• Journaling as a Bereavement Counseling Tool (January 2010)
• Children and Funerals (August 2009)
• Helping Teens in Grief (July 2009)
• Helping Family Caregivers Find Balance (January 2009)
• Cause of Death and the Course of Mourning (October 2008)

Journaling as a Bereavement Counseling Tool

Children and Funerals

Volume 8, Number 8

August 2009

            When contacted by a family with children in the immediate aftermath of a death, the most frequent question I hear is some form of, “What about the kids and the funeral—should they go, should they not, and why or why not?” Over the years, I have developed a fairly straightforward response—neither force attendance nor forbid it, but strongly encourage it with complete, factual information. So this month, we turn to this sometimes complex topic in GriefConnections.

            At the outset, I believe it is important to strongly encourage any child of any age to attend and participate in the funeral of a person to whom they are “connected.” Let me explain. Once upon a time, I thought young children were best excluded from the funeral service—their presence might be to distracting for the “grown up mourners.” As I have studied the role of death-related rituals around the world and in history, however, I’ve changed my mind.

            We Westerners (western Europeans, Canadians, and Americans) were apparently the first people to think up the notion of excluding children from community death-related rituals. People groups who have recently immigrated to our shores seem to rarely consider excluding children, even though the services may last many hours, or even days, with great complexity. When living In southern California, I frequently observed the customs of Cambodian Buddhist families in Long Beach, and saw that children were always included, even if they had no connection to the deceased other than that they were all Cambodian, perhaps lived or worked nearby, or possibly attended the same temple.

            The notion of keeping children away from funerals is of relatively recent evolution, even among westerners. When I was a child in 1960’s Louisiana, kids were expected to attend funerals of neighbors, church people, and certainly of family members. You will be hard-pressed to find a person born before World War II who did not attend many funerals as a child, and many of those services would have been for people the child barely knew.

            So is the idea that we should protect kids by excluding them from rituals a more “evolved” perspective, demonstrating our great depth of understanding in how children are emotionally wired? I don’t think so, and there is quite a bit of research to support my perspective. Nearly ten years ago, a National Institutes of Mental Health-funded research study with broad application followed 318 parent-bereaved children age 5-17 for more than two years. Perhaps the most significant finding for the purpose of this discussion was a conclusion reached by the researchers, told best in their own words:

Parents frequently request guidance, particularly for younger children, on whether attending a funeral home (or other type of) visitation will negatively affect the child. Interestingly, in our study, 11 percent of children’s families did not have a visitation. By one year post-parental death, these children had twice as many behavior, anxiety, mood, and other symptoms, and they experienced more severe depressive symptoms than children who had attended a visitation. At two years post-parental death, they had more PTSD symptoms than children who had attended a visitation (Fristad, et. al, 2000/2001).

            Of course there could be other confounding variables in the study. Perhaps the same family-systems issues, for example, that caused a family to depart from the community’s “traditional norms” might have been causative for the higher incidence of psychological symptomatology. The visitation/funeral-positive findings of the Fristad study, however, were also confirmed in a much smaller British research project. The researcher found children had no negative effects from attending funeral rituals and tended to regret not attending or having been excluded (Holland, 2004).

            The Harvard Child Bereavement Study conducted by Phyllis Silverman and my mentor, J. William Worden, reached similar conclusions. Reporting that 95% of children attended their parent’s funeral, Worden (1996) writes,

Children were included in funeral planning and in the funeral itself in various ways. This participation did not lead to later behavioral/emotional difficulties; on the contrary, most children felt positive about their involvement. Being included also helped children feel important and useful at a time when many were feeling overwhelmed. A 10-year old boy who helped carry his father’s coffin said, “It was kinda heavy but it felt good to carry his coffin” (Worden, 1996).

            If it is true that children are best served when they attend and participate in the memorial ceremonies, the professional and volunteer caregiver must also work alongside parents to make the experience meaningful for the children. Asking a child if she wants to attend a funeral when she has never attended one before is a bit like asking if she wants to fly to Mars; she just doesn’t have enough information to decide. So the first item on my agenda is to encourage parents (and other caregivers) to use the five senses in dialoguing with children: you will see some people laughing, some crying, and dad in a beautiful box called a casket. You will hear Mrs. Doudy playing the organ and John Mitchell singing a couple of Grandma’s favorite hymns. You will smell and see the beautiful flowers people have sent to remind us they love us. You will taste the delicious food people bring so we can eat without having to think about what we will cook. At the end, a man will release some white doves and they will circle around and then fly away, reminding us that Mom’s spirit has left this world to go to God. These sensory images help create a photo is the child’s mind of what he or she will experience.

            Children are curious. If the casket is open, some might want to know, “Where are Grandpa’s feet?” I was present several years ago when a young funeral director removed the casket flowers and opened the bottom half of the casket so the kids could see that their grandfather’s legs were intact—and he was even wearing his warm, colorful wool socks to the astonishment and comfort of all who saw!

            A child might want to touch the hand or face of the deceased, so preparing them for how the body will actually feel is helpful. On a few occasions, I have given a child a candle that has spent ten minutes in the refrigerator—it is cool with a slippery or “waxy” feel, much like a deceased loved one’s skin might feel when he touches it.

            At the funeral, I like to play a “game” with young children where they point out flowers they think would be mom’s favorites—based on their colors or aromas. Kids can also be involved in distributing memorial folders, bringing the gifts of bread and wine for communion, as well as the more common roles of speaking. One pastor gathered a dozen school-aged and preschool siblings and cousins for an impromptu presentation of the old song, “Jesus Loves Me, This I Know” at the funeral for the family’s young infant.

            Children and families are well-served when a teacher, coach, neighbor, or other caring adult offers to sit with the kids during the service, perhaps on the row right behind or even among family members. Preferably, children and their “attending adult” should sit with the rest of the family instead of in the back of the chapel or church.

            Far from attendance and participation in funeral ceremonies “traumatizing” young children, my experience and the majority of research points out the benefits of child participation in the funeral, and even suggests in some cases, that children are clearly harmed when they are denied the opportunities to attend and participate. Like much of life, what we are learning about the importance of children participating in funerals is that sometimes growth occurs in environments where the circumstances are the hardest. Subscribe FREE to GriefConnections.

References.

Fristad, M.A., Cerel, J., Goldman, M., Weller, E.B., & Weller, R.A. 2000/2001. The role of ritual in children’s bereavement. Omega: Journal of Death and Dying, 42 (4), 321-339.

Holland, J. 2004. 2004. Should children attend their parent’s funerals? Pastoral Care in Education, 22, 10-14.

Worden, J.W. 1996. Children and grief: When parents die. New York: Guilford.

Helping Teens in Grief

Volume 8, Number 7

July 2009

            Robert died in a car crash at age 46, leaving his wife of 18 years, Barbara, and two teenage children: a 15 year old daughter and a 13 year old son. Certainly his family’s grief was complicated, in part because of the unexpected trauma of Robert’s death. Additional details discovered in the investigation, however, further complicated their grief. The accident occurred in a different city than the one in which he had told family and coworkers he would be visiting. And the investigation revealed he had spent the night in a motel with the woman who was killed in the accident with him.

            Brittany and Bryan, the teens, were in need of support from their school, faith community, neighbors, and friends. Understandably, most of the people in the teens’ world, were unsure of where to start. Here are some of the principles their caregivers and counselors learned in the aftermath of Robert’s death.

            Teach, model, and embrace the importance of truthfulness. With children and younger teens, well-meaning parents and friends often conspire to hold back part (or all) of the unpleasant truth. Bryan and Brittany’s mother seriously considered not telling the kids about “the other woman,” partly out of her own shock at the discovery. Not everyone was shocked, however; three of Robert’s buddies had known of the affair for most of the last two years.  Barbara’s reticence to tell her kids what happened was understandable; she wanted to protect their image of Robert, as well as avoid the shame she felt on his behalf.

            The problem with withholding the truth from children and teens, however, is really twofold. First, kids have an uncanny way of learning the truth. A family member or friend makes a casual comment, understandably expecting all the facts have been told; suddenly, the kids realize they haven’t been told the truth. Second, when the kids do learn the whole painful truth, they begin wondering about the truthfulness of other things they have been told, eroding trust in their relationship with family members and friends at a time they most need to be able to trust.

            Commit to truth-telling and help parents understand the importance of truthfulness. In my work with parents who are lying to their kids or who are grappling with whether or not to tell the “whole story,” I inquire about how widely the “whole story” is known and then ask the parent to consider where they would most like their kids to hear the truth—from them or from someone else. My experience suggests children are rarely kept in the dark for long, and for teens, the truth is usually learned even more quickly. Truthfulness is really the only viable option.

            Educate parents and other caregivers. Most of us must have missed the parenting class entitled, “Helping Your Children Deal with Death!” Perhaps we hope we’ll never need to have these discussions, or perhaps we’ve never allowed ourselves to experience the full impact of our own losses, but whatever the reason, most parents really don’t know what “normal” should look like in their grieving teenagers.

            When I was called into a high school where several members of an athletic team had been killed in a rollover crash, one of my tasks was to meet with parents of grieving students. More than 200 concerned parents turned out for the meeting, and on reflection, I realize my greatest service to them was helping them normalize their kids’ behaviors.

            The teens had held a “memorial bonfire” at a nearby beach the night after the crash—and parents and teachers had been excluded. Several parents were concerned about the impromptu “shrines” of photos and memorabilia that had appeared in kids’ rooms. And of course the school administration was grappling with what to do with the hundreds of candles, teddy bears, and other items that had been placed around the school’s flagpole.

            When it comes to a friend’s death, teens tend to be very symbolic. My research into the therapeutic use of rituals and my experience with grieving people indicates this is both normal and helpful. Teens will turn out for the funeral, often whether they actually knew the deceased student or not. The only student who died during my high school career was two years my senior and not a student I knew at all. Yet, long before I became professionally interested in death and bereavement, I attended his funeral—mostly because that’s what my friends were doing and I needed to be part of the “community of grief.” Parents need to be taught that behaviors like these are entirely appropriate.

            Protect teens’ wish to not be identified or singled-out. Teens are most often caught up in wanting to fit in with their peers, so being identified as “different” because of the death of a parent or sibling may not be the “label” a kid wants to wear! More than with any other age group, teachers and school administrators, for example, need to learn directly from their bereaved students how much the student wants told to the entire student body. Remember that teens can be quite voyeuristic and may fear others “looking in on them” in the same way they had looked at others!

            This hope for anonymity also complicates the provision of bereavement services to teens. Being part of a “grief group” might be very objectionable to a teen because he or she doesn’t want to be different. I worked with one high school to provide a 30-minute lunch break grief group for the dozen students the counseling staff had identified. Instead of calling it a grief group, we called it a “lunch discussion,” and presented the idea that these students had much to teach each other and the rest of us. We focused on what they were learning and what they still felt they needed to learn to effectively make sense of what had happened.

            This very cognitive-sounding grief group actually surfaced some important affective material—but the group felt “safe” for those who didn’t want to be singled out. Several months later when I was back on that campus, the school psychologist with whom I had worked pointed out to me that several of the kids still met at a corner lunch table on Fridays, the day our group met.

            Teach and model the value of writing. Many teens are less expressive verbally than they are in written form. We sometimes learn much later that teens who are “pegged” as “kids who won’t talk,” are kids who keep volumes of journals about their experiences. Some of the most articulate words I have encountered were written by teens who scribbled them into journals rather than speaking them aloud to a grief group or individual counselor.

            Teens sometimes need help getting started on journaling. After suggesting this invaluable way to “talk through their writing,” suggest a few journal starters such as, “Today, I missed you the most when. . .,” “I most remember this holiday because. . .,”  “My greatest memory of you was when we. . .,” or “I am glad you were in my life because of the way you. . .” Invite teens to share some entry from their journal with you or with a group, but be sure no one feels pressured to share these words.

            Respect the role of hormones. After puberty, the average male possess eight times the level of testosterone as the average female. This hormone is often maligned for its role in aggressive behavior and its affinity for “preventing emotional connection,” but criticizing testosterone is like telling a person his ears are too large. It might be true, but there isn’t much that can be done about it (apart from radical surgery!)

            Without wading into the gender wars, what I know is that testosterone-flooded brains tend to process crises, stress, and bereavement differently than brains without such high levels. While I refuse to “blame it all on hormones,” I believe we must continue to find safe, creative ways for teen boys to express grief that transcend asking them to tell their story, create memory boxes, and draw pictures. These strategies will find their place among some, to be sure, but we must also have other strategies.

            Most likely, effective bereavement interventions with teen boys, like their adult male counterparts, will come on the basketball court, the rock climbing wall, the camping trip, or the wood and metal shop. One of the most effective grief counselors with teen boys I have known helps boys make memory boxes, all right. They make memory boxes—using the power tools in his garage! By his account, more grief-related guided conversation occurs over the din of the power saws and drill presses than ever occurred in his pre-power tools days.

            Grieving teens are not just adults who haven’t quite grown up fully. Instead, they are people with unique ways of viewing life and death in the world around them. Perhaps the most important truth I have learned from supporting grieving teens, however, is to allow them to be my teacher and me their learner. Then, generation gaps fade, choices of music become unimportant, and we are all better served. Subscribe FREE to GriefConnections.

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Helping Family Caregivers Find Balance

Volume 8,

Number 1

January 2009

            Perhaps as many as one out of every four families is caring for a parent or other older relative. Sometimes referred to as the “Sandwich Generation,” this unique group of family caregivers are often trying to balance the often-conflicting demands of providing care for the patient, taking care of young children, and managing a career, as well. The word sandwich fits well—these folks are sandwiched, not only between generations but between many competing demands on their time, energy, and resources.

            Family caregiving is taxing on many levels. First, family caregivers often experience guilt at not doing enough. No matter how much care they provide, regardless of how often they put their own schedules and priorities aside to provide care, many feel they still haven’t done enough. Often, the guilt is magnified by feeling that the caregiver’s own spouse, children, friendships, and career are suffering because of the caregiving demands.

            Additionally, family caregiving often magnifies long-standing conflicts and dysfunctions in the family system. One adult child bears the primary responsibility for caregiving while other children saunter in and out at will. Even when others offer to help, the primary caregiver might rebuff their efforts, judging them to be insincere or incompetent for the task.

            One woman with whom I worked in bereavement told me she had moved in to become her dying father’s full-time caregiver. By her own admission, she rarely returned to her own home, her husband, and her teenage children during the seven months of her dad’s illness, not even talking on the phone with them very often. She then seemed mystified that the relationships with her spouse and children were deeply damaged, insisting that she was only “doing her part” and that they should have just understood. So how do we support family caregivers as they provide such life-giving care? These are some of the ways I have found support to be most effective:

            Assess personality variables and family history. Inquiring about other responsibilities can be a great way to start this conversation. People who are trying to manage career, family life, and caregiving can easily become overwhelmed. Asking questions about how he or she has coped with overwhelming challenges in the past can be helpful; I also like to ask about what parts of the caregiving role offers the most fulfillment and the least fulfillment.

            Caregivers are certainly not immune to debilitating mental health history, either. In fact, I had one family who wanted to depend heavily on an adult daughter with an active mental health diagnoses, because, in the minds of siblings, it would give their mother a constant companion and would keep their mentally disabled sister “out of trouble!”

            Help identify roles. The work of Steven Covey (famous for his book, The Seven Habits of Highly Effective People) is useful here as you invite family caregivers to identify their key roles (ie “I am a husband, a son, a marketing director, a dad, a Rotary committee chairman, a caregiver to my aging father, a soccer coach, a Sunday School teacher, etc.”) Sometimes helping caregivers list in writing all the roles for which they assume responsibility is a big step in self-understanding; when a caregiver realizes in how many directions he or she is being pulled, it is much easier to manage the stress and competing demands. Encourage him or her to write out what constitutes a “good job” or “success” in each of those roles.

            Provide practical help for achieving balance and self-renewal. I challenge caregivers to think about something they can do each week to be renewed in four key areas which I have labeled, the “Four F’s”. . .fitness, faith, fellows, and faculties. Fitness is fundamental—and I like to talk practically with family caregivers about how they are eating, exercising, and resting. Taxed caregivers often rely heavily on prepared foods—which are often short on nutrition and long on sugar, fat, and sodium, the excess of which deals a death-blow to energy and fitness.

            Faith is also extremely important. Though some would prefer the word “values” or “personal mission,” the key is reconnecting to one’s belief system. For me, that means making it a point to get to worship weekly and to invest some time in devotional reading and prayer most days. One hospice volunteer coordinator has a knack for accessing volunteers who are Jewish or Seventh-day Adventist to provide respite care for hospice patients whose primary caregivers wanted to be able to attend church on Sunday.

            Fellows refers to the family and social network to which one is connected. Sixteenth century poet and philosopher, John Donne said it best when he wrote, “No man is an island entire of itself. . .” Family caregivers need continual connection and interaction with supportive others. In addition to phone calls, emails, and an occasional lunch out, encourage family caregivers to connect with others in creative ways. CaringBridge.com, a web-based interaction site for patients and families facing serious illness, can be a lifeline of connection with concerned friends.

            Renewing one’s faculties means continuing to look for mental engagement. Whether it’s in taking time to read the morning paper, enjoying a good biography, or researching a topic of interest on the internet, the information age demands people become lifelong learners.

            I echo the thinking of Steven Covey, however, that setting priorities and goals by the week rather than by the day can be helpful for maintaining perspective. If, in the course of a week, we encourage caregivers to do something that renews their fitness, their faith, their fellows, and their faculties, this will seem far less overwhelming to a person who already feels stretched thin.

            Recommend good resources. Whether a book to read (such as The Caregiver’s Survival Handbook reviewed below), a website to visit, or a caregiver support group to get involved with, family caregivers need the perspective that can be brought by access to resources. Alienation is one of the most debilitating of caregiver maladies and connection to good resources goes a long way to alleviating this condition.

            Though many readers of GriefConnections will know how to access these resources, organizations such as the Council on Aging, the Alzheimer’s Association, the American Heart Association, and the American Cancer Society have both national and local resources. Help caregivers learn how to access the resources available to them. Subscribe FREE to GriefConnections.

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Cause of Death and the Course of Mourning

Volume 7, Number 10

October 2008

            One of the occupational hazards of working in the bereavement counseling and death education fields is having an insatiable appetite for such things as mortality statistics! Using data accumulated from the more than 2.4 million death certificates filed in the United States every year, researchers can see clear trends into how people die. Interventions and prevention strategies often account for marked improvement in preventing or reducing certain kinds of death, witnessed in the cutting by half the incidence of Sudden Infant Death Syndrome in the last decade, largely because of the “Back to Sleep” campaign that taught parents to put their babies in bed on their backs.

            But in addition to the macro-trends that can be discerned from understanding how people die, understanding cause of death information is imperative in providing good counsel and support to bereaved people. Therese Rando (1993) gives cause of death a prominent place in her Grief and Mourning Status Interview and Inventory while J. William Worden (2008) considers cause of death to be one of the seven “mediators of mourning” (see below). Ester Shapiro (1994) concludes, “Rather than talk about grief as a monolithic process, we find instead that we have to consider the particular circumstances of a death and of the mourners. We must ask not only who died and who they were to the family in terms of their actual day-to-day as well as psychological significance, but also how they died and how much the death itself disrupted ongoing family functioning.”

            There are several reasons the counselor will want to explore cause of death information with the bereaved client or family. First, knowing the cause of death is often a pivotal piece in survivors being able to eventually move on with life. Though knowing the cause of death might engender additional existential questions (ie Why did he die instead of me? What did she do to deserve this kind of death? Where was God in the middle of all of this?) While few bereaved people find final answers to these kinds of questions, exploring the questions with a competent caregiver can be great medicine itself. I often tell grief groups and individuals, “There is nothing wrong with asking all the questions you want. . .as long as you’re okay with not finding answers to most of them.”

            The second reason the cause of death is necessary is because in the early part of grief, the “death story” is at least as important as the “life story.” For a couple of years, I sat in on the interactions between funeral directors and the families who came to make funeral arrangements for their loved ones who had just died. I witnessed many different styles and approaches to the process and some excellent caregiving skills being exhibited by these funeral service professionals. But what I most noticed was the freedom with which families told the story of “how, where, and when” their loved ones died. There seemed to be no more important story to tell in the early days of grief.

            The third reason that cause of death is important is because knowing how a loved one died often provides the impetus for growth, the birth of a “cause that empowers life” if you will. How many of us have worked with families whose loved ones were the victims of drunk driving incidents who went on to become activists in groups like Mothers Against Drunk Driving? Hospice volunteers often begin their work because they walked with a dying spouse or parent through the final stages of a malignancy.

            Finally, cause of death information helps us respond most effectively to the bereaved family. A person whose loved one died traumatically and who is re-living aspects of the trauma (re-experiencing the trauma through flashbacks or the like), is not likely to be actually dealing with grief and loss issues; rather, this person is dealing with the after-effects of trauma. The distinction becomes more clear when we listen for the content of the survivor’s story; does he or she describe details from the relationship that has been lost (bereavement) or does he or she mostly describe the details of the death event itself (trauma). Since it is widely held that trauma symptoms must be dealt with before an individual is ready to work on the grief part, knowing cause of death and assessing for symptoms of traumatic stress or even Post Traumatic Stress Disorder is imperative.

            As we are discussing cause of death information, I often ask bereaved clients to explain how they think things would have turned out differently if their loved one had died by some other cause. This imaginative activity helps the client to place the death of their loved one in context of the whole relationship, but it also helps delineate what some of the issues are that might be tripping up the survivor, issues of which he or she may not even be aware. Subscribe FREE to GriefConnections.

References

Rando, T.A. (1993). Treatment of complicated mourning. Champaign, IL: Research Press.

Shapiro, E. R. (1994). Grief as a family process: A developmental approach to clinical practice. New York: Guilford.

Worden, J.W. (2008). Grief counseling and grief therapy: A handbook for the mental health practitioner. New York: Springer.