventions with
children based on their ability to interpret and understand themselves in relation to the
world around them.
Piaget described children’s cognitive development as occurring in stages (Zastrow
& Kirst-Ashman, 1997). Although these stages happened consecutively it was
understood that there would be some common characteristics between the stages as
children obtained more knowledge about the world around them. Piaget designated
cognitive stages broken down by age of the child and defined them as Sensorimotor
stage: birth to two years, Preoperational stage two to seven years, Concrete Operational
stage 7 to 12 years, and Formal Operations stage: 12 to 16 years.
8
During the Sensorimotor stage children are still developing the awareness of what
is real and permanent. In this stage they see death as being reversible and do not
understand that all living things will eventually die. Children are moving from basic
reflexive actions to more sophisticated motor skills, to developing their various senses
and as they integrate from these they develop an understanding of themselves in
relationship to the world around them. Within this stage children also develop the
concept of object permanence, meaning that they know that objects still exist even when
they are out of sight (Zastrow & Kirst-Ashman, 1997). This concept can lead to a child
developing more extensive grief as they do not forget that something exists simply
because they cannot see it.
Moving into the preoperational stage children gain a more richly developed use of
language and can view themselves in relation to other people (Zastrow & Kirst-Ashman,
1997). Children at this age are still very imaginative and do not view death as being
permanent or concrete. They are egocentric and having difficulty interpreting the affects
of their actions on those around them. In this stage children may be more able to describe
their feelings of grief through the use of words, art, or play.
Many new skills are developed during the concrete operational stage including the
ability to empathize with others and to use more logical thinking (Anthony, 1972). Based
on these new abilities, children are able to understand the reality of death and become
aware of the fact that it is in fact both permanent and universal. This allows children to
use grief work more effectively because they’re able to understand the reality of the death
9
and move through the feelings of loss. Even children who have experienced grief therapy
at a young age may need to return to it once they hit this developmental milestone. Piaget
argued that this skill is generally not acquired before the age of nine (Balk & Corr, 2010).
In the formal operations stage children begin to accept a more adult view of death,
grief, and loss. They have now developed the ability to use logical and abstract thinking
and are able to use these techniques to solve problems in their own lives (Anthony,
1972). At this point in time support groups can be very beneficial as children now have
the ability to empathize with others and can both provide and accept support from peers
who have experienced loss as well.
These developmental stages serve as a concrete way for the writers of this
curriculum to develop age appropriate activities for children experiencing CTG. Piaget
provided effective tools for looking at children’s ability to understand, accept, and
process the reality of death as well as the feelings of grief. These developmental
milestones in combination with the following model of grief from William Worden are
the basis for the research and development of this project.
Grief Models
Dr. J. William Worden developed his four tasks of mourning as a grief model
with the intention of focusing inner feelings outwardly. The four basic tasks are to 1)
accept the reality of the loss, 2) to work through the emotions and accept the pain
associated with the loss, 3) to learn how to cope with practical tasks of living without the
support of the deceased, and 4) to find a new place in one's emotional life for one's
10
relationship with the deceased (Worden, 1991). These tasks relate to the ideas of denial,
anger and grief, learning to cope and moving on. The bereaved person does not pass
through stages but undertakes tasks—this helps explain why some individual’s recover
from trauma faster than others. The accomplishment of each task, ending in the
reinvestment in life and other relationships does not merely occur through the passage of
time, but demands an active role on the part of the grieving person (Worden, 1991).
Worden also asserts that although the tasks of mourning may have been appropriately
accomplished, grief does not necessarily end. The pain accompanying the loss of a loved
one simply flares up less often.
Worden’s model (1991) has frequently been used in bereavement groups that are
directed toward children because it is task focused and simple. This theory is important
in conjunction with trauma because without adequate intervention of the trauma
symptoms children will not be able to complete the grief tasks laid out by Worden.
Trauma can interfere with a child’s ability to have memories of the deceased, which
directly interferes with all of Worden’s grief tasks (Cohen et al., 2006). As this is the
general model used in grief groups for children it is easy to understand why it would not
be adequate to use this theory independently when working with CTG.
Therese Rando expanded on this model by adding two more tasks of mourning.
Rando’s model includes six tasks 1) Recognize the loss (acknowledge and understand the
death), 2) React to the separation (experience pain; feel, identify, accept and express the
reaction to loss and identify and mourn second losses), 3) recollect and re-experience the
11
deceased and the relationship, 4) Relinquish old attachments to the deceased and old
assumptions of the world, 5) Readjust to move adaptively into new world without
forgetting the old (develop new relations with the deceased adopt new identity), 6)
Reinvest by putting new emotional energy into developing a new interest in life (Rando,
1993).
Research Questions
Through our research and interviews of experts in the field of children’s grief we
hoped to answer questions related to the resources needed to address children who are
experiencing grief and trauma symptoms simultaneously. We looked for common
themes and objectives that can be developed as interventions for a group curriculum. We
hoped to answer the following questions in this project:
1. How frequently are professionals observing clients with CTG?
2. How do current curriculums address CTG?
3. What strategies or interventions will be most affect at treating CTG?
4. What are some of the situations in which children are most commonly
experiencing CTG?
Assumptions
Through the author’s review of the literature, multiple conclusions were made
about children’s responses to grief and trauma. These conclusions were adapted as part
of the foundation for the research of this project as well as the development of the
curriculum.
12
1. Children will process grief differently than adults do.
2. Children can only experience grief in relation to their cognitive development
and understanding of the reality of death.
3. CTG is a condition that needs to be addressed with specific interventions that
combine treatment for both grief and trauma issues.
4. Therapists who work with children will be good contributors of information for
developing curriculum materials on CTG.
5. Group therapeutic interventions are commonly used for treating grief
symptoms.
6. Trauma symptoms may affect a child’s grieving process.
Justification
The death of a parent, brother, sister, or someone else close is a profound and
challenging experience for a young person. Over the last two decades, services to
support bereaved children and their families have emerged as a new form of
establishment (Rolls & Payne 2003). Their growth could be seen simply as an organized,
collective expression of the compassion that we feel towards a child who has been
bereaved. Based on the increase of supportive services being developed for this purpose,
the authors of this project intend to contribute by developing an in depth curriculum
designed to further address the painful subject of children’s grief. By incorporating
information on the various types of grief and accepting that a generic intervention is not
13
effective, the authors hope to provide a consolidated curriculum designed for social
workers who are specifically working with CTG.
Definition of Terms
Bereavement: the actual state of having suffered the loss of someone in whom the
individual had an emotional investment.
Complicated Grief: There is no formal definition of complicated grief, but researchers
describe it as an acute form persisting more than six months, at least six months
after a death. However, these authors do not feel that this is a significant enough
amount of time to diagnose complicated grief. Its chief symptom is a yearning for
the loved one so intense that it strips a person of other desires. Life has no
meaning; joy is out of bounds. Other symptoms include intrusive thoughts about
death; uncontrollable bouts of sadness, guilt and other negative emotions; and a
preoccupation with, or avoidance of, anything associated with the loss. It is an
extreme form of grieving, often called complicated grief or prolonged grief
disorder, and has attracted so much attention in recent years that it is one of only a
handful of disorders under consideration for being added to the DSM-V, the
American Psychiatric Association's handbook for diagnosing mental disorders,
due out in 2012 (Schumer, 2000).
CTG: Childhood traumatic grief may occur following a death of someone important to
the child when the child perceives the experience as traumatic. The death may
have been sudden and unexpected (e.g., through violence or an accident), or
14
anticipated (e.g., illness or other natural causes). The distinguishing feature of
childhood traumatic grief is that the trauma symptoms interfere with the child's
ability to go through the typical process of bereavement. The child experiences a
combination of trauma and grief symptoms so severe that any thoughts or
reminders, even happy ones, about the person who died can lead to frightening
thoughts, images, and/or memories of how the person died (NCTSN, 2010).
Grief: the personal and unique response to loss by an individual.
Loss: a feeling of sadness that one has when someone leaves or dies, or when one does
not have something anymore.
Mourning: the overarching process of one’s response to loss. Mourning is culturally and
socially influenced and incorporates a beginning, middle and an end.
Delimitations
Due to the constraints of time and resources, this project was limited to
researching a limited scope of work. While children experience many different traumas
and feelings of loss related to these incidents, this project focused only on loss associated
with the death of a loved one. Other forms of trauma and loss connected with abuse,
divorce, parental rights, parental incarceration, physical ability, and other significant life
changes are equally important in the lives of children and should be addressed with
appropriate interventions.
The researchers of this project are also aware that there are a variety of cultural
influences that greatly affect the bereavement process for children and families.
15
Although the curriculum developed in this project does not specifically address these
differences, clinicians should be culturally aware and competent of coping with different
cultural grief practices and reactions. This project also does not provide interventions
based on gender differences of the bereaved.
The final limitation of this project was the ability to interview clinicians from a
variety of different communities. The authors of this thesis conducted a convenience
sampling of social workers in the Sacramento area. For a more extensive research project
it would be valuable to interview clinicians who had worked with a wider range of clients
including those from rural and urban communities and different cultural and socioeconomic backgrounds to assess which interventions would be most effective.
Summary
This study is aimed at not only researching but addressing an issue that is
complicated and serious in the lives of modern children. As they are faced with
increasingly high levels of violence it is inevitable that they will take on some of the
trauma associated with these types of deaths. The following chapter will provide in depth
research on the details associated with grief and trauma as it applies to children. The
authors of this project believe that this information will provide social workers with a
rationale for properly differentiating, assessing, and treating Childhood Traumatic Grief.
16
Chapter 2
LITERATURE REVIEW
Introduction
Grieving is not instinctual for us—it requires learning. The grief process
produces intense and painful emotions within people and the sudden, unexpected death of
a loved one forever changes the lives of their family members. The way a person
responds to this loss is affected by her or his cultural and religious background, coping
skills, mental history, support systems, as well as social and financial status. It is
particularly important that adults attempt to teach their young about grieving. If a child
does not grieve in an appropriate manner, repressed grief may surface years later, a
phenomenon that sometimes happens to adults as well. Children suffer from death much
like adults, but with even less understanding. When dealing with children, it is important
to realize that they probably know more than what we give them credit for. Children
need to see adults cry, which will give them permission to cry also and to express
emotions that may otherwise remain hidden.
Social workers need to be knowledgeable about grief and loss treatments in order
to assist individuals during the grieving process and to address personal loss in a healthy
manner. It is interesting to note that the American Psychiatric Association is considering
adding a diagnosis of complicated grief to the Diagnostic and Statistical Manual of
Mental Disorders (DSM V; American Psychiatric Association [APA], 1994) as well as a
developmental trauma disorder diagnosis for children and adolescents (The National
17
Institute for Trauma and Loss in Children [NITLC], 2010). Certainly, some mourners
need more than the loving support of friends and family. But, making a disease of grief
may be another sign of a huge, and potentially pernicious, shift that has taken place over
the past century; what perhaps might be called the privatization of grief (O’Rourke,
2010).
Mourning rituals in the West have begun to disappear, for reasons that are not
entirely evident. The British anthropologist Geoffrey Gorer (1965), the author of Death,
Grief, and Mourning, surmises that the First World War was one cause in Britain:
communities were so overwhelmed by the sheer numbers of dead that they dropped the
practice of mourning for the individual. With the rise of psychoanalysis came a shift in
attention from the communal to the individual experience. Only two years after social
theorist Émile Durkheim wrote about mourning as an essential social process, Freud’s
(1917) Mourning and Melancholia defined it as something fundamentally private and
individual. In a stroke, the work of mourning had become internalized. As Ariès says,
within a few generations grief had undergone a fundamental change: death and mourning
had been largely removed from the public realm (O’Rourke, 2010). The terms grief,
mourning, and bereavement often are used interchangeably when discussing loss
experienced by family and friends when a loved one dies (Rando, 1984).
Grief and bereavement are terms often used similarly when in fact there is one
major difference between the two. According to Rando (1984), bereavement is reserved
specifically for the recognition of a person having experienced the death of a significant
18
other whereas, grief can be the result of incidents of loss not only involving death, but
also such as loss of job, loss of a limb, loss of status. There is also a difference between
bereavement and mourning although they too are also sometimes used interchangeably.
In fact, a distinct difference also exists between these two classifications. Bereavement
identifies the specific reality of a death and reactions experienced following the death of a
significant other whereas, mourning speaks to the way the individual displays his/her
grief and recognizes those behaviors that are promoted by cultural norms and rituals that
serve to guide the behaviors of “how one responds to death” (van der Kolk & Pynoos,
2009, para. 2).
Processing grief helps individuals to recognize that grieving, although
uncomfortable, is a normal, healthy process as a response to loss. By talking about grief
and teaching new coping skills, it may assist people with the pain and anxieties
associated with loss and help to bring resolution thereby, avoiding unresolved grief. It is
also necessary to help individuals to develop strategies for seeking support for learning
self-care during times of trauma.
This review of the literature will begin with a broad and extensive discussion of
the different theoretical perspectives of the grief process. Also discussed will be the
developmental stages of grief, children and grief, as well as trauma and loss.
Theoretical Perspectives on Grief
There are many theoretical perspectives that may be used to explain the
grief process. The authors of this project have chosen to focus on the following
19
originators of observations and theories about grief: 1) Sigmund Freud, 2) Colin Murray
Parkes, 3) Elizabeth Kübler-Ross, and 4) John Bowlby.
Sigmund Freud
Freud published his influential essay on Mourning and Melancholia in 1917 in
which he described the essence of melancholia by comparing it to the normal affect of
mourning. He explained that grieving is a person’s reaction to loss which is expected,
causes pain, loss of interest in the outside world, an inability to love and a withdrawal
from anything not having to do with the deceased loved one. He also noted that these
symptoms are normal, should not be interfered with and are expected to disappear after
time (Freud, 1917). The review of the literature indicates that even today his
observations are consistent with what we normally associate with grief. Additionally,
Freud details that grief represents as a loss of an object (the deceased) and calls the
psychological input needed to rectify this loss as “grief work” (Clewell, 2004), that is, a
specific grieving job should be finished before the next job begins. By this, he suggested
the importance of expressing grief and detaching emotionally from the deceased in order
to recover full function.
Colin Murray Parkes
Dr. Colin Murray Parkes was one of the first psychiatrists to identify the stages of
grieving (Ironside, 1996). Through his research on the grief of the widow’s, with whom
he worked, Parkes developed a constructive model that identifies a variety of feelings that
bereaved people now realize are normal. The stages of Dr. Parks’s theory are as follows:
20
1) numbness, the first stage which involves being stunned and in denial gives way to 2)
pining, which involves a yearning and searching for the lost loved one; and 3)
disorganization and despair, which includes depression and a lack of desire to look to the
future or find any purpose in life, and 4) and lastly, reorganization where bereavement
breaks down attachments to the deceased loved one and begins to develop new
relationships and a renewed interest in life (Parks, Stevenson-HInde, & Marris, 1991;
Keegan, 2002).
Elizabeth Kübler-Ross
Elizabeth Kübler-Ross, a Swiss-born psychiatrist has been widely recognized as
one of the foremost authorities in the field of death, dying and transition. Although it was
first published in 1969, Dr. Kübler-Ross’ book, On Death and Dying, was influential in
identifying the “stages of grief” model, which conceptualized the grief process and
provided a framework for thinking about grief and the healing process. She expanded on
the grief models by Bowlby (1980) and Parkes (1996), by proposing in her model the five
stages a person goes through when they are told they have a terminal illness: denial and
isolation, anger, bargaining, depression and acceptance. Kübler-Ross (as cited in
Friedman & James, 2008) also repeatedly stipulated in her book that a dying person
might not go through all five stages, nor would they necessarily go through them in
sequence.
Although On Death and Dying (Kübler-Ross, 1969) was written for the dying, it
has also been widely used in bereavement work, as it is influential in helping the griever
21
as well. The “stage theory,” as it has come to be known, quickly created a paradigm for
how Americans die. It eventually created a paradigm, too, for how Americans grieve:
Kübler-Ross suggested that families went through the same stages as the patients.
Decades later, she produced a follow-up to On Death and Dying entitled On Grief and
Grieving (Kübler-Ross & Kessler, 2005), explaining in detail how the stages apply to the
grieving process. Even today, Kübler-Ross’s theory is taken as an important account of
how we grieve. It pervades pop culture—the opening episodes of this season’s “Grey’s
Anatomy” were structured around the five stages and it shapes our interactions with the
bereaved (O’Rourke, 2010).
John Bowlby
Attachment theory is the joint work of John Bowlby and Mary Ainsworth
(Ainsworth & Bowlby, 1991). They assert that attachments are necessary to ensure
security and safety, and go beyond the need to meet biological derived for food and sex.
These attachments develop early in life and are usually directed to a few significant or
primary figures. Adults as well as children form these attachments and these bonds are
active throughout the lifecycle. Attachment theory has been widely used as a tool for
understanding key aspects of close relationships and their effects on socioemotional
functioning throughout the lifespan.
About 10 years after Elisabeth Kübler-Ross introduced her five stages of grief
theory, Bowlby (1980) put forth a less rigid theory of the way people progress through
grief: grief was an extension of the natural human response to separation. Bowlby’s
22
model explains that the stages of the grieving process can shift and overlap, and utilizes
an ebb and flow epithet. In explaining this, he noted that all stages of the grief process
may even take place at the same time and that the amount of time spent in each phase
may be influenced by a huge number of factors including age, personality and the
circumstances surrounding the death of the loved one (Bender, 2007). The four stages of
Bowlby’s Ebb and Flow model are: shock and numbness, yearning and searching,
disorganization and despair, and reorganization (Bowlby, 1980).
The literature indicated that task models of grief, which emphasize individuality
and stress autonomy, include accepting reality, working through grief, adjusting to loss,
and restoring one’s own life. More work is needed to recognize the many ways grief
affects individuals, and to understand how it varies in its physical, emotional, cognitive
and spiritual effects, but that grief, like most emotions, is a universal experience.
There are a number of predominant issues that determine a person’s individual
reaction to loss and grief. In 1944, Erich Lindemann coined the term "grief work" to
describe the necessary process that takes place between a person’s initial reaction and
eventual adaptation to the death of a loved one (Rando, 1984). The term is still
appropriate today and shows that an individual who faces loss must actively work at if
he/she is to resolve it in a healthy fashion.
Helen Keller said, “Although the world is full of sorrow, it is full also of the
overcoming it" (as cited in Bruun & Getzen, 1996, p. 600). Grieving is a normal life
process—an adjustment reaction to loss. It is the means by which we cope with the
23
division of life before and after death. Change and letting go are also key elements of life
as well important components of grief and loss.
While early work on grief and the healing process have been conceptualized in a
stages model, more recently the research indicates a moving away from the conventional
views of stages in the healing process. A more recent conceptualization of grief defines it
as the conflicting feelings caused by the end of or change in a familiar pattern of
behaviors (Friedman & James, 2008).
Emily Dickinson, the supreme poet of grief, may provide more solace to the
mourner than the glad tidings of those who talk about how death can enrich us. In her
poem “I Measure Every Grief I Meet,” the speaker’s curiosity about other people’s grief
is a way of conveying how heavy her own is:
I wonder if It weighs like Mine—
Or has an Easier size.
I wonder if They bore it long—
Or did it just begin—
I could not tell the Date of Mine—
It feels so old a pain—
I wonder if it hurts to live—
And if They have to try—
And whether—could They choose between—
It would not be—to die. (as cited in Franklin, 1998, p. 561)
24
Components Influencing Grief Processing
Psychological Reactions
The bereavement literature has identified a number of features of the death
experience that might contribute to traumatic reactions. Scientists who study pain and
doctors who treat pain consider the experience a strictly physical phenomenon, in the
sense that it can only be caused by injury to the body (Biro, 2010). Psychiatrists are wary
of speaking about pain in their patients, reserving it only for those rare and strange cases
of psychogenic pain or somatoform pain disorder—that is, physical-like pain localized to
a part of the body that has not been injured, the modern-day equivalent to what Freud
termed hysteria or conversion reaction (American Psychiatric Association as cited in
Brio, 2010). According to the experts on psychopathology, psychological pain
experienced by patients with acute depression simply does not exist.
The divide between professionals and laypersons is vast. When we ask people
about certain aversive emotional experiences and listen to their words, we find that they
not only use the generic word ‘‘pain’’ to label these experiences, but also describe them
in the same ways they describe physical pain (Biro, 2010). Grief symptoms are described
as affecting an individual in many ways: spiritually, behaviorally, physically, and
cognitively. Normal changes during grief include crying, sighing, agitation, changes in
eating habits and sleep patterns. Modern grief researchers claim that grief is a
psychological problem necessitating extensive study and intervention by trained
professionals (Granek, 2010).
25
Physical Reactions
The physical sensations associated with grief and its processes are normal and can
be expected. William Worden (1991) reports that often the grievers discomfort caused
by these symptoms may cause him to seek medical attention. Often during these times,
grievers are prescribed drugs to help them cope in the initial phases of grief. It is also
during this time when mourners are venting their emotions and realizing the loss is of
utmost importance; social supports are at their strongest and may help the survivor cope
with the intense emotional distress. Since the bereaved person is already numbed by
grief, the effectiveness of drugs during this time is questionable.
Grief also has a physical impact on grievers. It is especially important during this
time to maintain adequate nutrition. Poor nutrition affects the body and brain in
significant ways. According to the literature, it is common for the bereaved to have a
greatly reduced appetite for food. The evident negative consequences for extended
periods of anorexia are a matter of concern and will add to the complexity of the grieving
process. Although the “body” also grieves for the lost loved one and any of the bodily
processes or functions may be affected, it is important to make proactive measures for
maintaining health, including nutrition, rest, exercise, sleep, reduction of stressors and
simplicity of routine (Jozefowski, 1999).
All of the literature reviewed, agree that grief will, to some extent, impact
practically every person’s physiology. Contemporary psychologists that have examined
Freud’s grief theory empirically have claimed that grief is a pathology that should be
26
included within the psychological domain (Granek, 2010). Medicine regards pain as a
signal of physical injury to the body despite evidence contradicting the linkage and
despite the exclusion of vast numbers of sufferers who experience psychological pain.
By broadening the concept of pain and making it more inclusive, it not only is possible to
better accommodate the basic science of pain but also makes more recognizable what is
already appreciated by the layperson— that pain from diverse sources, physical and
psychological, share an underlying felt structure (Brio, 2010).
Unresolved Grief
Individual reactions to grief are personal, unique and specific to individuals.
Because of the countless physical, psychological, social and cultural factors that impact
grief, not everyone faced with the loss of a loved one experiences healthy grief and
resolution of the loss. If for some reason grieving is interrupted or avoided for whatever
rationale, a person can suffer from complicated grief or unresolved grief. Researchers are
unsure of exactly what specifically causes unresolved grief, but there are certain
psychological and social reasons and risk factors that may include any of the following:

If a death is unexpected, a violent death or suicide;

Lack of social support;

If there were traumatic events in one’s childhood such as abuse or neglect or
experience of separation anxiety;

Lack of ability to adapt to life’s changes, and;
27

Caregivers caring for a loved one with a terminal illness are at an increased risk of
complicated grief, even before the death.

Lack of acknowledgment by one’s social community or culture of the loss,
including lack of rituals to acknowledge the bereaved. (Tomarken, Holland, &
Schachter, 2008)
When complicated/unresolved grief is left untreated, a myriad of complications can occur
such as: thoughts or increased risk of suicide, alcohol or drug abuse, clinical depression,
anxiety, post-traumatic stress disorder, and an inability to perform everyday/routine
activities (Tomarken et al., 2008). According to Meyer (2000), normal grieving is timelimited and benign, but unresolved mourning is ongoing and can lead to psychiatric
problems, medical illness and even death.
Anticipatory Grief
The term anticipatory grief, the normal grieving which occurs before the actual
loss, was introduced by Lindermann in 1944 (as cited in Worden, 1991), but the concept
of individuals preparing for and anticipating the death of a loved one under certain
circumstances is recognized in all the literature reviewed. Kübler-Ross’s (1969) research
with terminally ill patients specifically dealt with issues of their anticipation and
acceptance of the inevitability of their own deaths. Anticipatory grief can be a response
to threats of loss of ability to function independently, loss of identity, and changes in role
definition, which underlie fear of death (Hottensen, 2010). Anticipatory grief is
described as a range of intensified emotional responses that may include separation
28
anxiety, existential aloneness, denial, sadness, disappointment, anger, resentment, guilt,
exhaustion, and desperation (Cincotta as cited in Hottensen, 2010). Dealing with
multiple losses is the preeminent coping task faced by a dying patient (Block as cited in
Hottensen, 2010).
Rando (1984) defines anticipatory grief as being a form of normal grief in the
anticipation of a future loss. She states that anticipatory grief allows the person to absorb
the reality of the loss gradually. It gives them an opportunity to complete any unfinished
business with the dying person such as resolving conflicts or sharing feelings.
Anticipatory grief also allows the griever to begin changing his or her identity and
assumptions about life and the world. This includes the process of making plans for the
future without her or his loved one. Rando (1984) contends that although anticipatory
grief is complex, complete with anxiety and the struggle to accept a difficult reality, it is
simpler than having to cope with these same feelings after a death that is sudden and
unexpected.
The review of the literature consistently suggests that anticipatory grief is
beneficial to the grief process. Although many aspects of mourning are postponed until
after death, mourners have several tasks to fulfill to manage their anticipatory grief in a
healthy way. Anticipating a loss is an important part of experiencing that loss (KüblerRoss & Kessler, 2005). By being able to express fears and come closer to the acceptance
of death grievers are able to be more responsive to their own needs as well as be able to
share some of their intimate thoughts with the dying (Hottensen, 2010). Grief work is
29
rarely completed through the anticipatory stage and there is usually a significant amount
of grief work remaining to be done after death. Furthermore, if there is too much
anticipatory grief work to be done, or if the expected loss does not occur, the mourner
may prematurely detach from the dying loved one, causing anger, frustration, resentment
and an inability to emotionally reinvest in the relationship (Rando as cited in Hottensen,
2010). The research has shown that adjustment to the death of a loved one is positively
related to the process of anticipatory grief. It also indicated that the incidence of
abnormal grief is decreased if anticipatory grief has occurred (Rando, 1984).
Trauma
Trauma can be both physical and mental. Psychological trauma may accompany
physical trauma or may exist independently of it. In psychiatry, trauma has assumed a
different meaning and means that a person has suffered a severe life event; it is an
experience that is emotionally painful, distressful, or shocking, which often results in
lasting mental and physical effects. Trauma is also the Greek word for wound and for
damage and defeat (trauma, 2010). Situational trauma can be caused by man-made and
natural disasters, including war, abuse, violence, earthquakes, mechanized accidents (car,
train, or plane crashes, etc.) or medical emergencies.
The literature reveals that there is a substantial body of research on the effects of
trauma on individuals (Isotupa, 2000). A traumatic event involves a single experience, or
an enduring or repeating event that completely overwhelms an individual's ability to cope
or integrate the ideas and emotions involved with that experience (Bendall, Jackson, &
30
Hulbert, 2010). According to Freud, trauma is a two-fold concept in that it relates to
mental experience and links an external event with the specific after-effects on an
individual 's psychic reality (Zepf & Zepf, 2008). The sense of being overwhelmed can
be delayed by weeks, years, even decades, as the person struggles to cope with the
immediate circumstances.
Freud first discovered that adult neurotic disorders, specifically hysteria, were
caused by psychic shock, or trauma, which he saw as a three-part process:
1. a traumatizing event, an actual assault or injury, happened, which,
2.
the victim experienced and perceived as traumatic or stressful, and
3. to which, the person reacted to with psychological defense, such as dynamic
(active) forgetting or repression (Freud, 1962).
Psychological trauma has been a source of terror and horror, and of fascination,
for people for thousands of years. Experiences that confront a person – or an entire
community or society – with actual or imminent death or destruction are terrifying and
life changing. Something unique happens when you ‘see your life flash before your very
eyes’ – and that ‘something’ is a biological, psychological and spiritual shock that is
technically described as traumatic stress (Ford, 2009).
Post Traumatic Stress Disorder
In some cases, the difficulties resulting from exposure to trauma persist over time
and can result in what is called Post-Traumatic Stress Disorder (PTSD). Almost since the
inception of PTSD as a major diagnostic category in the Diagnostic and Statistical
31
Manual of Mental Disorders (DSM-III; APA, 1980) the question of which events should
be considered traumatic stressors has been hotly debated (Kaltman & Bonanno, 2003).
Recently, changes to the PTSD diagnosis in the latest version of the DSM have widened
the scope of the stressor criterion to include learning about unexpected or violent death as
that experienced by a family member or other close associate (APA as cited by Kaltman
& Bonanno, 2003). As a result, the death of another person, for the first time, fell into
the category of potentially traumatic events. Following violent deaths, clinicians should
expect that PTSD symptoms may develop and that depression symptoms may persist for
longer periods of time than expected with bereavement following natural deaths
(Kaltman & Bonanno, 2003).
PTSD is diagnosed when an individual has specific symptoms that continue for a
month or more following exposure to a traumatic event. Not all people exposed to a
trauma will develop PTSD, and for some individuals PTSD symptoms will lessen
naturally over time. However, an individual who experiences the disorder often has a
variety of symptoms that can significantly impact their day-to-day functioning. These
symptoms fall into the following general categories:

Re-experiencing: recurrent upsetting thoughts about the event, repeated
distressing nightmares, or repetitive play in young children.

Hyperarousal: nervous, jumpy, or agitated behavior, irritability or anger, and
hyper- vigilance or increased startle reaction.
32

Avoidance: avoiding thoughts, feelings, or places that remind the person of the
trauma, withdrawing, becoming disinterested in activities, or developing
emotional distance.
If left untreated, PTSD can lead to more serious difficulties over time. PTSD has
been linked to adult depression, substance abuse, eating disorders, and other psychiatric
difficulties. If an individual shows symptoms of PTSD, it is important that they be
evaluated, and consultation with a qualified mental health professional is encouraged
(NCTSN, 2010).
Traumatic Grief
Traumatic grief is a condition that some people develop after the death of a close
friend or family member. Individuals struggling with traumatic grief experience the
cause of that death as horrifying or terrifying, whether the death was sudden and
unexpected (due to homicide, suicide, motor vehicle accident, natural disaster, war,
terrorism, or other causes) or due to natural causes (such as cancer or a heart attack).
When an individual is struggling with traumatic grief, the person’s trauma reactions
interfere with their ability to go through a normal bereavement process. Children can
also experience traumatic grief, which is known as Childhood Traumatic Grief (CTG).
Symptoms of traumatic grief include:

Intrusive memories about the death: These can be expressed by nightmares, guilt
or self-blame about how the person died, or recurrent or disturbing thoughts about
the terrible way someone died.
33

Avoidance and numbing: These can be expressed by withdrawal, acting as if not
upset or avoiding reminders of the person, the way he or she died, or the things
that led to the death.

Physical or emotional symptoms of increased arousal: Children may show this by
their irritability, anger, trouble sleeping, decreased concentration, drop in grades,
stomachaches, headaches, increased vigilance, and/or fears about safety for
oneself or others (NTCSN, 2010).
One aspect of trauma frequently cited in the literature as a risk factor for “poor
bereavement outcome” is sudden and unexpected death (Sanders, 1993). This is
consistent with the characteristic emphasis on the link between violence and trauma
reactions, violent deaths have often been implicated in excessive or traumatic grief
reactions.
One reason for these ambiguous findings may be that suddenness of a loss is
usually confounded with the violent nature of the deaths studied (Bonnano & Kaltman,
2003). Thus, it may be the violent nature of sudden deaths that accounts for association
of this factor with more severe, traumatic grief symptoms. The literature suggests that
bereavement following a violent death is associated with higher levels and more
persistent distress than bereavement under more natural circumstances, thus resulting in
more traumatic grief symptoms. Psychologically, the bottom line of trauma is
overwhelming emotion and a feeling of utter helplessness. There may or may not be
34
bodily injury, but psychological trauma is coupled with physiological upheaval that plays
a leading role in the long-range effects (Terr, 1991).
Children’s Grief
It was once thought that children do not have the capacity to experience grief in
the same way as adults. It has since been recognized that while children’s understandings
about death vary according to their developmental stages, they are still capable of
experiencing the deep pain and sadness associated with loss. It is important that adults
identify the scope of this experience for children so that they can properly support them
through the grief experience. In order to understand this experience it is important to use
a multidimensional approach to determine the child’s level of social, emotional, and
cognitive functioning (Worden, 1996). This will enable caregivers and clinicians to most
effectively address the child’s grief experience. It is also necessary to recognize that
while every child has the capacity for resilience, the duration and intensity of the grief
process will be unique for each individual based on their reality (Balk & Corr, 2010).
Factors Influencing Children’s Responses to Grief
While each individual child will experience grief differently, there are important
factors that can be indicative of a child’s ability to process these emotions. Children who
have access to a safe and caring adult who can help them process their grief is an
essential component of positively processing loss. There are varieties of different factors
that can lead to the eventual healing from the death of a loved one. However, trauma can
leave a child feeling scared, angry, and confused. Wolfelt (1983) provides a list of
35
important factors that can manipulate a child’s grief process. The major factors he
includes as affecting a child’s capacity to cope with death include the relationship with
the person who has died, the nature of the death, the child’s own personality and previous
experiences with death, the child’s chronological and developmental age, the availability
of social/family/community support, and the behavior or responsiveness of significant
adults in response to the child’s grief (Wolfelt, 1983).
The Harvard Child Bereavement Study performed in 1986 also found important
indicators for children who were at risk of having difficulty processing grief. While the
majority of children (80%) appeared to be coping well at the first and second anniversary
of the death, there were specific indictors of children who were struggling. The study
suggested that children who adjusted the most easily to the loss were those who were able
to maintain a continuing bond with the deceased, had a caregiver that maintained a high
level of functioning following the death, and were receiving emotional support (Doka &
Tucci, 2008). One of the most important implications of this study was the knowledge
that it is possible to screen for indicators of children who will likely need help processing
their grief. This type of screening allows for the most effective utilization of resources.
Children’s Reactions to Death
Based on these contributing factors children’s outward responses to the death can
take on many different appearances. The research provides a multitude of reactions that
can become apparent in 3 different aspects of a child’s life. These symptoms take place
in the form of physical, behavioral, and emotional responses. Due to the varying degrees
36
of the loss and the ability of each child to cope with these experiences, not every child
will exhibit symptoms in all of the areas. These reactions may come in waves or could
become apparent all at one time.
Physical symptoms are very common, especially in children who are unable to
use language as a way to express their emotions. These symptoms can also be apparent
in the early stages of acute grief. Some of the most common physiological changes or
somatic symptoms include tiredness or lack of energy, difficulty sleeping or prolonged
sleeping, changes in appetite, tightness in throat, shortness of breath, general nervousness
or trembling, headaches, stomach pain, loss of muscular strength and skin rashes
(Wolfelt, 1983). Although these symptoms are very common grief responses it is always
important to consult a medical doctor to rule out any other possible causes if a child is
experiencing any physical changes.
A second source of expression for children who are grieving is through behavioral
changes. These changes can sometimes be difficult for adults to understand or cope with
but it is essential that they provide extra attention and caring in these situations (Balk &
Corr, 2010). Often these changes can appear as “acting out” behaviors and are especially
prominent for teens. Some of the most frequent examples of this type of grief expression
include temper tantrums, becoming unusually loud or noisy, initiating fights with other
children, defying authority, drop in grades, change in groups of friends, and running
away from home (Wolfelt, 1983). The primary intention of these behaviors is attention
seeking and it is important that caregivers are responsive and attentive to this need.
37
The final area of visible grief responses in children is emotional. These can take
on many different forms and are part of a fluid process, which can change from day to
day or even from moment to moment. Common emotional grief responses experienced
by children include numbness, sadness, anger, confusion, fear, worry regret, loneliness,
guilt, and self blame (Balk & Corr, 2010). These emotions may change depending on the
stage of grief the child is experiencing as well as their development stage and ability to
understand the death. For young children, who lack the understanding of the permanency
of loss, it is more common for their emotions to take a rollercoaster type of course. Balk
and Corr (2010) also remind clinicians and caregivers that it is important to remember
new emotions may resurface as children experience subsequent losses or hit new
developmental milestones.
Childhood Traumatic Grief
This is just a message, to particularly young people
in a similar situation as I am, if you’ve suffered
bereavement. This is to say if you are having trouble,
don’t be afraid to ask for help.
Young people need someone to listen to them, and
they just need to have clear information. (Penny, 2009, p. 1)
Recent research has shown evidence that children who experience traumatic grief,
that is untreated, frequently exhibit unhealthy behaviors well in to their adult life. These
behaviors put them at risk for a variety of mental health issues including anxiety,
38
depression, and substance abuse. Child sexual, physical, and emotional abuse as well as
child neglect and domestic violence, community violence, and Childhood Traumatic
Grief may also result in significant and long-lasting emotional and behavioral difficulties,
such as intense and prolonged traumatic experiences interfere with neurobiological
development and functioning (Cook, Blaustein, Spinazzola, & van der Kolk, 2003).
Children who lose a parent or caregiver to a traumatic death tend to experience similar
symptoms to those with PTSD including numbing and avoidance. For this reason they
disassociate from positive memories of their parent and focus instead on the trauma of the
death itself. The inability to form attachments to healthy memories contributes to an
inability to process grief. Children who experience these issues may continue to act out
until they have had an opportunity to properly deal with their loss (Brown, 2005).
One of the important issues raised in all of the literature on this issue is
distinguishing the differences between Childhood Traumatic Grief and normal
bereavement. One of the most essential components of Traumatic Grief when compared
to normal bereavement is the child’s inability to function in their daily lives because of
the trauma symptoms they are experiencing. These symptoms are similar to those
experienced with PTSD, but focus on the trauma of the death. Children suffering from
traumatic grief are also unable to process their loss and move through the grief process
because they are fixated on the death itself (NCTSN, 2010).
Some of the symptoms children may exhibit when suffering from Childhood
Traumatic Grief include intrusive memories of the death. These memories may appear in
39
the form of nightmares, intrusive traumatic thoughts, replaying of the death itself, roleplaying, and self-blame. These children may also use avoidance and numbing to cope
with the death. They do this by refusing to acknowledge the death or being unwilling to
talk about the person who died and their experience or feelings surrounding the death
(Brown et al., 2008). One of the final symptoms discussed in the literature are physical
and emotional symptoms that may appear including stomachaches, headaches, acting out,
fighting, trouble sleeping, and increased fears regarding the safety of themselves or others
(NCTSN, 2010).
Signs that practitioners should evaluate in a child for Traumatic Grief were
observed in some of the literature for this project. Some of the most frequently discussed
reactions in children were the externalizing of the grief in ways that were negative for the
child and her or his support system. Children suffering from Traumatic Grief often
exhibit the following behaviors, a decrease in academic functioning, becoming
withdrawn, increase in violent or aggressive behaviors, difficulty eating, difficulty
concentrating, lack of self care, infantile behaviors and weight gain or loss (Crenshaw &
Mordock, 2005).
There are also specific factors that may increase the likelihood of a child
developing CTG. The reactions of adult family members to the death have shown a
significant effect on the way the child experiences grief. In addition, witnessing the death
or knowing specific details about the way a person died put children at an increased risk
of developing CTG. Finally, deaths that are associated with being traumatic including
40
violent or suicidal acts may affect the rate of trauma displayed by children. Individuals
who have experienced another trauma within a year prior to the death are also at a higher
risk of developing CTG symptoms (Brown, 2005).
Therapeutic Interventions
Researchers have also found that there are important skills that can be developed
in helping children cope with grief. Most of these canter around the child’s ability to
cognitively deal with the death and loss they have experienced. Some of the skills
practitioners focus on developing is resolving issues with the deceased, creating positive
memories about the deceased, stress management, emotive regulation, and being able to
tolerate detailed memories about the death without using avoidance tactics (NCTSN,
2010).
When dealing with symptoms of both trauma and grief activities of addressing
memories of the deceased can be difficult for children. While there are a variety of
treatment options available for working with CTG, this project will focus on the use of
TF-CBT and narrative therapies. These interventions address the trauma symptoms that
can prevent children from becoming stuck on the gruesome details of the death instead of
processing the memories of the deceased.
TF-CBT an Overview
TF-CBT is an approach that is most frequently used in treating children and adults
suffering from symptoms of PTSD, depression and anxiety. As a treatment for CTG the
research shows that this intervention integrates a component based treatment, respect for
41
the individual and family, adaptability to the child’s needs, family involvement, healthy
and trusting therapeutic relationships, and self-efficacy skills (Cohen et al., 2010).
Two of the key components that were not addressed in the current curriculum
materials were observed by the authors of this project to include a parent component in
treatment and relaxation techniques. Parents are an important source of information and
support for children, so it seems essential that they be involved in children’s treatment
models. In recent studies evidence has been found that there are long lasting positive
benefits to including parents in trauma focused treatments of their children which include
lower levels of trauma related fears, lower degrees of symptomology, lowered PTSD, and
depressive symptoms, as well as less parental distress related to the trauma (Cohen et al.,
2010). Although it is not always possible for parents or caregivers to be included in the
treatment process, the authors felt that it was an important component to suggest in this
curriculum.
Relaxation techniques are not commonly adapted into current children’s grief
curriculum. These techniques are extremely affective at treating the trauma symptoms
associated with CTG. Some of the physical symptoms that can be reduced when using
relaxation techniques include shortness of breath, muscle tension, anxiety, headaches,
dizziness, lightheadedness, stomachaches, nausea, skin rashes, itching and other irritation
(Cohen et al., 2010). Under normal circumstances, these fear reactions subside once the
danger is over, however in children experiencing CTG the symptoms remain long after
the trauma was experienced. Focused breathing, meditation, and body awareness can be
42
effective self-regulation strategies for treating these fear-based responses. The literature
indicated that based on the nature of the loss families would need to work toward
adapting new ways of relaxation including bedtime rituals and safe places.
Summary
This chapter summarizes an extensive amount of research and literature that has
been developed in response to the experiences of grief and trauma. These include
descriptions, theoretical models, symptomology, and treatments of both of these issues.
Also included is an explanation of Childhood Traumatic Grief, a condition that
incorporates the symptoms of trauma with the need to grieve.
Extensive research has been done in the fields of both grief and trauma including
the symptoms, diagnosis, and variety of treatment models. Within the last couple of
decades, more information has emerged about the significant issues that can infringe on
an individual’s ability to experience and process grief in a healthy and positive way.
CTG is one of the situations in which traditional grief treatment models are not a
significant intervention.
Without intervention, traumatic grief appears to have the potential for long-lasting
effects on children and adolescents (Nader, Pynoos, Fairbanks, & Frederick, 1990;
Pfefferbaum et al., 1999; Pynoos, Frederick, & Nader, 1987). A number of treatment
models have been proposed for traumatic grief in children and adolescents (Cohen et al.,
2000; Goenjian et al., 1997; Layne et al., 2001; Murphy, Pynoos, & James, 1997;
Salloum & Vincent, 1999). All but one of these models (Salloum & Vincent, 1999) use a
43
group-therapy-format or a combination of group and individual therapy (Goenjian et al.,
1997; Murphy et al., 1997). The remaining model (Cohen et al., 2000) proposes an
individual, child-focused therapy approach with a parallel parental (or caretaker)
component. All of these include components of trauma-focused cognitive behavioral
therapy (CBT) (Cohen, Mannarino, Berliner, & Deblinger, 2000), which is consistent
with recent research suggesting that CBT is effective in decreasing PTSD symptoms in
children (Cohen et al., 2000).
Murphy et al. (1997) have developed a trauma/grief-focused group psychotherapy
model for elementary school children exposed to interpersonal violence. Phases of
treatment include individual therapy, group therapy, and mentorship, with each phase
consisting of 10 to 12 weekly sessions over the course of 1 year. The individual phase
identifies and clarifies issues relating to violence and traumatic loss and provides parent
psycho-education. The group therapy phase includes activities to provide greater peer
acceptance of the child’s experience, increase affect tolerance, and enhance social skills.
The mentorship phase provides an identified mentor who meets with small groups of
children to maintain a sense of connection to the community and decrease the experience
of feeling excluded from society. Throughout all three phases, parent interventions,
including home visitations, parenting skills building, and joint sessions with children, are
provided. Preliminary findings indicate behavioral, educational, and family
improvements by the end of treatment (Murphy et al., 1997).
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Studies that are more recent have also shown that TF-CBT is now empirically
supported in the field of trauma. TF-CBT has been consistently demonstrated as an
efficacious treatment for post traumatic stress disorder (PTSD), anxiety, depression and
other related symptoms (Little, Little, & Gutierrez, 2009).
Included in this chapter are suggestions for ways to adopt a treatment plan that
would incorporate the dual treatment of trauma and grief as well as research to support
this idea as an appropriate intervention for CTG. This includes awareness of factors that
can complicate grief, cognitive and emotional development skills as they relate to death,
TF-CBT, relaxation skills, and parenting components. These strategies also address
typical grief models developed by skilled grief theorists including Elizabeth Kübler-Ross,
William Worden, and Alan Wolfelt.
While the research on CTG is limited it is obvious that a more specialized
treatment needs to be developed when working with children who have had traumatic
losses. The inability to process grief will have long lasting affects well into adulthood.
Appropriately trained Social Workers can provide a positive and supportive relationship
to help children conquer symptoms of trauma while grieving the loss of a loved one.
Using a curriculum designed specifically for this purpose can assist children in utilizing
their natural skills of resiliency and working through an otherwise horrific experience.
45
Chapter 3
METHODS
Introduction
This chapter explains in detail the collection and analysis of data used for
development of the Childhood Traumatic Grief curriculum guide. This section will
provide information about the research design, research questions, and appropriateness of
the methods used to obtain this data. The writers will also discuss the inclusion and
exclusion of participants and the development of the interview questions. These
participants were protected through the approval of the human subjects committee and
the steps taken to reduce the risks posed to them will be addressed in this chapter.
The study is a qualitative analysis of Childhood Traumatic Grief and group
treatment options based on the information studied in the literature review and the
empirical data obtained through interviews of professional Social Workers. This data
was collected in an effort to obtain suggestions from professionals currently working with
Childhood Traumatic Grief on how to best address the symptoms that they are treating in
their practice. Although this study is at an exploratory level, the writers of this research
felt that it was important to obtain empirical data as a base for this project. This data was
combined with extensive research to develop a treatment curriculum guide that the
writers feel will be most effective in treating the symptoms of CTG.
46
Design
These authors performed an exploratory study examining aspects of group work
with grieving children that are most effective at addressing both trauma and grief. This
will include qualitative interviews using open-ended questions to obtain information and
suggestions about the current curriculum materials that are being used to treat Childhood
Traumatic Grief. This method was chosen because there is very little information on
Childhood Traumatic Grief and these authors wished to explore a variety of different
techniques for treating CTG in a group setting.
The strengths of using this method for developing a curriculum guide were the
opportunities to interview professionals on their personal insight on this topic. This
weakness associated with this type of study is that it leaves openings for personal bias
based on the wording of the questions and the interviewees own opinions (Yin, 2009).
These authors attempted to avoid personal bias by interviewing professionals from
multiple agencies, and incorporating information obtained through extensive review of
the literature on this topic.
Research Questions
This study is qualitative in nature with the purpose of developing a curriculum so
these researchers did not develop a hypothesis. The questions that these authors wish to
explore in more detail include:
1. How frequently are professionals observing clients with CTG?
2. How do current curriculums address CTG?
47
3. What strategies or interventions will be most affect at treating CTG?
4. What are some of the situations in which children are most commonly
experiencing CTG?
These questions will be addressed through a process of interviewing professionals
who work in different agencies with children who have experienced trauma and loss.
These authors will include common themes and topics discovered through these
interviews in the development of a group work curriculum.
Participants
The participants in this research were social workers from multiple agencies in the
Greater Sacramento Area who have experience working with children and grief and
practice as well as practice in facilitating groups. We interviewed 10 professionals who
were contacted in person and interviewed as experts in the field. These subjects are
social workers that we know personally or have been referred to us as having knowledge
about children dealing with trauma and grief.
There was some difficulty finding Social Workers who specialized in the fields of
both trauma and grief, and there were very few curriculum guides developed on this
topic. To overcome these issues the researchers of this project interviewed professionals
from many different agencies to elicit information on multiple strategies being used to
treat trauma and grief. Although there were not many developed curriculum guides, there
were techniques described in the interviews that these Social Workers believed were
effective in their practice.
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Instrumentation
The instrument used for gathering this data was an interview questionnaire
developed by researchers in this study (see Appendix A). The questionnaire included
questions about the interviewees experience in working with Childhood Traumatic Grief
as well as participants suggestions for developing an effective group work curriculum
guide for this issue. This instrument was designed based on the topics and themes
identified through extensive research of the current literature on this topic.
Data Gathering Procedures
Consent was obtained from the interviewees through a signed consent form, of
which they were given a copy (see Appendix B). The data was gathered through a
process of interviews with notes being taken by the researchers.
Protection of Human Subjects
These researchers felt that no risk was posed for participants in this study. The
California State University Sacramento requirements for the protection of Human
Subjects were followed by the approval of the Human Subjects application. These
researchers in collaboration with their faculty advisor proposed that this study would be
“no risk” for participants because it was related to the work that they are trained to do and
the interview questions were not personal in nature. The Request for Review by the
Committee for the Protection of Human Subjects was submitted and approved by the
University as no risk.
49
The information obtained in the interviews was confidential, only the recurring
themes were used as input for the development of a curriculum guide. The participants
were informed of the content of the interview questions prior to our meeting and were
given an option to pass on any questions that made them uncomfortable. Informed
voluntary participation was assured through a consent form participants were given to
read and sign prior to the interview session.
The signed consent forms were kept separate from the interview materials, which
did not have any identifying personal information. The consent forms and interview
materials were kept in separate locked boxes and stored at the researcher’s home. All of
the materials were shredded following the completion of this project. Participants were
also provided with contact information for any issues that could arise following the
interview.
Data Analysis
These researchers used the data gathered from the interviews in conjunction with
the extensive review of the literature to develop a group work curriculum for treating
Childhood Traumatic Grief. The data were analyzed by looking for recurring themes and
suggestions given by the interviewees and applying them to the building of a curriculum
guide.
Summary
Based on the limited amount of materials available for review on this topic, these
authors felt that it was necessary to obtain further data from professionals in the field.
50
Using an exploratory method with open-ended interview questions allowed for critical
input about what treatment options would be most effective in a group work curriculum.
This data also allowed the researchers to develop a curriculum that addressed the greatest
needs being seen by practitioners in the field. The information the authors included in
this manual was extensively researched and evaluated through a variety of different
methods and sources in an effort to best meet the needs of this population and the
professionals who work with them.
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Chapter 4
FINDINGS
Introduction
Presented in this chapter are the findings of the interviews conducted, as well as
the completed project. In the findings section, the researchers will provide information
on the overarching themes and suggestions shared by the participants of the study. The
project is broken down into two guides, one for use with children and one for use with
teens based on developmental appropriateness. The guide is developed for use with an
eight-week group and the authors present the objectives, activities, and materials needed
for each session. The activities follow the grief models developed by Worden (1991) and
Rando (1984) presented in Chapter 1 as well as two sessions that include a parenting
component and a closing activity. These lesson plans were developed and adapted from a
variety of sources including other grief support curriculums, children’s art therapy books,
and the authors own experiences working with bereaved and traumatized children in
multiple settings.
Findings from Interviews
These researchers interviewed 10 participants who had three or more years of
experience working with children. There was some difficulty in locating professionals
who worked specifically with children and grief. Throughout the interview process the
researchers discovered that although grief was not necessarily a specialty of the agency,
most people working with children were addressing symptoms of trauma and grief in a
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variety of different settings. One of the difficulties that occurred during the interview
process was the lack of a standardized treatment for CTG. Of the 10 participants six
were unable to specify a treatment model used by their agency for working with
traumatic grief. The other four participants specified TF-CBT as the most commonly
used treatment method. Despite this lack of cohesiveness the researchers were still able
to identify very specific tools that the participants believed would be effective if
incorporated into a curriculum guide.
Throughout the interview process there were certain themes that the researchers
heard expressed by multiple professionals regarding this curriculum guide. Ten
participants were interviewed for this project and all stated that they were frequently
seeing children who had experienced traumatic losses. These children were experiencing
a variety of symptoms including depression, PTSD, and anxiety disorders related to the
loss.
One of the main findings of this research was the need to include a parenting
component when working with children suffering from traumatic grief. Several
professionals interviewed suggested that this was an essential part of successfully
working with bereaved children. Participants suggested that the parenting component
should provide activities, resources, and discussion topics for parents to use at home.
A second consistent theme in the interviews was the need for more developed
relaxation techniques as part of the curriculum. Based on the high levels of anxiety these
children were experiencing, the participants of this research felt that relaxation was an
53
important component for groups. Multiple social workers also felt that these relaxation
techniques should be included in the parenting component as a way to assist parents in
dealing with their children’s high levels of anxiety.
The area of the current curriculums being used that the participants felt was most
effective were activities for creating a continued bond, and allowing for completion of the
relationship. These were also important when ending the group session. These types of
activities provided the children with a way to remain feeling connected even though the
group was also ending, which some children see as another loss. Some of the suggestions
provided for this purpose were collaging, writing a letter to the deceased, positive
affirmations, that could be used at home, and creating a support plan.
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Childhood Traumatic Grief a Group Work Curriculum Guide for Children and
Teens
Introduction
This guide is divided into two sections one for use with children and one with
teens and is intended for an eight-week group utilizing 90-minute sessions. The
foundation for the curriculum comes from the eight tasks of grieving developed by
Worden (1991) and Rando (1993). The guide follows these tasks in sequence and the
activities are organized around each concept. Each session coincides with a grief task in
this order: 1) Recognize the loss (acknowledge and understand the death), 2) React to the
separation (experience pain; feel, identify, accept and express the reaction to loss and
identify and mourn second losses), 3) recollect and re-experience the deceased and the
relationship, 4) Relinquish old attachments to the deceased and old assumptions of the
world, 5) Readjust to move adaptively into new world without forgetting the old (develop
new relations with the deceased adopt new identity), 6) Reinvest by putting new
emotional energy into developing a new interest in life (Rando, 1993).
The writers of this curriculum also incorporated trauma treatment techniques into
the guide to address the traumatic aspect of the loss. Based on the review of the literature
on CTG, children who are not treated for the trauma aspects of their loss may have
difficulty completing the tasks of mourning. Using information gathered through
research and professional interviews these writers incorporated a parenting component,
psycho education, retelling of the trauma narrative, and relaxation techniques into the
grief curriculum. The parenting component involves education about common symptoms
55
and treatments for CTG. The members of the group address the trauma in the beginning
of each session by retelling their trauma narrative, which has been described as an
effective skill in multiple research studies (Cohen et al., 2006). Based on information
gathered in the professional interviews, a relaxation technique follows each session to
help children and teens develop emotional regulation skills.
The curriculum would be most effective when used by a facilitator and cofacilitator. One person can be providing instruction while the other provides materials
and makes observations and takes notes. Occasionally the feelings being discussed in
group may become overwhelming and a child may exhibit behavioral problems in
response that are distracting for other group members. At this time a co-facilitator can
step out of the group with that child to address these responses.
Facilitators should assess for children/ teen readiness for the group based on the
intake phone call from the referring source. Children/teens who are experiencing severe
emotional or behavioral problems may have difficulty working well in a group setting. If
a facilitator is unsure about how a member would affect the safety of the group he or she
should discuss their concerns with their supervisor before beginning treatment.
As children begin to address their trauma experience their symptoms may become
more intense or more frequent. It is important that the facilitator discuss the
unpleasantness of the grieving process with the group members and with caregivers at the
first session. When it becomes apparent that a child/teen needs more intensive treatment
than the group can offer, the facilitator should provide the family with a list of therapists
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that specialize in trauma and grief in their area that can provide individual counseling
services.
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Children’s Group
Ages 6-11
Session 1: Parent Group
Purpose: Psychoeducation regarding CTG physical and emotional symptoms,
parent/caregiver reactions to these symptoms, treatment strategies, and providing support
to parents and caregivers living with a child who has experienced a traumatic loss
Materials: The book I Miss You: A First Look at Death by Pat Thomas: Barrons
Juveniles, 2001.
Procedures: Begin the group with parent introductions, allowing paricipants to share
their name and as much as they feel comfortable with about their child’s situation.
Read the book I Miss You: A First Look at Death by Pat Thomas. Provide normalization
by projecting a calm, unhurried attitude around common emotional and behavioral
responses to trauma and grief for children of this age group. Provide education on the 6
tasks of mourning and how these concepts will be utilized in the group sessions. Validate
the concerns and feelings of the caregivers as they work to assist their children in this
group experience.
Discuss common symptoms related to CTG such as fear, depression, anger, avoidance,
guilt, anxiety, denial, shock, regression, and difficulties at school and at home. It is also
helpful to describe common physical symptoms related to grief like headache, stomach
pain, and difficulty eating or sleeping. Go over strategies for symptom management
58
including helping the child discuss their trauma narrative, normalizing the process of
grief, and the relaxation techniques included in the curriculum guide.
The purpose of the psychoeducation component for parents is to normalize the reactions
experienced by both the child and family members in response to the traumatic grief.
Encouraging parents to acknowledge that these responses are normal, as well as
providing strategies for symptom reduction can be immediately comforting. This
component also gives parents an investment in the support group that they may not have
had otherwise.
59
Session 2: Introductions/Who died?
Purpose: Getting to know the group members and acknowledging the reality of the death.
Materials: ball of yarn, scissors, tape, markers, construction paper.
Procedures: Begin with introductions and sharing of who died/what happened.
Explain to the children that they will be using the first activity to get to know each other
better. The children sit in a circle and the facilitator begins by sharing something about
him/her. After doing this the facilitator holds the end of the string and rolls the ball to
one of the group members. The group member shares something and wraps the yarn
around his or her wrist before rolling it to another member. When everyone has shared
the facilitator points out that they are all now connected because they have shared
something with one another. The facilitator goes on to discuss the fact that they are also
connected because they have all experienced the death of someone they love.
Allow the children to design a badge of bravery. They can use the scissors to cut out any
shape they want and decorate it using the markers. When it is their turn to share they can
tape their badge of bravery to their shirt. Explain to them that telling their story can be
difficult but it is an important part of starting to feel better.
The children are free to share as much or as little as they like but ask them to
begin with their name, who died, and what happened. Some children may choose not to
share and this is ok. The facilitator should encourage them to share at least their name
and remind all members that participating helps the group feel safe and understood by
one another. If a child continually refuses to share the facilitator may want to discuss this
60
with the child and caregiver outside of the group. Before the facilitator begins they
should encourage the group to develop a silent signal when the story begins to feel
overwhelming. This signal can be used by the child telling the story or by someone who
is listening when the conversation gets to be too much. If a child puts up this signal it
means that they need to be excused and a co facilitator should accompany them to
another area until they are ready to return. Continue around the circle until everyone has
had an opportunity to share.
Finish with Relaxation/Breathing Exercise (see Appendix C).
Allow 10 minutes for snack and free play.
Evaluate Observations.
Take notes for each child regarding the details of their trauma narrative and their
reactions to sharing it. These notes can be used to further assess the child’s progress in
further groups. Also, evaluate the dynamics of the group interactions to assess for any
interventions that may be needed for specific group members.
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Session 3: Feelings
Purpose: Identifying and accepting the emotions experienced around the death.
Materials: balloons, feelings cards, paper, watercolors.
Procedures: Begin with introductions and sharing of who died/what happened.
On small pieces of cardstock, write a variety of common grief and trauma
reactions. Turn the cards over in the middle of the table. Explain that sometimes it can
be hard to talk about how we are feeling. If we keep our feelings inside eventually we
“pop” by doing things that we do not normally do, like yelling, hurting someone, etc.
Provide each child with a balloon. Read aloud each feeling card and ask them to blow a
breath of air into the balloon for each time they hear a feeling they have experienced. As
the balloons get filled discuss how it would feel if you kept all of your feelings inside like
this. Go around and ask each child to say out loud one of the feelings they have had and
let a little bit of air out of the balloon. Do this until all of the balloons are empty.
Ask the children to divide their paper in half and use the watercolors to draw one good
feeling and one bad feeling they have had since their person died.
Finish with Relaxation/Breathing Exercise.
Allow 10 minutes for snack and free play.
After they have finished ask each child to share their painting and times they have had
each of these feelings. Discuss people/ places where they feel comfortable sharing these
feelings.
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Session 4: Redefining
Purpose: Experience the relationship with the deceased in a new way
Materials: Pictures/Belongings of Special People, crayons, paper, the book Barklay and
Eve: Sitting Sheeva by Karen L. Carney: Dragonfly Publishing, 1997.
Procedures: Begin with introductions and sharing of who died/what happened.
Define the word memory and discuss the importance of memories after someone dies.
Allow each child to share a picture or belonging of their special person with the group.
Read the book Barklay and Eve: Sitting Sheeva and discuss the ways that different
cultures use symbols to remember someone after they die.
Provide the children with paper and crayons and ask them to draw their “best memory”
with their loved one. Provide time for those who feel comfortable to share their memory
drawing with the group.
Finish with Relaxation/Breathing Exercise.
Allow 10 minutes for snack/free play
This activity will emphasize that although someone’s physical presence is gone,
memories are a way that the children can keep that person close to them. This activity
can also help children identify memories that are not part of their trauma narrative.
Assist the children in matting their best memory picture to take home and hang in a
special place.
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Session 5: What I miss
Purpose: Adapting to a world without the deceased.
Materials: permanent markers, 3” fabric squares and 3’x3’ pieces of fabric in multiple
colors, fabric glue.
Procedures: Begin with introductions and sharing of who died/what happened.
Discuss the activity from the following week and introduce the concept that some
of our best memories are attached to the things we miss the most about our special
person. Help the students brainstorm things that have changed since they lost their loved
ones and what they miss and why.
Provide the children with the fabric squares and encourage them to write all of the
things they miss on a square. When this is finished have a conversation about new things
that make them feel better when they are missing their special person. Write these things
on the fabric squares as well.
Assist the children in gluing their squares onto a large piece of fabric to create a “quilt”.
Finish with Relaxation/Breathing Exercise
Allow 10 minutes for snack/free play
Each child will be able to take home the quilt as a comfort item that helps preserve their
memories and reminds them of coping strategies that they have developed.
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Session 6: Support Systems
Purpose: Relinquish old attachments strengthen supportive relationships.
Materials: support item, chairs, plastic Easter egg, help cards, music.
Procedures: Begin with introductions and sharing of who died/what happened.
Prior to the group, the facilitator creates help cards that provide a variety of
different situations where the children might need help. For example: if you are sad, if
you need help with homework, when you want to laugh, etc. Develop the situations
written on the cards based on the needs of the group.
Ask the children to bring in an item that gives them comfort and support such as a
picture, stuffed animal, book, song, etc. At the beginning of the session, ask the children
to share what their support item is and how it helps.
Discuss self-care and support. Brainstorm with the children about things they can
do to keep themselves healthy. Brainstorm about things that they may need/want help
with from other people to support them.
Arrange the chairs in a circle fold one of the help cards and place it in the egg.
Begin the music and have the children pass the egg around the circle as they would for
“hot potato.” When the music stops the child holding the egg reads the card out loud and
shares who they would ask for support in the given situation. Continue until everyone
has had an opportunity to share.
Finish with Relaxation/Breathing Exercise.
Allow 10 minutes for snack/free play.
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The facilitator should take written notes and evaluate the strength of each child’s
understanding of her or his own support system.
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Session 7: New energy
Purpose: Developing new interests and putting energy back into life
Materials: shoe boxes, glue, craft supplies, I’ll Always Love You by Hans Willhelm:
Dragonfly Books, 1988.
Procedures: Begin with introductions and sharing of who died/what happened.
Facilitate a discussion about time-outs from grief. Explain that although we do not want
to keep our sad feelings in all the time, sometimes everyone needs to take a break from
grieving. Reassure the children that this does not mean they do not still love or care for
their special person who died, and they should not feel guilty about taking this time out.
Brainstorm different places or activities that they feel give them a time-out. This could
be lying on their bed, playing a sport, watching a movie with a friend, going for a walk,
etc.
Once each child has a good concept of what they like to do for their “time-out”
have a conversation about what types of materials they will use to construct their time out
box. Assist the children in turning their idea into a shoebox diorama using the craft
supplies provided. Allow time for the children to share their dioramas.
Finish with Relaxation/Breathing Exercise.
Allow 10 minutes for snack/free play
This activity normalizes the process of moving forward in grief, and encourages the
children to not become stuck in the process. It also allows them to identify a specific
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activity they can do or place they can go when they need relief from their grief and
trauma.
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Session 8: Saying goodbye
Purpose: Group closure and learning how to say good-bye.
Materials: snacks, large garden stones one for each child, permanent markers multiple
colors.
Procedures: Begin with introductions and sharing of who died/what happened.
Review the first session where the children introduced themselves and talked about being
connected through their losses. Provide time for each child to share some of their
feelings regarding saying goodbye to the other members.
Provide each child with a garden stone and ask them to decorate it with their
name. Explain that although we are leaving the group everyone has shared something
special with the others that they can take on their grief journey. Pass the garden stones to
the right and ask each child to write something loving, kind, or special on the stone of the
other child. Continue passing the stones until everyone has had a chance to write on each
stone. The children will take these with them as a way to remember the group.
Finish the group with snacks and allow time for any final questions or comments from
the group.
Finish with Relaxation/Breathing Exercise
The goodbye stones promote self-esteem and provide the children with a lasting
connection to the group. It is also a way to show them that sharing your grief can be
scary, but it can provide strength for yourself and others.
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Pre-teen & Teen Groups
Ages 12-17
Session 1: Parent Group
Purpose: Psychoeducation
Materials: Grief Support Interview, the book Healing Your Grieving Heart for Teens:
100 Practical Ideas by Alan D. Wolfelt PhD: Companion Press, 2001.
Procedures: Begin the group with parent introductions, allowing them to share their
name and as much as they feel comfortable with about their teen’s situation.
Handout and read the 6 tasks of teen mourning identified in the book Healing Your
Grieving Heart for Teens: 100 Practical Ideas by Alan D. Wolfelt PhD: Companion
Press, 2001. Provide normalization, and discuss common emotional and behavioral
responses for this age group who experience CTG.
Go over strategies for symptom management including helping the child discuss
their trauma narrative, normalizing the process of grief, and the relaxation techniques
included in the curriculum guide.
The purpose of the psychoeducation component for parents is to normalize the
reactions experienced by both the child and family members in response to the traumatic
grief. Encouraging parents to acknowledge that these responses are normal, as well as
providing strategies for symptom reduction can be immediately comforting. This
component also gives parents an investment in the support group that they may not have
had otherwise.
70
Session 2: Introductions/Who died?
Purpose: Getting to know the group members and acknowledging the reality of the death.
Materials: Puzzle pieces, markers/crayons.
Procedures: Begin with introductions and sharing of who died/what happened.
Have child draw something about themselves on the puzzle pieces (e.g., favorite
color, food they hate, best friend’s name, etc.) Have the group members put pieces
together to form the shape of a heart. This signifies healing a broken heart through the
support of others.
Ask each teen to draw a picture of the funeral or memorial service. If they did not
attend, they can draw any memory that is meaningful for them. When they have finished
ask each person to share their picture and the emotions that they experienced both during
the event and as they were working on it.
Finish with Relaxation/Breathing Exercise.
Allow 10 minutes for a snack and sharing, ask members to share something fun, exciting,
or good that happened to them that week.
The opening activity gives the facilitators an opportunity to learn about each teen
and for the group to establish themselves as a support system. Depicting the funeral or
memorial service reaffirms the finality of the loss. Facilitators may want to take notes
about the funeral services and each teen’s reaction to the activity. Teens that did not have
an opportunity to attend may have a different need for closure then those who did.
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Session 3: Feelings/ Exploring Death
Purpose: Identifying and accepting the emotions experienced around the death.
Materials: Drawing sheet: dispelling common myths, a blackboard with myths written on
it, and crayons, coffee cans, art supplies, magazines.
Procedures: Begin with introductions and sharing of who died/what happened.
Define “myth” – a myth is something that may be true in some cases but is generally not
true. Discuss and go over common myths about death with the group on the blackboard
(i.e., “only old people die,” “death is contagious,” etc.). Have the group correct the
myths. Help members brainstorm about the idea of fairness in relation to the world.
Discuss the idea of death as feeling unfair and ask the group to share their experiences
around this concept. Ask the teens how they have dealt with the fact that death “just
happens”.
Explain to the students that we will be creating an inside/outside can. The outside
of the can will show the feelings and emotions the teens present to those around them.
The inside will be their true feelings that they may not share with others. Give them
freedom to decorate the cans however they choose. Their feelings can be expressed by
using color, symbols, collage, etc. Allow them to share their can and discuss which
feelings they believe are appropriate to show and which they keep inside themselves.
Finish with Relaxation/Breathing Exercise
Allow 10 minutes for a snack and sharing, ask members to share something fun, exciting,
or good that happened to them that week.
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This experience gives teens a forum to talk about death. Teens discuss death concepts:
irreversibility, causality, universality. It also gives an opportunity to explore how they
express their grief, and who they feel safe talking to about these emotions.
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Session 4: Redefining
Purpose: Experience the relationship with the deceased in a new way.
Materials: Music, paper, markers.
Procedures: Identifying and accepting the emotions experienced around the death. Prior
to this meeting, ask the teens to bring in a piece of music that reminds them of their loved
one or is particularly touching to them.
Discuss the concept of a new relationship with the deceased. Explain that death is
the end of a physical relationship but not necessarily a spiritual or emotional one.
Allow each teen to share their piece of music and discuss why it is important to them.
Provide the teens with paper and writing utensils and encourage them to write a letter to
their loved one. This letter can include things they felt they did not get a chance to say,
or simply talk about what is going on in their life that they would normally have shared
with the deceased. It may be helpful to brainstorm some different ideas for the letter
prior to beginning the writing. If the teens choose, the facilitator can play their piece of
music during the writing session.
Finish with Relaxation/Breathing Exercise
Allow 10 minutes for a snack and sharing, ask members to share something fun, exciting,
or good that happened to them that week.
These letters can be very personal. Give the teens the option of sharing them but
remind them that they can always pass if they feel uncomfortable. The facilitator may
74
also want to give the option of destroying the letter before they leave the group if it is too
personal.
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Session 5: What I miss
Purpose: Adapting to a world without the deceased.
Materials: magazines, glue, cardstock, scissors, paper, pencil.
Procedures: Begin with introductions and sharing of who died/what happened.
Discuss the different types of changes people experience after a traumatic loss
including physical, psychological, spiritual, and emotional. Give the teens 15 minutes to
do free writing about the changes they have experienced since their loved ones death.
Following the free writing, provide time for sharing.
Based on these changes the teens to develop a missing you collage. The collage
can include things they miss as well as things they do to provide relief. They can use
colors, symbolism, and words cut out from the magazines to do this. Allow time for
sharing their collage.
Finish with Relaxation/Breathing Exercise
Allow 10 minutes for a snack and sharing, ask members to share something fun,
exciting, or good that happened to them that week.
This activity acknowledges the magnitude of change experienced by the teens in
the group. Teens are cognitively able to understand symbolism so collaging can be a
very meaningful activity for them.
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Session 6: Support Systems
Purpose: Relinquish old attachments and strengthen supportive relationships.
Materials: paper, writing utensils.
Procedures: Begin with introductions and sharing of who died/what happened.
Brainstorm with the teens about different types of support. When are times that they need
emotional support, help with school or college applications, someone to laugh with,
someone to pray with, etc.? Discuss the type of support their loved one had previously
provided for them. Assist them in developing a chart based on the different types of
supports you brainstormed. This can include physical, emotional, stress, fun; spiritual,
etc. list these across the top of the page horizontally. Once the chart is complete, provide
15 minutes for the teens to make a list of any person in their life that provides them with
support. You may need to give some suggestions like teachers, co-workers, and
friends/family. The teens will then fill these people into the chart that they developed. It
is ok for one person to fill multiple categories.
Finish with Relaxation/Breathing Exercise.
Allow 10 minutes for a snack and sharing, ask members to share something fun,
exciting, or good that happened to them that week.
Allow the teens to share their chart with the group and assist one another in
recognizing areas of support that may be lacking. Are these areas important to them?
Why do they feel they do not have very many people to provide that type of support?
77
What can they do to change this? The facilitator can ask these questions to encourage
more discussion about support systems.
78
Session 7: New energy
Purpose: Developing new interests and putting energy back into life.
Materials: paper, markers, pencils, glue, scissors.
Procedures: Begin with introductions and sharing of who died/what happened.
Allow for a 20-minute free write; provide 10 minutes for the teens to write a paragraph
describing where they are now in their grief. Encourage them to include as many
descriptive feeling words as they can think of. After 10 minutes ask them to start a new
page and in the same style describe where they would like to be in the future.
Provide a variety of different colored construction paper and markers. Explain to
the teens that they will be using the words from their free write to build a grief road. Ask
them to cut out shapes to build their road; these can be bricks, rocks, stones, whatever
seems appropriate to them. On each of these shapes, they will write one of the words
they used to describe grief in their free write. They can then begin to assemble the words
into a path using a piece of construction paper and glue. Allow time for sharing their
bridges with the group.
Finish with Relaxation/Breathing Exercise.
Allow 10 minutes for a snack and sharing, ask members to share something fun, exciting,
or good that happened to them that week.
Discuss the concept of grief as a journey. Remind the teens that although it is a
path it is not always as straight forward as their road may depict. Most people go back
79
and forth through grief, making some progress and having some setbacks. Reassure them
that this is a normal and important part of the process, but there is hope in their future.
80
Session 8: Saying goodbye.
Purpose: Group closure and learning how to say good-bye.
Materials: A snack, CDs for each teen, permanent markers multiple colors.
Procedures: Begin with introductions and sharing of who died/what happened.
Review the first session where the teens introduced themselves and talked about being
connected through their losses. Provide time for each member to share some of their
feelings regarding saying goodbye to the other members.
Prior to the session, compile the songs provided by each teen in session four onto
a CD. Provide each teen with a CD and ask them to decorate it with their name. Explain
that although we are leaving the group everyone has shared something special with the
others that they can take on their grief journey. Pass the CDs to the right and ask each
teen to write a take away message to the other person. Continue passing the CDs until
everyone has had a chance to write on each one. The teens will take these with them as a
way to remember the group.
End the session with snacks and allow time for any final questions or comments from the
group.
Finish with Relaxation/Breathing Exercise.
The goodbye CDs promote self-esteem and provide the teens with a lasting connection to
the group. It is also a way to show them that sharing your grief can be scary, but it can
provide strength for yourself and others.
81
Summary
This curriculum incorporated the information and findings discovered through the
combination of research and interviews. Based on the suggestions from professionals the
authors incorporated the retelling of the trauma narrative, a parenting component, and
relaxation techniques into the more traditional grief support curriculum. These authors
believe that these components combined with a traditional grief support curriculum will
be more effective at treating aspects of both trauma and grief for children and teens. The
separate curriculums were developed based on the differing needs of children and teens
cognitively, socially, and emotionally.
82
List of Books for Child/Teen Bereavement
Altebrando, T. (2008). What happens here. New York: MTV Books.
Brown, M. (1996). When dinosaurs die: A guide to understanding death. Boston: Little
Brown.
Carney, K. L. (1997). Barklay and Eve: Sitting Sheeva. Oklahoma: Dragonfly Publishing
Inc.
Fitzgerald, H. (2000). The grieving teen: A guide for teenagers and their friends. New
York: Simon and Schuster.
Holmes, M. (2000). A terrible thing happened. Washington, DC: Magination Press.
Perschy, M. K. (1997). Helping teens work through grief. Washington, DC: Accelerated
Development.
Sabin, E. (2006). The healing book. New York: Watering Can Press.
Thomas, P. (2001). I miss you: A first look at death. New York: Barron’s Publishing.
Viorst, J. (1971). The tenth good thing about Barney. New York: Antheneum Press.
Willhelm, H. (1988). I’ll always love you. Oklahoma: Dragonfly Books.
Wolfelt, A. D. (2001). Healing your grieving heart for teens: 100 practical ideas.
Bozeman, MT: Companion Press.
83
Chapter 5
CONCLUSION AND IMPLICATIONS FOR SOCIAL WORK
Introduction
Based on personal experience and the perception of professionals in the
community, it appeared that there was a need for a Curriculum guide to facilitate support
groups with children in Childhood Traumatic Grief (CTG). In CTG, children are
overwhelmed by the trauma response and, as a result, unable to accomplish the normal
grieving tasks. CTG symptoms include those for posttraumatic stress disorder (PTSD)
(i.e., re-experiencing, avoidance, and arousal) plus, both a yearning for the deceased and
a lack of acceptance of the death. Evidence suggests that a cognitive-behavioral
approach to treatment, one providing both trauma- and grief-focused modules to children
may be an effective means of reducing CTG symptoms (Brown, Pearlman, Robin, &
Goodman, 2004).
Throughout the interview process there were certain recurring themes expressed
by the professionals interviewed regarding the curriculum guide. One of the main
findings of this research was the need to include a parenting component when working
with children suffering from traumatic grief. This finding coincides with a recent study
by Cohen et al. (2006), who found that including a parental component to TF-CBT
therapy, children reported a significant improvement in CTG, PTSD, depression, anxiety,
and their parents also reported significant improvement in children’s PTSD, internalizing
and total behavioral problems. The findings of this project also confirmed the need for
84
more developed relaxation techniques as a part of the curriculum based on the high levels
of anxiety these children were experiencing. Many of the social workers who were
interviewed for this project felt that the relaxation techniques should be included with the
parenting component as a way to assist parents in dealing with their child’s high levels of
anxiety.
Review of the Findings and Relevance
The findings of this research have shown that relatively little is written about how
to treat children who experience traumatic grief. The current concept of Childhood
Traumatic Grief (CTG) is that it results from the loss of a loved one in traumatic
circumstances and is characterized by the encroachment of trauma-related symptoms on
the child’s ability to negotiate the normal bereavement process (Layne et al., 2001;
Nader, 1997). Traumatic experiences in childhood can have a severe and long-lasting
effect. Children who have been traumatized see the world as a frightening and dangerous
place. When childhood trauma is not resolved, this under-lying sense of fear and
helplessness carries over into adulthood, setting the stage for further trauma.
The consequences of unacknowledged and unresolved grief are persistent
throughout life. This research is relevant to the field of social work by educating and
providing material to care providers about childhood traumatic grief, introducing others
to principles of treatment that have been identified as helpful in treating the condition of
CTG, and offering practitioners an opportunity to enhance their CTG treatment skills
through use of the curriculum guide. The end goal of this research is to improve
85
awareness about childhood traumatic grief as well as increase the ability of clinicians to
respond in the most effective way possible.
Implications
The implications of this study on the field of social work are many. The hope of
these researchers upon completing and disseminating this curriculum guide is that social
workers working as child mental health providers will learn to adequately identify and
treat childhood traumatic grief in a timely fashion. Social workers need to pay special
attention to and should be educated on the clinical presentation of and appropriate
treatment for childhood traumatic grief. It is extremely beneficial for social workers in
the field to become knowledgeable and receive training regarding the latest treatments for
Childhood Traumatic Grief (CTG) to meet the needs of children who are victims of a
traumatic event and insure the best possible prognosis for these clients.
Recommendations for Further Research
The research does provide substantial support for using TF-CBT to help children
talk directly about their traumatic experiences in a supportive environment and additional
use of a parental treatment component and several child-parent sessions teaches parents
effective parenting skills to provide optimal support for their children. The parent-child
session encourages children to discuss the traumatic events directly with the parent, and
both parent and child learn to communicate questions, concerns, and feelings more
openly.
86
Based on the findings of this research, it appears that now the body of research
that exists on this topic is limited in scope. While the research provided shows promising
data about traumatic grief–focused CBT interventions, it also shows there is a clear need
for more research among other groups of children with traumatic grief (Cohen,
Mannarino, Greenburg, & Shipley, 2002).
Clearly, children are experiencing traumatic events. However, most social
workers are not receiving specific training in efficacious service delivery (Little et al.,
2009). TF-CBT needs to be evaluated with much more scrutiny to determine its relative
effectiveness and practical utility with young school-age children as well as adolescents,
as well as the social acceptability and habilitative properties for social workers,
psychologists and others who work with children and trauma in the field (Little et al.,
2009). To further develop this curriculum guide the writers recommend that it be shared
with other social workers and field tested at various sites with a variety of client
populations
Summary
When a child or adolescent experiences the death of a loved one, a grieving
process will naturally occur. When the severity and scope of the loss is traumatic in
nature (i.e., murder, natural disaster, car accident, etc.) some children may experience
Childhood Traumatic Grief (CTG). The primary purpose of the project was to facilitate a
guide for social workers in the field to aid school age children and adolescents in the
bereavement process following the traumatic death of a loved one. The secondary
87
purpose of the project was to enhance the research on the topic of Childhood Traumatic
Grief and therapies used to treat it. The findings of this study suggest that TF-CBT is a
conjoint child and parent psychotherapy approach for children and adolescents who are
experiencing significant emotional and behavioral difficulties related to traumatic life
events. It has proven to be effective in addressing posttraumatic stress disorder,
depression, anxiety, externalizing behaviors, sexualized behaviors, feelings of shame, and
mistrust. The parental component increases the positive effects for children by reducing
parents' own levels of depression and emotional distress about their children's abuse and
improving parenting practices and support of their child. This treatment can be used by a
variety of mental health professionals including clinical social workers, professional
counselors, psychologists, psychiatrists, or clinical counselors. TF-CBT has been
evaluated with Caucasian and African American children, and it has been adapted for
Latino and hearing-impaired/deaf populations. Currently, TF-CBT is being adapted for
Native American children and for children in many other countries (e.g., Zambia,
Uganda, South Africa, Pakistan, the Netherlands, Norway, Sweden, Germany, and
Cambodia). The end result of this collaborative research project was the development of
a group work curriculum guide designed to provide clinical interventions for children
suffering from Childhood Traumatic Grief by using TF-CBT.
88
APPENDICES
89
APPENDIX A
Interview Questions
Questions asked of social workers who have experience working with children and grief.
The purpose of these questions is to explore the level of trauma interventions currently
included in children’s grief curriculum, specifically TF-CBT and narrative therapies. The
questions will also focus on the best way to incorporate these interventions with
traditional grief treatment models.
1. How often are you seeing children ages 5-12 and teen’s ages13-18, who exhibit trauma
symptoms related to grief in your practice?
2. To what extent do social workers/therapists utilize narrative therapy in group work
practice with grief?
3. To what extent do social workers/therapists utilize TF-CBT in group work practice
with grief?
4. How effective do you feel the current curriculum you are using is at addressing
symptoms of PTSD, anxiety, and depression?
5. Does the current curriculum contain a parenting component?
6. Does the current curriculum incorporate relaxation techniques?
7. What components of the current curriculum do you feel are most successful at treating
traumatic grief?
8. Depending on the age of the children you see in your practice, what suggestions do you
have for developing a curriculum that incorporates TF-CBT and narrative therapy with
90
the traditional children’s grief models, such as sand tray, art therapy, play therapy or
music therapy?
9. Do you have any suggestions for group activities that would address the traumatic
aspects of grief?
91
APPENDIX B
Consent to Participate in Research
You are being asked to provide information through interviews to assist in
developing a group work curriculum by Aja Michael and Laurie Thompson, graduate
students in the Social Work Department at California State University, Sacramento. The
purpose of this project is to create a curriculum for treating Childhood Traumatic Grief
that incorporates aspects of narrative therapy and TF-CBT.
You will be asked to respond to questions about the current effectiveness of group
work curriculum at treating trauma associated with grief. There will also be an
opportunity during the interview for you to provide suggestions on how to best create a
curriculum for this purpose. The information obtained from the interview will be used to
develop a group work curriculum for treating Childhood Traumatic Grief.
There is no risk associated with participating in this study. We will only be
asking questions about your professional experiences with clients, and covering topics
that you work with on a regular basis. After completing the interview your answers will
be incorporated into the development of this project.
Your participation in these interviews as well any personal identifying information
obtained during the interview process will be kept confidential. In the final draft of the
thesis only the key therapeutic themes that you share and that emerge from the other
interviews will be published as input for the curriculum. No personal comments will be
included. As participants of the survey, you will be informed of the content of the
interview questions prior to our meeting and may choose not to answer any questions that
make you uncomfortable. You will be given a consent form to read and sign prior to the
interview session. Your signed consent form will be kept separately from the interview
materials which will not have any of your identifying information. Your consent forms
as well as interview materials will be kept in separate locked box and stored at our own
home. All of the materials will be shredded following the completion of this project.
92
You will also be provided with contact information if you have any issues that arise after
the interview. Your name will not be connected with the information you have provided,
however the project as a whole will be shared as public information. If you have any
questions about this interview please contact Dr. Joyce Burris by e-mail at
burrisj@csus.edu or by telephone at (916) 278-7179. You may also contact either of the
researchers if needed, Laurie Thompson at lauriestanton@sbcglobal.net or (530) 6157928 and Aja Michael at ajamichael@sbcglobal.net or (916) 397-5091.
You may decline to participate in this study without any consequences. You will
receive a $5 Starbucks gift card in return for your participation in this study. Your
signature below indicates that you have read and understand the information provided in
this page and agree to participate in the interview.
Print name
Signature of Participant
Sincerely,
Laurie Thompson and Aja Michael
Date
93
APPENDIX C
Relaxation/Breathing Exercise
Pretend there is a large balloon in your stomach. As I count 1-2-3-4 fill up the balloon
with air. 1-2-3-4 now HOLD the air...then let all of the air out of the balloon (repeat 3
times).
Imagine yourself at the beach. Feel the warm sun on your skin, and hear the waves
roaring up and down the beach.
Take off your shoes and let your toes settle in the sand. Stretch out your legs and feel
them resting and relaxing. Take a deep breath and let it out.
Tighten the muscles in your arms as tight as you can, now let them relax.
Tighten the muscles in your neck and lift your shoulders up as high as you can.
Now relax the muscles in your neck and shoulders.
Make a frown with your face as tight as you can.
Now relax all of the muscles in your face.
Imagine all of the tightness washing out with the waves on the beach.
Take another deep breath and count to 10 then let it out with all of that tightness.
Finish with 3 normal breaths.
(adapted from Mourning Child Grief Support Curriculum)
94
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