WORKING WITH TEENS THROUGH GRIEF AND LOSS: A RESOURCE MANUAL Gaylene Clark B. Ed. , University of Victoria, 2004 PROJECT SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTERS IN EDUCATION IN COUNSELLING UNIVERSITY OF NORTHERN BRITISH COLUMBIA April 2011 © Gaylene Clark UNNERSITY of NORTHERN BRITISH COLUMBIA LIBRARY Prince George, B.C. 2 Table of Contents Title Page ............................................................................................. .1 Table of Contents ............... ...... ............... ....... .. .. ........ ................ . .... ..... ... 2 List of Tables ........................................... ..... ..................................... ... .. 4 Acknowledgements ............................................................................ .. ..... 5 Dedication ....... ... ......... .. ............... . . ... ..... .. ..... .... ............... .. ................... 6 Part One: Introduction ......... ............ .................. .......... ..... ........................... 7 Purpose and Rationale ......... ............. ........ ............................. ............. 9 Teacher Training and Grief Work within Schools ...................................... .11 Part Two: Literature ...................... ... ..... ..... ...... ....................... ................. 13 Defining Grief and Loss .......................... ........ ................................ ... 13 Intuitive and Instrumental Grief. ........ ....... ................................ 14 Grief as a Whole .......... .................................................. .................. 17 Tasks ofGrieving .......... ..... ... ......... ................................... .. 18 Developmental Concerns .............................. ... ... .................... ........ ... 20 Bereaved Youth ...... ... .................. .. . .................................... 22 Connecting with Schools .................................................................... 26 Part Three: Grief Manual. ............... ..... .. .... ......... . ........................ ........ ...... 29 Counselling Frameworks .................................................................... 30 3 Considerations .. ..... ..... .... .. .. . ................................. ... ....................... 33 Structure ...... ... ......... . .... . . .. . ................... .... .......... ..... .............. .. ..... 38 Loss and Family .................. . ... . .. ...... ....... . ....................................... 39 Prolonged Loss ....... ...... ....... ........... ........ ......... ............................... 48 Traumatic Loss .. ...... ....... ..... .. ........ ............... .... . ..... ..... .................... 55 Postvention with suicide survivors ........................ ... .. .. .................. 63 Other Losses ..... ... ................ .. ............... .. .......... ... ...... . ................... 72 Divorce ..... ..... ........ ... .... ................... .. ................................... 74 Anger. ...... . . .... ............. ..... ....... .............................................. 75 Grief Techniques ........................................................... . ................. 80 Conclusion .................. .... ............ .... .............. . ...................................... 82 Appendix 1: Grief Pattern Inventory ...................... .. .......... ..... .... ............. ... .. 83 Appendix 2: Teen GriefRealities ...... . .............. ....... .. ... ...... ...... .. ..... ...... . ...... 89 Appendix 3: How Schools Can Help Students with the Tasks ofGrieving ... ........... ... 92 Appendix 4: Are You Worried About Saying Something Stupid ... ... .. ..................... 94 References .... .. ........ ...... ........... .. ............ ...... .......... ...... ................... ...... 96 4 List of Tables Table 1 Grief Goes to School: Warning Signs ........ ................ .. .. ... .......... ... ..... 28 Table 2 Suggestions when Grieving a Loved One who has been Murdered .......... ..... 56 Table 3 Suicide Intervention Strategies . .. .. . . . .. . ... ..... ...... .... .... ............... ............ 62 Table 4 Eight Principles from Suicide Postvention Programs for Schools .................. 64 Table 5 Assisting Students during Traumatic Crisis ....... . ..... ........................... .... 66 Table 6 Counselling Techniques with Youth and Anger. .............. .... . . ................. 77 Table 7 Useful Techniques for Grief Counselling .. . ... .............. . ..................... ... 80 5 Acknowledgments I must acknowledge a number of people who have each played a part in making the completion of this project possible for me. First, I must express my gratitude to my supervisor, Dr. Linda O'Neill , as her expertise, drive, understanding, and patience helped push me through this graduate program. Linda has spent countless hours reviewing my work and providing me with direction when I felt lost, while also helping me with my day-to-day work as a counsellor. I also thank my other committee members, Brian Bulgin and John Sherry for their many resources, contributions and encouragement to complete thi s work. I am also appreciative of Mike Carson for taking the time to scrutinize the final copy, ensuring there are no mistakes. I am also grateful to my friends for providing their opinions and support throughout this whole process. From beginning my very first Master' s class, to completing this piece of writing, my friends have helped me in many immeasureable ways as we have travelled life' s journey. Thank-you to Maggie Crain, Kelly Crowe, Sherry McCoy, and Shandee Whitehead for their unremitting friendships. Thank-you also to my sister, Annette Gobbi , who has stood by me through all of life ' s accomplishments and downfalls, and the completion of this Masters is no exception. She is someone I hope to have standing beside me through all our future travel s. I can ' t count the number of times I have said thank-you to my parents, Peter and Anne Yates, for their love and support. I thank them for instilling in me the aspiration, confidence, and drive to take on my Masters project, and for the countless hours of babysitting so that I had the time to write. Finally, I must acknowledge my husband, Tyler Clark, as this has been an enormous undertaking for him 6 as well. He always stands beside me, encouraging me to keep going even when the end seemed so far away. He has never complained about the hours that I am gone to class or the weekends I have spent writing. He's just there, loving me. Dedication I wish to dedicate this project to my parents, my sister, my husband, and my children, Hannah and Layne. It is because of the lifetime of love and support from these special people that I have been able to do this. I love you all. 7 Part One: Introduction Loss and transition are natural human processes. Life gains meaning and value from the knowledge that it is finite, that we do not have an endless supply of tomorrows. Dreams, aspirations, hopes, and experiences are all intensified by the knowledge that there will one day be an end. However, as a future-oriented society, to consider a time when life will end arouses anxiety. In order to cope with this anxiety each of us takes a standpoint ranging from complete denial to complete existential acceptance (Rando, 1984). One person may avoid the topic of death altogether, refusing to attend funerals , write a will , or see a doctor; another may counter death entirely by defying it, putting himself in dangerous situations, or purposefully ignoring medical instructions; and someone else will put all his faith in a life after death . There are countless ways to react to the knowledge that we will die, whichever path is chosen will lay the groundwork for how one will deal with death as it presents itself. Grief is work. A person expends endless amounts of both physical and emotional energy as she manages and moves through the stages of grief. Many people are not prepared for the intensity of emotional reactions to grief and struggle with how to properly accept and express reactions (Rando, 1984). Society's often unreali stic and inappropriate responses to the griever' s normal reactions often make the experience much worse than it has to be, contributing to the griever feeling conflicted in how he should express his grief. Attachment theorist John Bowlby (1969) describes attachment as a lasting psychological connectedness between human beings. Through his research he has shown that the earliest bonds formed by children with their primary caregivers have a 8 tremendous impact that continues throughout that child ' s life. Lack of secure attachment early in life can have a negative effect on behaviour, relationships, and managing stress. As children develop, they form new attachments with their peers utilizing the same tools and behaviours they did as children. Linking this attachment theory to loss, Stroebe (2002) writes, "people who have experienced a lack of dependability and consequent insecurity in their early childhood relationships will subsequently remain influenced by this in forming , maintaining, and relinquishing relationships" (p. 133). Having a better understanding of this link may help clarify why some people adjust to loss while others suffer tremendous difficulties including mental and physical health effects. Children have many of the same needs as adult grievers. There is controversy over the age at which a child can legitimately be said to mourn in a process similar to an adult' s. Components of this controversy include; a child ' s capacity to mourn, identity formation, maintenance of object constancy, and cognitive understanding of the concepts of irreversibility and permanence (Rando, 1984). Youth will respond in different ways to loss, depending on their age, experience, personality, context of loss, and attachment to caregiver (Holland, 2008; Stroebe, 2002); however, it has been accepted that there are four main tasks in grief work. One, accept the reality of the loss ; two, experience the emotions associated with the loss; three, adjust to the environment in which the significant person is no longer there or change has occurred; and four, withdraw the energy used in dealing with the loss so it can be reinvested in new relationships and life events (Worden, 2002). A bereaved person does not progress through these tasks in an orderly fashion , and may be working through more than one task at a time. Just like 9 adults, youth need time to conduct their grief work in an environment that understands their specific needs. It is for this reason I am proposing to construct a manual for mental health practitioners to help them better assess and address the needs of youth when they have experienced a loss. As a high school counsellor I see students every day who are experiencing some form of grief. Often, as I attempt to work with the youth in creating some life and school balance I find that I do not have the background knowledge or tools to be effective beyond simply being a compassionate person. It was my desire to gain more knowledge and more skills to become a better grief counsellor that sparked the beginning of this project. Purpose and Rational for Resource Book One may ask why, since everyone has experience some form of grief, a manual would need to be written? In truth, grief is experienced by all , but youth in the 21 st Century are facing grief-related issues involving safety and protection that many adults have not experienced (Goldman, 2004). Additionally, the grief experienced by youth from the death of a loved one is becoming less frequent, which is both hopeful for those who have not lost someone, and isolating for those who have. In today' s Western society, elderly and terminally ill patients are often sent to live in care facilities, rather than being taken care of in the home (Charkow, 1999). Medical technology, vaccinations, increased education and awareness and better child care have all contributed to significantly lower morbidity and mortality among children and youth (Kubler-Ross, 1969; Rando, 1984). In western society the topic of death is often viewed as taboo and youth are cautiously excluded from the mourning that takes place in the hopes that they will be protected 10 (Charkow, 1999; Kubler-Ross, 1969; Parkes, 1985). When a death does occur, the body is immediately sent to a funeral home to be taken care of by specialists and removed from the good-bye process that youth may want to have. As stated by Kubler-Ross (1969), Parkes (1985) and Goldman (2004) a much more wholesome way to introduce death to youth is to include them in the discussions, allow them to express their fears, and see that they aren't alone in their grief, and instead they are participating in shared mourning. This helps better prepare them for future loss and aids youth in viewing death as a part of life. Younger children will go to great lengths to hide their feelings if this is what they believe others want them to do (Abrams, 1999), and older youths, for example, may dive into academics or athletics, or may branch out and begin spending more time at friends ' houses than at home. Research has identified groups and characteristics of youth who are at greater risk for complications or making harmful decisions when they are bereaved. As outlined by Wolfelt (2003), some characteristics that may put a youth at risk include insecurity, abandonment, low self-esteem, experiencing multiple losses, and concurrently dealing with family issues such as alcoholism or abuse. Areas that have shown to contribute to poor grief outcomes are ; type of death (cause for blame, sudden death), characteristics of the relationship (parent death), characteristics of survivor (intense clinging, insecure, anxious, low self-esteem, previous unresolved losses, needing to uphold 'macho' selfimage), and social circumstances (detached from traditional support systems, low socioeconomic status) (Eppler, 2008; Clements, DeRanieri, Vigil , & Benasutti, 2004; Goldman, 2004; Parkes, 1985). 11 Teacher Training and Grief Work within Schools It is imperative the teachers receive some grief training. Teachers need to be aware of the grieving process, understand the developmental stages of grieving, and support students in feelings of loss (Eppler, 2008; Wolfelt, 2003). Teachers and schools can be very important resources in the facilitation of youths death education and grief work. This project will give community counsellors and school counsellors a starting point when working with youth who are experiencing grief. It will by no means replace specialized training in grief counselling, but instead will provide a platform for safety and communication. This manual is intended to provide counsellors with the appropriate tools and knowledge to be able to provide effective support through crisis situations and prolonged feelings of loss. Reeves (2001) indicates that it is common for children and teens to respond to the news of a loss with "How does this affect me?" If counsellors are aware that statements such as this are normal , the gap between counsellor and client may be better bridged therefore allowing for a deeper, more effective relationship as the path of healing is followed . Additionally, bereaved teens may experience confusion or an inability to focus on school work, lack of energy, a tightness in the chest or hollowness in the stomach, sleep or appetite changes, upsetting dreams, restless overactivity or a loss of interest in previously enjoyed activities, problems with interpersonal relationships, or a sudden need to search for a sense of meaning (Doka, 2000). While many of these experiences would be common among any age group of bereaved people, teens are also managing changing bodies and minds as they work through developmental stages making the grieving process even more complex. 12 I feel honoured that I am able to work with this unique group of people every day. Adolescents are careful about choosing who they let into their inner circle of secrets and needs; I am touched when I am chosen to be this person. Once there, adults must be able to work with whatever is thrown their way. Although it is difficult to address the multitude of challenges that a teen throws at me surrounding grief, I can empathize and do my best to help him or her move forward. My hope is that this resource book will provide counsellors with language, skills, and counselling techniques that are specifically adapted to meet the unique needs of a grieving teen. 13 Part Two: Literature Defining Grief and Loss To establish clarity, the terms grief, loss, and bereavement must be defined . Rando (1984) describes grief as the process of psychological , social , and somatic reactions to the perception of loss ; Jeffreys (2005) defines grief as a system of feelings, thoughts, and behaviours that are triggered when a person is faced with loss or the threat of loss; Corless, Germino, and Pittman (2003) state that grief as the complex emotional , cognitive, and perceptual reactions that accompany loss; Martin and Doka (2000) describe grief as the psychic energy that results from tension created by an individual ' s strong desire to (a) maintain his or her assumptive world as it was before the loss, (b) accommodate themselves to a newly emerging reality resulting from his or her loss or (c) incorporate this new reality into an emerging assumptive world, and Charkow (1999) states that grief is the emotional suffering caused by a death or bereavement. Grieving may occur for some aspects of every major life change as both positive and negative changes result in the process of letting go. Corless et al. (2003) define loss as the separation from a part of one ' s life to which one was emotionally attached, while Reeves (200 1) writes that loss occurs any time there are feelings of diminishment or restriction. Loss includes both physical (tangible) loss, such as having a friend die or losing a possession, and psychosocial (symbolic) loss, such as getting a divorce, a job demotion, or moving to a new town. Martin and Doka (2000) remind us that for every loss there will also be a secondary loss. For example, the death of a person may encompass a wide range of losses in its wake, such as the loss of other, dependant relationships with in-laws and friends , loss of income, and loss of hopes. Counsellors need to be aware of these 14 secondary losses as each Joss will need to be identified and mourned. Bereavement is the state of having suffered a loss. Jeffreys (2005) defines bereavement as a cultural/social role or condition for a person who has experienced a death and engages in cultural rituals and behaviours associated with death. Corless et al. (2003) state that the bereavement process is comprised ofthree elements: loss, grief, and resolution. Grief is a reaction characterized by a departure from normal life functioning, including crying, raging, and confusion (Archer, 1999; Jeffreys, 2005). It is expected that people who have suffered some form of loss will grieve; however, reactions can become dysfunctional. When levels of depression, anger, and/or guilt become extreme or prolonged, the griever is at risk for both physical and emotional illness, and professional assistance is recommended. Grief is dynamic, changing from morning to night and from week to week. The complexities of an individual ' s grief are rooted in the ethnic and cultural practices which have been taught surrounding how one is to act as a mourner, speak about a death, or express feelings of grief (Charkow, 1999; Jeffreys, 2005). For example, a counsellor may feel that she has not helped her client get in touch with her grief if there are no tears present, when, in fact, the client may have come from a background where grievers do not cry uninhibited in public. For example, a counsellor who carries with him a religious belief that a death was part of a spiritual plan and that the deceased is now at peace may not connect with a client such as a young mother who gave birth to a stillborn baby. Intuitive and instrumental grief. Martin and Doka (2000) identify two distinct major patterns of grief, intuitive and instrumental , and a third blended pattern combining elements of both . These patterns 15 vary in two general ways; by the griever' s internal experience of the loss and the individual's outward expressions of that experience. Patterns, or styles, of grief differ according to the direction taken by converted, grief-generated energy, as well as by the external demonstration of that energy. Internally, the cognitive and affective domains are where differences are experienced. The intuitive griever puts more energy into the affective domain and invests little into the cognitive. Grief consists of profoundly painful feelings often expressed through crying and the desire to share inner experiences with others. The instrumental griever directs most of the grief of bereavement into the cognitive domain rather than the affective. Painful feelings are tempered as grief becomes more of an intellectual experience. Instrumental grievers may channel energy into activity, and may also prefer to discuss problems rather than feelings . Thus, it is the degree to which the griever' s thoughts and feelings are affected that accounts for the differences between the patterns. Exactly what a griever is feeling cannot be directl y observed, it can only be inferred by observing how the individual expresses his or her experience. In particular, the griever' s desire for social support, the need to discuss feelings , and the intensity and scope of activities are varying ways of expressing grief and are often important in distinguishing between patterns. These expressions of grief usually reflect choices that the griever has made or is making to adapt to his or her losses. Intuitive and instrumental grievers usually choose different primary adaptive strategies. These primary adaptive strategies are the principle ways of expressing grief as the griever assimilates and adapts to his or her losses over long periods of time. The choices of how to grieve differ according to the pattern of grief as grievers use additional , secondary adaptive strategies at various times under various 16 circumstances. For example, intuitive grievers may choose additional strategies that enable them to accomplish tasks requiring planning, organization, and activity, all expressions more common to their instrumental counterpart. Alternately, instrumental grievers need to find ways to express their feelings about their losses as this type of griever is less familiar with strong feelings. Grievers adopting a blended style of dealing with loss are less likely to be identified with a specific primary or secondary adaptive strategy. These grievers choose strategies that are more evenly balanced reflecting balance between the cognitive and affective responses. Understanding the patterns and needs of both intuitive and instrumental grievers is crucial when working with teens as many will believe they should be a certain type of griever, yet will experience grief in a very different and perhaps confusing way. Some teens will need to cry, but find they are having difficulty doing so. As the counsellor, suggest that he tries to let it go in the shower. No one hears or sees a good cry in the shower, or sees any evidence afterwards. Many would say that females are more likely to be intuitive grievers and males are more likely to be instrumental grievers. While this may occasionally hold true, it is not always the case and can further complicate a teen's grief. A fifteen year-old male who has recently lost his father may feel pressure amongst his peers to grieve in a more instrumental way, yet truly feel more connected to grieving intuitively. Now he not only has to deal with the loss of his father, but he is also both grieving in one manner publicly and another privately, or perhaps feeling like he is being ostracized by his peers. Sometimes we assume that teens will find comfort from their peers, but when it comes to death, this may not be true. Many bereaved teens are actually greeted with indifference by their peers (Wolfelt, 2003). Unless their friends have 17 experienced grief themselves, they present feelings of helplessness by ignoring the subject of loss entirely, or worse, some peers may be intentionally cruel. Grief as a Whole Grief can be described as a natural human reaction, since it is a universal feature of human existence (Archer, 1999). Much research has been done on the psychological processes of grief including the brain' s stored memories or schema' s in comparison with the perceptions of the outside world; if the balance is off, alarms bells ring therefore initiating a person ' s grief response, which could range from crying and sadness to depression and psychosis (Bowlby, 1969; Archer, 1999; Horowitz, Bonanno, & Holen, 1993). Established patterns of life may end abruptly as a result of accident or illness. The external world changed suddenly and irrevocably, the inner experience of what has been lost remains intact and cannot change quickly or easily (Archer, 1999). What has been called normal grief encompasses two major components; an acute episode and a chronic background disturbance (Parkes, 1985). The acute episode involves feelings of restlessness, anger, pining, and anxiety, and closely resembles ' separation anxiety ' of young children. The chronic episode may include lasting feelings of dejection, loss, any sense of purpose or meaning in life, withdrawal, difficulty concentrating, and changes in memory, appetite, and sleep. Remember, people move through grief under a number of diverse circumstances, including losing a job, experiencing divorce, or sustaining a disability (Archer, 1999; Parkes, 1985). No matter what grief experience an individual has had, many ways of living and coping with problems has to be relearned (Parkes, 1985). 18 Tasks of grieving. The process of grief and healing is not uniform and does not follow certain rules. However, in order to gain understanding and clarity at a time when none exists, many have accepted William Worden's (2002) documented four tasks of grief to aid in understanding. Task one: To accept the reality of the loss. The initial news of a death is usually shock and disbelief. These feelings are slowly replaced by a dawning recognition of the reality of what has taken place. Although tremendously difficult, we are gradually able to acknowledge that the deceased is gone from our lives forever. When the death has been prolonged, the griever may be less likely to get stuck in the denial of the reality of death. This task is complicated when the death has been sudden or violent, and the griever may be more likely to get stuck in denial. Obvious forms of denial can include discussing the deceased in present tense or retaining his possessions, while more subtle denial can include denying that the relationship with the deceased had any meaning in an attempt to mitigate the significance of the loss. When the death occurred by suicide, some grievers may wholeheartedly deny it as the cause of death, and insist that the death was by accident. Task two: To work through the pain of grief. For many people, the normal feelings of grief are sad and uncomfortable. From a variety of life experiences we are all familiar with the sadness, anger, hurt, emptiness, and loneliness that accompany loss. An unexpected death may also carry the pain and regret of unfinished business as well as feelings of guilt that perhaps we could have done something to prevent the death. More specifically, homicides leave the griever with fear and concern about violence and safety, 19 while suicide often burdens the griever with feelings of responsibility for the death. Ignoring these feelings does not make them disappear, they are simply stored up and the griever will be confronted with them at a later time. Acknowledging and talking about these feelings gives the griever the opportunity to understand them and put them in perspective. Task three: To adjust to an environment in which the deceased is missing. This task is defined by the rearranging and restructuring that takes place as the griever identifies and fills the roles formerly occupied by the deceased. When the deceased played an important role in the griever's life, he may be left feeling like he has lost a part of himself, therefore making this task difficult to move through. The readjustment takes place over time as the griever comes to terms with the loss and fills both the symbolic and concrete gaps that the death has created in his life. Task four: To emotionally relocate the deceased and move on with life. The resolution of the work of grieving takes place when this fourth task is completed. This task encompasses the moving away from the feelings of loss and longing, to being able to hold the memory of that person in our hearts. The deceased becomes a part of our lives in a way that allows us to go on living without them. Although sadness will still surface, we are less conscious of the loss as we move through daily tasks. Grieving a serious loss like death or divorce may take years to complete. For some, the first year can be the easiest. The youth is numbed by the loss, and family, friends, and teachers tend to be the most understanding and supportive during this time (Marta, 2003) . The magnitude ofthe loss may not set in until the second year, when many adults assume that the youth has finished grieving. The pattern of grief as well as the time to 20 move through the stages of grief will be different for every youth. When beginning work with a new client, a counsellor may wish to use a tool such as the Grief Pattern Inventory, (see Appendix 1), to assess a client's current state of grief. It is not an exact predictor, but may provide the counsellor with some insight as to where the youth sits on the continuum of grief as well as what type of griever the youth is. Developmental Concerns Adolescence is described as being a time of dramatic and complex changes for the whole family, a time when children are now seeking independence and autonomy from their parents (Molinari, Everri, & Fruggeri , 201 0). Adolescence, as conceptualized in our Western culture, is suggested as including three phases; early, middle, and later adolescence (Doka, 2000). Each phase includes a number of developmental tasks marked by an increased sense of self, acceptance of responsibility, and direction in life. Developmental tasks facing early adolescents, ages ten to fourteen, include coming to terms with their changing bodies, learning new social skills with peers, mastering more difficult academic material, and gaining increasing autonomy from parents. Middle adolescents, ages fifteen to seventeen, are expected to demonstrate increased maturity and decision making, spend more time away from home and with their peers, and rely more on their peers in times of need. Additionally, many in this developmental stage are also learning how to manage school , life, and part-time work. Later adolescence extends from eighteen to approximately twenty-two. In this last developmental stage, adolescents are separating from their parents, gaining independence, and entering into intimate relationships. Fulfilling tasks specific to this stage are much easier if the youth has completed the developmental tasks of the previous stages. Bereavement is a type of life 21 crisis; a crisis that can pose both a threat and an opportunity for growth . For adolescents, the life crisis of bereavement places obstacles in the way of fulfilling the necessary developmental tasks of each phase. If coped with successfully, moving through the crisis can lead to greater maturity and a greater appreciation of life; however, it can also leave youth with diminished self-confidence and grasping for purpose well into adulthood (Doka, 2000). Loss is an intensely individualized experience. Given the understanding of human growth and development that the field has, some general predictions about the concept of death and the grief reaction can be made based upon common patterns of cognitive and emotional maturity at various stages of childhood and adolescence (Schoen, Burgoyne, & Schoen, 2004). Youth receive death education by watching both the actions and inactions of those around them as they respond to death and loss. Youth grow up in society, learn from it, and absorb its wisdom, myths, practices, anxieties, and shortcomings. Much of youths ' learning is done through observational learning called modeling (Corless et al., 2003). Models can be real people, or symbolic, verbal, audio, or visual representations. Modeling is recognized as one of the most powerful means of transmitting values, attitudes, and patterns of thought and behaviour (Corless et al. 2003). Youth will adopt values and beliefs from significant adults in their lives, such as parents, teachers, and public figures including athletes, and famous actors. They also learn from their symbolic environments. Knowingly or unconsciousl y, adults pass their acquired fears along to their children , including fears about death (Kubler-Ross, 1983). Attitudes about death are learned when youth visit a cemetery, take part in a memorial service, or observe adults 22 discussing the subject. Much of this education is informal and unplanned, but becomes part of the youth's schema, and will stay with her or him into adulthood. Bereaved youth. The experiences of bereaved youth are unique, yet are rarely focused upon in books on bereavement. Teenagers in particular fall between the two main levels of bereavement research, child and adult, yet they are a vulnerable group in need of proper support, understanding and recognition in coping with death (Abrams, 1993; Doka, 2000; Schoen, Burgoyne, & Schoen, 2004). Immense pressure is placed on youth who are grieving, often making it impossible to grieve. Society has taught many adults not to express their grief in certain contexts such as public settings or at work, while children are often unaware of such rules and may speak freely of their loss to strangers or ask questions of external adults (Doka, 2000). Adolescents find themselves somewhere in the middle. They are often in situations where they must suppress the expression of their grief, yet may still feel the need to reach out and speak to an external adult about their feelings. Bereaved adolescents often have to take on new family responsibilities that do not allow time for them to properly express their grief. Youth often struggle both with how to grieve as well as how to grieve in an unaccommodating world, often putting it off in order to get through the next day, therefore delaying grief (Abrams, 1999). Doka (2000) argues that youth typically manage the normative crisis of adolescence by facing one issue at a time. The intensity, duration, and all-encompassing nature of grief does not usually allow normative issues to be placed on hold while the youth deals with bereavement. There is also a danger of focusing solely on grief and not accomplishing normal developmental tasks. Areas that 23 are of particular concern for grievers in this age group are; how their sexuality is affected, problems of being expected (if the eldest) to support surviving family members while they themselves are heartbroken by grief, and engaging in self-destructive behaviours (Abrams, 1993, 1999, Parkes, 1985). Generally, the loss of a parent in childhood has the most profound and enduring influence on a person's life. Bereavement in childhood has been implicated as an underlying cause of depression and suicide attempts later in life, such as during the teen years (Doka, 2000). According to Eppler (2008), Haine, Ayers, Sandler, & Wolchik (2008), Raveis, Siegel, & Karus (1999), and Weller, Weller, Fristad, & Bowes (1991 ), children who have lost a parent are at increased risk for social impairment and /or psychopathology, display lower levels of self-esteem and selfefficacy, and may also experience depressed states and increased levels of anxiety. These consequences of parental death may be present during the immediate post-death period, but can extend into adulthood as well. Children mourn according to their current developmental level , and may postpone future grief work until they reach a new developmental stage (Charkow, 1999; Eppler, 2008). This means that a high school teen may be experiencing unexpected levels of grief as he is just now at a new developmental level needs to work through grief experienced during his childhood (Goldman, 2004). Behavioural changes in grieving youth are normal reactions to a significant loss. When unable to express their feelings and emotions, grieving youth may act them out, which can be frustrating for adults surrounding the youth, but can also provide insight into the youth' s emotions. Marta (2003) and Wolfelt (2003) have outlined both normal and non-normal responses specific to age grouping. For youth aged eleven to fourteen typical responses to loss include becoming angry and ashamed, dramatic mood shifts, 24 egocentrism, limit testing, loss of sense of identity, distracted at school, and grades drop. Youth may seek out friendships with older adults such as a teacher, coach, or counsellor in an attempt to stabilize their lives. Non-typical responses to loss include becoming fixated on the idea of further loss, suicidal thoughts, and academic failure or gross overachievement. Any crisis or loss can cause intense, ongoing fears that may disrupt normal activity and recovery. For youth aged fifteen to twenty typical responses to loss include rebelling against family norms, egocentrism, increased moodiness, and impulsiveness. The youth may become negative and cynical and become angry. Often, youth attempt to satisfy their emotional hunger with material goods, but underneath they are still frightened by the prospect of being left alone. Non-typical responses to loss include significant increase in sexual activity, eating disorders, drug and alcohol abuse, gang activity or legal trouble, suicide and depression. A youth ' s increased sexual awareness is often further complicated by the fact that they are engaging in risky sexual behaviour, not caring about unwanted pregnancy or sexually transmitted infections. Some female youth even believe a pregnancy is desirable as some hold the belief that things will be better as this little person will love them unconditionally. Indulgent eating or being turned off of eating are normal reactions when youth are under stress or suffering from grief. Concern should be raised if a teen appears to be using the consumption or non-consumption of food as way to re-gain some control in her life. Drugs and alcohol are unfortunately readily available and will aid the youth in numbing the pain they are experiencing, resulting in an escape from their reality. The reasoning behind why some youth turn to gangs and crime to cope with their losses is as diverse as the youth themselves. For some its a shouting for attention, some may be so numb 25 within themselves they are trying to create some spark of internal emotion, some may see it as a way of getting even, and others are simply trying to find a place where they feel they now belong. Any talk of suicide must be taken seriously and be properly evaluated. For some youth, the thoughts will be real and the intent there as they may feel so lost in their new world that they have decided they don't want to be a part of it. For other youth, they may be saying they want to die, but only because they are hurting to see a lost loved one again and this is the only way to be reunited. Depression can come into play at any age, and can greatly interrupt the tasks of grieving as well as developmental tasks. When death is a result of sudden, traumatic loss, the immediate shock and chaos can lead toward complicated grief (Clements, DeRanieri, Vigil, & Benasutti, 2004; Doka, 1996; Feigelman & Gorman, 2008; Parkes, 1985; President & Fellows ofHarvard College, 2009). Many survivors place importance as to the manner of death of their loved ones, further affecting the grieving process (Feigelman, Jordan, & Gorman, 2009). Survivors of homicide and suicide loss face additional challenges such as shame and guilt as these types of death often carry negative stereotypes (Clements, et al., 2004; Doka, 1996; President & Fellows of Harvard College, 2009). Regardless of death, divorce, break-up, move, or any other situation that has led to a youth experiencing some form of grief, teenagers as a whole are a unique bunch. For adults, it seems there is a constant learning curve to keep up with today's teens, even though we have all also experienced our own teen traumas and dramas. As a counsellor working with youth experiencing grief it is important to remember that their experiences will be different than ones of your own past, but there will also be a number of similarities to draw upon (see Appendix 2). 26 Connecting with Schools In today' s society the responsibility for the welfare of children is deemed to rest with parents, teachers, caregivers, and a variety of other professionals who they encounter (Holland, 2008). The impact of loss is not straightforward, or predictable, and schools are in a unique position to help grieving youth. Loss affecting youth will ultimately cross the boundary between home and school and it is helpful when teachers, counsellors, and other staff and classmates are supportive, understanding, and caring (Corless et al. , 2003 ; Davidson & Doka, 1999; Goldman, 2004; Reid, 2002). A sensitive teacher or counsellor who is able to acknowledge the needs of the youth is vital in maintaining the feelings of safety that the school may provide, thus fostering an environment that will help with healing. When a youth' s parent or sibling has died, family who would normally provide nurturing care are often so devastated by the loss that they are unable to provide sufficient support, it therefore becomes especially important that the school assist the youth during this crisis period (Charkow, 1999; Corless et al. , 2003; Eppler, 2008). Youth experiencing grief are especially at risk as many may cope in negative ways such as becoming involved in substance abuse, promiscuity, or criminal activity (Holland, 2008). Even people who seem to have a negative connection to the deceased may experience grief (Davidson & Doka, 1999). An example of this would be a grade eight girl coming in for counselling after the death of a same-aged peer, not a girl she was friends with, in fact they may have been lightly bullying each other. The girl is feeling guilt that she may have contributed to the other girls ' sadness ' and also confusion as she herself is experiencing grief even though she would not consider them friends. She is unsure how to act in the hallway, especially when she is faced with the deceased girl's friends. 27 Schools must also consider how youth will receive support when returning to school after a type of loss. While curricular is important, youth who are carrying emotional pain may not be able to carry on with learning, and the role of empathetic caring is of primary concern (Reid, 2002). Schools are also occasionally in the distinct and unfortunate position of being a second epicenter for loss. Many losses, while having the largest impact on the families, also have significant devastation in the schools, leaving both staff and students experiencing grief. The death of a peer can destroy any sense of invincibility that youth may hold, igniting reactions ranging from rage, to denial and despair (Corless eta!. , 2003 ; Haviland, 2008). Complicated questions such as; who has the right to miss class, who should be at the funeral , or can I cry with my students move through the minds of many. A school must be prepared for mass grief situations. It is important that administration and counsellors have an established framework ready to implement when a school is experiencing grief. See Appendix 3 for an example of such a framework. Children and teenagers will face loss, and each will grieve differently. The teaching and role-modeling that each has been raised with will direct their path of grief. Some youth will have healthy attachments to parents, others will have been removed from their homes due to abuse, and still others will have been dropped into a foreign culture where they have no close friends. Consequently, counsellors must continue to research and develop their professional skill-set to better manage and serve the diverse youth population that is put before them. Youth don 't leave their grief at the door; it comes right into the classroom with them. Sometimes, concerns that youth suppress at home show up at school. Teachers 28 have reported that they can often predict as far as a year ahead of time when a student' s parents are getting divorced or when there is some other family trauma occurring. Their divination has nothing to do with extrasensory perception, rather is based solely on changes in the child. Following are warning signs that teachers have observed that signal a student might be experiencing turmoil at home. Table 1. Grief Goes to School: Warning Signs - Often leaves lunch, gym clothes, or assignments at home and wants to call home almost as soon as s/he arrives at school. - Has difficulty concentrating. Her homework and tests are incomplete. Grades decline. - Is very emotional or cries easily. - Acts out his feelings, becoming the class clown, truant, or a discipline problem. - Daydreams. She is preoccupied and often forgets assignments, game dates, and so on. - Has a disorderly locker or desk or turns in messy homework. The external messiness seems to coincide with his internal confused, "messed up" feelings. - Withdraws from school activities and social activities or sports. (Marta, 2003 , p. 34) 29 Part Three: Grief Manual For many, the teenage years are a time of joy, exploration, experimentation, and a certain camaraderie among friends that is entirely unique. Adults often reminisce fondly about this time in their lives. A major loss, during this phase of life, can change all of this, whether it is the death of a parent or sibling, or perhaps a parents' divorce; suddenly the life that existed has dramatically changed (Fitzgerald, 2000). In our society, it is common for the sorrow that follows a death to be hidden behind closed doors or as memories within the bereaved person's mind. The world of grief can be a lonely and secret place, often misunderstood by those who have not personally experienced the pain of an overwhelming loss. Survivor responses will vary based on age, cultural and religious beliefs, and/or past experience with loss, and may be related to one's available tools of adaptive coping methods that have worked previously (Clements et al., 2004). Cultural differences can vary greatly according to a study done by Lobar, Youngblut, and Brooten (2006). A few examples of differences they found are: Latino death rituals place high importance on spirituality and the belief that there is a continuing relationship between the living and the dead through prayer and gravesite visits, some Caribbean nations believe death rituals are governed by the saints as told by a holy man and often include animal sacrifice, Mexican children are socialized to accept death and celebrate the Day of the Dead to remember and honour, and Hindu people bathe the deceased, massage with oil, redress in new clothes, and cremate the body before the new sunrise to facilitate the soul's transition from this world to the next. It is important for the counsellor to listen and accept how a client of a different culture may wish to speak of or symbolize a loved one's death. A client who has immigrated to Canada from a nation 30 with different and specific cultural practices surrounding death may also be working through grief surrounding challenges of how they can properly honour the deceased if their current location does not allow them to perform certain rituals. Rando (1993) stated that complicated grief can occur when the grieving process has had some compromise, distortion, or failure in one of the ' six R ' s of mourning' : recognizing the loss, reacting to the separation, recollecting and re-experiencing the deceased and the relationship, relinquishing the old attachments of the deceased and the old world, readjustment to move into the new world without forgetting the old, and re-investment into the current world and life. Counselling Frameworks Existentialism emphasizes individual existence, freedom , responsibility, and meaning (Spillers, 2007). According to the existentialist viewpoint, events in life bring us face to face with the fundamental realities that infuse the human condition. Such events include; death - we are all going to die, freedom/responsibility- we are free to make our lives what we want, and we bear full responsibility for our choices, lonelinesswe are each ultimately alone in the universe, meaninglessness- life has no inherent, predetermined meaning (Spillers, 2007). How each person embraces these challenges and finds meaning in his or her life becomes a part of his or her own personal journey. The existential ideas of death, freedom/responsibility, loneliness, and meaninglessness complement models of grieving because grief is one medium through which people work out their existence (Spillers, 2007). An existential framework can offer a counsellor a vantage point from which to understand a client' s inner struggles to make sense of the loss. As stated by Yalom (1980), death is the most obvious and inescapable fact of life, 31 everyone is going to die. Our modem culture often does not embrace or acknowledge death, which can lead to fear and anxiety surrounding death beginning in early childhood. To avoid confronting this anxiety, people may fill their lives with distractions and diversions, whereas living with death awareness invites people into a ' mindfulness of being' encouraging them to have new priorities and values and not taking life or relationships for granted (Yalom, 1980). As a counsellor working from an existential framework part of the work necessary to complete with a client experiencing loss and grief is to help the client understand and realize that many of life's circumstances lie outside of our personal control, and although we are not to blame for these events, we do bear responsibility for choosing our reactions to them . Each person' s response and attitude toward the presenting life circumstance will either contribute to or help mend the suffering that comes with loss. Another useful approach to grief therapy is Carl Rogers ' person-centered therapy. Rogers (1951) began with two structures, organismic experiencing and self (Fernald, 2000). Experiencing refers to everything potentially available to awareness occurring within the organism, including all sensory experiences, conscious, and unconscious. The self refers to the portion of the experiencing that becomes the "I" or " me," which can be both external and internal. Rogers also outlined the need for positive regard. Healthy development throughout the lifespan requires that significant others provide the qualities of positive regard, such as; warmth , caring, respect, and sympathy (Fernald, 2000). It is vitally important that a counsellor provide and emulate these qualities when working with a youth experiencing grief as, due to circumstance, many may not be receiving these necessary items from their loved ones. A counsellor utilizing 32 this framework is also completely open to following the youth's grieving needs. Statements such as, "boys don 't cry," or "be strong for your mom," would not be said as they put limitations on how someone is ' supposed' to act when they are grieving. Properly utilizing positive regard in counselling allows the youth to use the relationship for growth and person development; the counsellor is simply there to provide support in times of need. This person-centered approach can be so useful when working with teens experiencing grief as part of its true core is change (Fernald, 2000). Change encompasses both physical changes throughout counselling such as; crying, trembling, sighs, tension, relaxation, new roles, new relationships and emotional changes such as; accepting the loss, setting new goals, and looking at the future. Additionally, counsellors using this approach would always keep their responses genuine, empathetic, and displaying positive regard while not offering interpretations or asking many questions. Cognitive-Behavioural Therapy, (CBT), is not a form of therapy often paired with grief and loss work, however, it is useful when working with a youth who has suffered some form of traumatic grief (Brown, Pearlman, & Goodman, 2004). A youth suffering from traumatic grief may be overwhelmed by the trauma response and be unable to accomplish the normal grieving tasks (Brown et al. , 2004). Symptoms of traumatic grief are very similar to those ofPTSD including; re-experiencing, avoidance, arousal, a yearning for the deceased, and a lack of acceptance of the death. Further symptoms may include anxiety, depression, externalizing behaviour problems, changes in home environment, and physical health complaints. Counselling using the CBT model attends to a diversity of symptoms including cognitive, physiological, and behavioural responses to a variety of emotions (Brown, Pearlman, & Goodman, 2004). The predictability of 33 CBT is often valued by clients who feel out of control due to their bereavement. The skills that are taught during CBT, like controlled breathing, validity testing, and writing in a journal are portable, allowing the youth to utilize these skills wherever he or she may be. Considerations Although the focus of this project is the support of youth who have experienced loss, one must first look at attachment, beginning with one of the attachment research founders, John Bowlby. Bowlby' s Attachment and Loss (1969) outlined the manner in which patterns of grieving are influenced, positively and negatively by the experiences one has in his or her family of origin. Since his original research, numerous others have continued to explore how origins of attachment are linked to the consequences of separation (Archer, 1999; Jeffreys, 2005 ; Parkes 1985 ; Stroebe, 2002; Swan & Scott 2009). Youth who have secure attachments are able to develop close relationships with others, express their thoughts, feelings and needs openly and feel valued and self worthy (Swan & Scott, 2009). Consequently, youth whose parents are emotionally or physically unavailable, intrusive, or abusive may develop insecure attachments. Findings continue to confirm that children are capable of showing grief reactions as soon as they have developed attachment relations (Archer, 1999). Parkes focu sed on bereaved individuals and led us to understand death as the most extreme form of relationship deprivation that a person can experience (Stroebe, 2002). When a person is not able to restore contact with a person or significant object, the reaction is protest, agitation, and separation anxiety, all behaviours identified as grief reactions (Jeffreys, 2005). As there can also be a deep 34 yearning for reunion with the lost person it is important to note that this can be misinterpreted as suicidal ideation. Clinical case illustration. Matt, a 17 year-old boy has come to see his school counsellor. Last week one of his best friends , Sean, was killed in a car accident. The accident was not his fault, he was simply driving over to pick up Matt for their evening hockey practice. Matt is devastated and harbouring a lot of guilt as Sean was on his way to pick him up. Matt is crying and saying things such as " Why didn't I drive that night?" and "If only he ' d been 1 minute later." As a counsellor, these are phrases that you would expect to hear from a grieving teen, but then Matt says "I want to die to." Now flags are raised, is Matt saying that he is feeling suicidal, or is this how he is expressing his grief? Also, how would the counsellor do a suicide assessment without escalating the feelings and while respecting the place Matt is in? The phrase "I just want to die," must be explored, but it may not mean that the youth is feeling suicidal; simply he or she can see no other way to reunite with the person who has been lost (Fitzgerald, 2000). It may be difficult for the youth to begin to feel happy again, or to even think about future events such as graduation and weddings. It is important that the counsellor explore these feelings of death with the youth, gauging if he or she is only displaying feelings of longing or if he or she is spending time thinking about and planning his or her own death . There is a distinction between counselling and befriending. Counselling is working with a person who has undergone training and supervision in order to obtain the skills necessary to support the bereaved, befriending requires little or no special training, but is 35 probably needed most by bereaved people (Parkes, 1985). When there is a more ' public' death in a high school , such as a suicide, there always seems to be questions about who should be out of class or should the school allow a group of grade nine girls to skip math in order to sit together in a room, and perhaps we should. While there is a place for a trained counselor to aid a youth who is grieving, there is also a place for friends , as they are who will be with the youth when he or she walks out the doors of the school. A friend can be a monumental support for a youth experiencing grief, but the friend may in turn need some guidance in order to provide support. Friends may be worried about letting someone down, not knowing what to say, or saying something that might make things worse. As a counsellor, you may want to provide some background support for the friend so he/she is able to communicate effectively and does not become overwhelmed (see Appendix 4). Additionally, it is important that the counsellor ensure that the bereaved understand that her friend is only doing her best, and some of that may come across incorrectly. Others, both adults and friends , may feel uncomfortable and inexperienced in aiding a youth through a loss, consequently saying something that hurts instead of helps (Wilken, 2006). Explain this to the youth and allow her to discuss it with you. You may wish to help provide language tools such as "I'm not ready to talk about it yet," that she can utilize in the future if others are making comments or asking questions that are causing further hurt or anger. At the other end of the spectrum are the grieving teens who carry on without any noticeable change in their personality or lifestyle. Many adults will breathe a sigh of relief and say, "Thank goodness, this kid ' s fine ," but counselors should recognize that they likely aren 't fine (Marta, 2003). These youth need help too, and are often harder to 36 reach than those who are in open rebellion because rather than dealing with grief and its emotions, they' ve stuffed their feelings deep inside. The concern is that a youth who is unable or unwilling to acknowledge their pain may never fully work through their grief, and it will haunt them throughout their lives (Marta, 2003). A youth ' s grief should never be ignored. When teens suppress the powerful emotions of grief they use an incredible amount of energy. This energy is diverted away from school, sports, hobbies, jobs, friends, and other positive opportunities in their lives. It is part of their potential , and it is lost forever. Marta (2003) continues to argue that repressed grief does not dissipate, but simmers within. She states that grief is sometimes expressed through chronic health problems and will invariably subtly shape and influence a youth as she grows up and becomes an adult. Submersed grief may colour a youth ' s outlook on life. At school , work, or with friends she may be cynical and treat even heavy matters like a joke. She may maintain a careful, calculated distance and may carry a fear of intimacy that will ultimately affect her decisions surrounding serious commitments and long-term relationships. Most adults can recognize the more obvious symptoms of grief, such as crying and sadness, but would they recognize the subtle cries for help? Most behaviour changes in grieving children and youth are normal reactions to a significant loss. Unable to express their feelings and emotions, grieving teens act them out. This can be frustrating for the adults in the youth ' s life, but it can also provide insight into the teen ' s emotions. Dramatic shifts in demeanor can indicate unresolved issues of grief and anger and should be viewed and handled in that context. Behavioural changes may appear immediately after a Joss, but more often they don ' t surface until several months later (Marta, 2003). 37 Some telltale signs of normal behaviour changes for youth are: eleven to fourteen years, mood shifts and a struggle for identity ; fifteen to twenty years, bravado disguising fear. Mood shifts may appear as significant differences in dress and appearance, withdrawing from friendships, isolating oneself to communication through technology only, such as chat rooms. When the family structure or status changes, youth in this age group often become angry and ashamed of being different. Their moods may shift dramatically and their emerging sense of identity may blur. They may become distracted at school , grades will drop, and as they are seeking to stabilize their lives, they often seek friendships with other adults, such as a teacher, coach, or neighbour. Late teens and young adults often respond to grief by rebelling against family norms. They may become negative, angry, and cynical. Often, they try to satisfy their emotional needs with material goods demanding the latest in phones, music players, etc. , and expensive name-brand clothing. Underneath this bravado, many are still children at heart. They are alarmed at the thought oftheir loss and frightened by the prospect of being alone. As a whole, many people suffering from grief will ask the same question, "Will I ever feel okay again?" Strong feelings are a good sign that someone is healing from the pain of their loss, but many have trouble expressing these feelings (Wilken, 2006). Strong emotions make people feel out of control , vulnerable, and scared, but expressing these feelings is essential to start healing. Grievers must give themselves permission to face their loss, and allow emotions to heal , and sometimes they need help to gain their own permission. It is okay to cry, okay to hurt, okay to be angry, and okay to mourn the loss of all that was looked forward to in the future. 38 Structure This resource book covers four types of loss: (1) Loss and Family; (2) Prolonged Loss; (3) Traumatic Loss; and (4) Other Losses. An overview of each category is provided including descriptions of each type of loss to clarify the type and terms being discussed. Additionally, each section includes; special considerations relating to the type of loss, counselling interventions and language, and examples of exercises/techniques that may be helpful for the griever. Specific acknowledgements and interventions that can be performed at the school are also outlined, as the school will hopefully become a place of support for the adolescent griever. Suggested supplemental readings and appendices are provided. The focus is on the adolescent as the griever, although many other people including teachers and staffwould be grieving surrounding any of these deaths. The format for each section of the resource book includes: );>Overview );>Special considerations );>Counselling language, interventions, and techniques );>School considerations );>Supplemental readings 39 Loss and Family This section of the resource manual is on the adolescent' s grieving process when suffering the loss of an immediate family member. This could include; grandparents, parents, siblings, or another person the adolescent would consider as being a family member. Support systems are essential for a teen that is grieving. When the death being grieved is that of a parent or sibling, the surviving immediate family may not be able to provide the support needed by the teen. Parent Death Youth will revisit the meaning of a parent's death many times over their lifetime. Whether the death occurred years ago, or is very recent, an adolescent who has lost a parent will continue to work through her grief throughout her high school years (Doka, 2000). She will experience her loss in different ways as she reaches different milestones in her life such as starting a new school , getting a driver' s license, graduating, etc. Rebecca Abrams ( 1999) shared that, "the experience showed me all too clearly how little support exists for people, particularly young people, struggling with a parent' s death" (p. xi), this statement is enough to spark the need for a guide such as this one. For youth, losing a parent creates a period of stress and sadness and can be an extremely isolating experience (Abrams, 1999; Eppler, 1998; Clements et al. , 2004). Clinical case illustration. A concerned teacher asks the school counsellor to meet Sara, a fourteen year-old girl who has just transitioned to her first year of high school. The teacher says that Sara seems reserved in class, often near tears, and just doesn 't seem to have any ' spark,' even when working with her friends. Upon meeting Sara, the counsellor discovers that Sara lost her mother when she was 6, 40 and she is feeling isolated as she would have turned to her mom for advice and comfort as she entered this new phase of life. Sara was told that her mother died in a workplace accident, but she still has a number of unanswered questions surrounding her mother' s death. She says that the one time she asked her father about the accident, his reply was " Shouldn ' t you be over this by now?" Her father has since re-married, a woman Sara says is OK, but this woman has never told Sara that she loves her. Though the counsellor may believe that it is Sara' s right to have her questions answered, he/she must remember that Sara is the client and the counsellor cannot fully enter into the family ' s personal business. Sara agrees to have weekly sessions with her school counsellor where the two of them begin to write letters to Sara' s mother and create a memory box; both activities seem to help Sara find some comfort. Friends who would normally lend support are often unable to do so as they do not have any experience; family members are experiencing their own forms of grief; and the hectic "normal" teenage life of exams, jobs, and maintaining poise all continue. Adolescents are particularly vulnerable when a famil y member has passed away as many are forced into roles of responsibility that were previously not theirs (Abrams, 1999; Abrams, 1993; Eppler, 1998; Goldman, 2004). Special considerations: Parent death. The death of a parent can be especially difficult for youth as this is often a time of conflict between parent and child, and there may be many issues unresolved when death occurs (Abrams, 1993; Fitzgerald, 2000). Teens are looking down the pathway that will be their futures , and this vision includes their parents growing old and becoming grandparents. A parent's premature death may 41 be viewed as the death of the teen's dreams for the future (Wolfelt, 1996). Teenagers and young adults are an especially vulnerable group when it comes to bereavement. This group is in need of proper support, understanding and recognition in coping with death. As Abrams (1993) states, the death of a parent at this age represents not only the loss of a central figure in a young person's life, but also a fundamental part of their personal identity. Losing a parent can destroy both their view of the world and their innate sense of self, therefore isolating them from friends and family and making all the normal business of young people seem remote and demanding. Many bereaved teens describe similar feelings that there was no-one to talk to, that no-one would want to listen to what they needed to say, and that articulating their feelings was risky as it might lead to a greater degree of isolation (Abrams, 1993). Following a parent' s death, unresolved tensions in the relationship can lead to acute feelings of guilt, regret, shame, unrealistic responsibility, self-hatred, and anxiety, all leaving the bereaved youth with an urgent need to resolve these difficulties, but neither the practical nor the emotional means to do so. The contradictory feelings towards the parent, which the youth now has no chance of resolving, can derail the process of mourning. It can be very difficult for youth to recognize that their behaviour prior to their parent's death was, in fact, normal (Abrams, 1993). Sibling Death Sibling. What does this word mean to you? The dictionary tells us that sibling means "each of two or more children or offspring having one or both parents in common ; a brother or sister" (Oxford Online Dictionary, 2011.) This definition, however, does not begin to capture the many meanings associated with the word. Siblings often share a 42 special bond and camaraderie that cannot be understood by parents. They share secrets, support one another, ally against others, and protect each other (Doka, 2000). When a sibling dies, a youth struggles with and then hopefully comes to terms with " it could have been me," and this can be frightening (Fitzgerald, 2000; Wolfelt, 2003). More so than with other deaths, it' s an early wake-up call to a teen's own mortality. Youth realize that they can die, but many do not usually believe it can actually happen to them Doka, 2000). When a sibling dies, they now have an understanding of death as universal , inevitable, and irreversible. Additionally, some parents will idolize a child who has died and the surviving sibling may feel unnecessary pressure to live up to higher expectations (Charkow, 1999). Adolescents will then work through the grief process in their own fashion. Parents may notice changes such as; irritability, mi sbehaving, decline or improvement in school work, regression of developmental tasks, fear, and loneliness to name a few. Clinical case illustration. When Rachael was 17, her older brother of2 years was killed in an accident involving alcohol. Rachael was a few months from graduation and immediately found herself alone and lost. Her parents were so overcome with their own grief that neither seemed to have time to be with her, and at the same time she felt silly that she needed them to be as she was almost an adult. In addition to the traumatic Joss, the family was struggling with how to answer questions and deal with judgmental comments surrounding the fact that alcohol was a contributing factor. Rachael didn't feel that her close friends could understand and support her, although she did feel that they were doing their best, so she sought out counselling. Years later, Rachael and her family have come to a place where they can reminisce 43 fondly about their brother and son, but many changes occurred as a result. Rachael's parents' marriage dissolved, another difficult time for her, but they have truly managed to remain friends and incorporate new partners into their whole family ' s' lives. Rachael will still state that she misses her brother every day. After a sibling' s death, the guilt that stems from normal sibling rivalry may be overwhelming. Bereaved siblings will benefit from opportunities to speak about their feelings, both at the time ofthe death and for many years afterwards. Years following a death, many siblings state that they still think about, miss, and even talk to their deceased brother or sister (Doka, 2000). It is common for siblings of a lost youth to be overlooked during the time immediately following the death. Sometimes it is assumed that the youth may need to be protected from what is perceived as a morbid situation, often it is due to the fact that their primary caregivers are in a state of trauma and are simply not able to extend themselves to help. This is where support networks can be helpful for the grieving youth (Worden, 2002). Special considerations: Sibling death. Intense relationships and attachments are formed between siblings. These relationships encompass competition , rivalry, Jove, anger, arguing, and friendship. Adolescents who lose a sibling may focus upon the negative interactions and feel a sense of guilt and responsibility for the death in some way (Schoen, Burgoyne, & Schoen, 2004; Wolfelt, 2003). This can happen easily when the death is the result of an accident, such as a car crash, but can also appear when a sibling dies after a prolonged illness (Doka, 2000). Siblings may also feel as if the child who died was their parents' faviourite child, and that they should have died instead. If these 44 feelings of inferiority were often present before the death, they are now compounded as both siblings and parents grieve the loss of their family member. Counselling Interventions and Techniques For many teens, the first special person in their life to die is a grandparent. If the teen was close to Grandma or Grandpa, this death can be a very significant loss and should be recognized as such. Often, people will say things such as, " She was very old and sick anyways" or "He lived a long, full life," but the fact that the grandparent was old does not take away the teen ' s right to grieve. Most other deaths that teens experience are sudden or untimely. Within the family unit this may include a parent dying of a heart attack, a sibling dying of cancer, or someone being killed in a car accident. The very nature of these deaths often causes the teen to feel a prolonged and heightened sense of unreality. Fear, panic, and withdrawal are common responses to sudden death (Wolfelt, 2003). An adolescent's emotions often take the form of rage after a sudden death, (family or friend) , especially if the teen feels there is someone to blame. An example of this would be if a youth ' s Mom was killed in a car accident by a drunk driver, the youth may express a desire to kill the driver at fault. As a counsellor, do not be frightened by this rage, it is a normal grief response and most youth know not to act on these impulses, however, some will need guidance in exploring the difference between feeling rage and taking negative action. Many teens will not be prepared for the death simply because they have not experienced death before. They may have many unanswered questions, but not know who they can ask. As a counsellor, be prepared for adolescents to ask specific and difficult questions such as: What does death look like?", "Do I want to be there when 45 he/she dies?", What ifl don ' t want to see the person who is dying, but my family is pressuring me to?'', and "What do they do with the body?" Knowing some of these answers in advance may help a grieving youth, and as the counsellor, if these questions are posed to you, you need to be able to appropriately and respectfully answer them. Depending on your relationship with your client and his/her family, you may want to begin by finding out what the family's plans are for the events leading up to and after the death . You could then assist the youth through these events utilizing the medical community to provide correct answers while remaining ever present to provide support as the youth processes these answers. School Considerations When a youth loses a parent or sibling, the school may take the brunt of the confusion, sadness, and anger as he tries to come to terms with his loss. Youth must have a place and people to reach out to, often this is not at home as other family members are also grieving, and so, it happens at school. When it comes to teen bereavement, many adults are uncertain as to how to approach this age-group and instead take refuge in the widespread beliefthat the young are resilient and will soon 'get over it. ' It is imperative that teachers are either able to receive adequate training and therefore feel more comfortable and be better equipped to listen to a grieving student, or be comfortable and confident to refer the student to the school counsellor. Supplemental Readings Reading will not help all people as they work through their grief, but some will find comfort in reading others ' accounts of simi lar experiences. Each section includes a selection of readings and websites that either I have found helpful in my research or have 46 come highly recommended by the grief counselling community. Some readings will be included in more than one section. Abrams, R. ( 1999). When parents die. 2nd Ed. London, EN: Routledge. Rebecca writes of her own evolving understanding of parental loss, as well as the experiences of various other teenagers who have suffered the loss of a parent. She writes of the continuing importance of the deceased parent in one ' s life and the critical role played by the surviving parent. She also discusses the impact of other types of loss such as divorce and adoption. Ajjan, D. (1994). The day my father died: Women share their stories of love, loss and life. Philadelphia, PA: Running Press. A collection of personal memories written by women who lost their fathers as adolescents. They write about their personal father/daughter bonds, and how they worked through their grief. Davies, B. (1999). Shadows in the sun: The experiences of sibling bereavement in childhood. Philadelphia, PA: Brunner/Mazel. Betty introduces the reader to the importance ofthe relationship between siblings and her understandings of what children know about death. She writes ofthe common responses of youth who have lost a brother or sister, as well as outlining key areas that will have long-term impact on the surviving sibling. Edelman, H. (1995). Motherless daughters. Reading, MA: Addison-Wesley. Hope shares the voices of women who have lost their mothers; women with a void in their lives they cannot seem to fill. Their common experiences help motherless daughters understand how this loss will shape their lives forever. 47 Fitzgerald, H. (2000) . The grieving teen. New York, NY : Simon & Schuster. Helen writes of the special needs of adolescents struggling with loss, while also providing tools they may need to work through their pain and grief. She addresses the wide range of strong and difficult emotions teens may experience and the new situations they will face, including family changes, issues with friends , problems at school, and the courage needed to move forward . Hospice Foundation of America. http://www.hospicefoundation.org This website provides guidance to both patients and families regarding end of life care. There are numerous links including: about hospice, end of life, grief, finding support groups, questions and answers, and finding a hospice in your area. Krementz, K. (1986). How it feels when a parent dies. New York, NY: Alfred Knopf. Youth speak openly about the experiences with the death of a parent. 48 Prolonged Loss This section of the resource manual will focus on the adolescent's grieving process during a prolonged illness and subsequent death. The focus will be on the prolonged illness of an immediate family member, but there would be similar grief patterns with the death of a close friend . When a family member has been ill for a long time and doctors have said there aren ' t any further treatments they can do, the youth (and family) begins to prepare herself for the likelihood that the person will die. She is already grieving, and processing what life will be like without that person. She will already have thoughts of what needs to be done to plan a funeral or memorial , but most importantly, she will have the chance to say good-bye. This does not, however, mean that the process of grief will be easy. A teen ' s need to push away painful realities is stronger than an adult' s, so they sometimes feel a greater sense of shock and numbness when the person who has been ill dies (Wolfelt, 2003). Issues such as disfigurement, suffering, the experience ofthe illness, and the stresses of care giving will all complicate the grief process (Doka & Davidson, 1997). Furthermore, for an adolescent, feelings of uselessness, helplessness, and anger are brought to the forefront as adults make decisions surrounding medical care and end of life care. Special Considerations Even in the shadow of the ultimate loss of death , there are other losses that have already occurred that necessitate a grief process. By the time a loved one dies after a prolonged illness, a youth will already be submersed in the grieving process, often referred to as anticipatory grief (Wolfelt, 1996). A teen ' s need to push away painful realities is often stronger than an adult' s resulting in a greater sense of shock and 49 numbness when the person who has been ill dies. Teens may also feel a sense of relief after the long illness of someone they love; this is normal and does not negate the love they have for the person who has died (Wolfelt, 1996). Clinical case illustration. Ryan, a 17 year-old in his last year of high school is also silently dealing with the impending death of his father. Just over a year ago his father was diagnosed with an aggressive cancer and despite treatment attempts, his father is now considered terminal and looking at hospice care. Ryan has always been a very quite, keeps to himself type of boy, and now is no exception. He doesn ' t speak to his mom , sister, father, or friends about how he is feeling or what he would like; something that is also weighing heavily on his mother. His mom contacts the school counsellor, outlining the family ' s situation, and asks that the counsellor attempt to speak with Ryan. As the counsellor, how would you first approach Ryan? What would be your main concerns? What key developmental points need to be considered? Anticipatory grief is the process of normal mourning that occurs in anticipation of death and its consequences. Rando (1986) defines anticipatory grief as "the total set of cognitive, affective, cultural, and social reactions to expected death felt by the patient and family" (p. 156). Rando (1986) has outlined six main tasks that a griever will work through when faced with anticipatory grief. Task one: Remaining involved. This means participating in the reality of the other, responding to what the dying person is going through , as well as sharing personal experiences. This can aid both the dying person, as he still has some control and say in 50 the family matters, and the bereaved person, as he is able to communicate and lower feelings of abandonment. Task two: Remaining separate. The bereaved needs to develop her own sense of self, separate from the dying. She must acknowledge the fact that the loved one will die and begin to contemplate a future in which this person does not exist. Task three: Adapting to role change. This refers to the reassignment of roles within the family and adapting to new demands. This shift is one of the most difficult tasks the bereaved will encounter. Examples include; a husband/father assuming the mothering role, an adult child assuming the parent role with a dying parent; a widow assuming financial responsibilities, or a youth assisting in taking over a deceased sibling's chores. In the terminal illness of a family member, family system functioning is highly threatened . There may be power struggles as well as reluctance to assume responsibilities that feel overwhelming. The struggle for the family to achieve a new balance is stressful , yet necessary. Task four: Bearing the affects of grief. Usual feeling such as sadness and guilt are present when faced with a loved one's death . Additionally memories and affects of past losses are also commonly revived during the process of anticipatory grief. Task five: Facing reality. Each family member needs to face the reality of the anticipated loss. This is a process requiring time for comprehension and internalization of this painful information . Brief glimpses into the future in which the loved one no longer exists need to be normalized, and discussion of medical requirements, plans for care, funeral arrangements, and financial concerns may need to be addressed over and over. 51 Task six: Saying goodbye. During this task, the bereaved acknowledges the reality of the impending loss. This critical time requires a lot of support and role modeling from caregivers and counsellors. The family member may have difficulty recognizing when the end is near, and should be guided and supported in saying goodbye as goodbyes left unsaid or incomplete can be devastating for the survivor. Many people who are facing the imminent death of a loved one wrestle with the choice between being there as he/she passes, or not; this choice is especially difficult for adolescents. As many youth will not have experienced any death in their lives, this decision can be exceptionally difficult as they have no idea what to expect and may also feel they have to " live up" to family and friends ' expectations. As a counsellor, it is important to listen to the youth as she weighs the pro ' s and con ' s of each decision, but be mindful of your own opinion and do not sway her to choose one or the other. The decision is extremely difficult, and she will likely carry some guilt and unrest with either decision. It will be important to continue to remind her of her instincts and why she made the decision she did, and support the choice she makes during and after her loved one ' s passing. When a terminally ill individual cannot fulfill assigned roles and expectations within the family, there is a shift in the balance of the family. The family must work toward reestablishing balance while dealing with the stress and grief of loss. While anticipatory grief can serve to bring people together, too much of it or inappropriate application of its processes can result in premature detachment from the dying person. Rando (1986) suggests that long-term anticipation of loss may appear at times to lead to less grief because the emotional exhaustion following the prolonged illness may lead to temporary numbness, to temporary suppression of grief after the loss, 52 or even to relief that the long and excruciating struggle is over. Additionally, anticipatory grief can make post-death grief more problematic. If a person was highly involved in the care of the dying loved one then that care can make the loss hurt more or leave one with more memories and emotional involvement to disengage from after the loss. Counselling Language and Techniques The search for precise techniques in which to help people experiencing anticipatory grief is not a useful endeavor. As a counsellor, flexibility and adaptivity to fit the individual ' s needs, lifestyle, past losses, and grief reactions prove to be much more beneficial for the client. It is imperative that the counsellor is aware of the many factors that may affect the bereaved. Rando (1986) has outlined four important ones to which special attention should be given. First, know the changes that have occurred in an individual's life prior to, at the time of, and following the news of an impending death, as well as following a death . Second, strive to understand each person ' s personal death history. The best way to accomplish this is to have the bereaved prepare an inventory of the losses they have experienced. This can assist in discussing the full scope of their reactions to a death or anticipated death. Third, treat each bereaved person as a unique individual as well as a member of a family . This is important because the reactions within a family also represent individual dilemmas and responses for each member of the family . The critical point is that although part of a unit, each individual reacts in accordance with his or her own personal relationship with the deceased. Fourth , recognize that a particular person's actual or anticipated death can have as many different effects as there are individuals experiencing the loss. Each bereaved person will be touched on many different levels, and their lives will be altered in different ways. When 53 a death is expected to occur it may be beneficial for the bereaved to move through the processes of grieving by asking significant questions of their loved one. Examples include: "If death is close, what matters most?", "If death is inevitable, what would make it acceptable?", " What can one do to prepare for a death?", "What might lead one to want to die?" , and "At what point do you want others to stop ' keeping you alive?"' There aren 't any right answers to these questions, they are presented as they are difficult yet realistic questions about impeding death, and avoiding them may make the process of anticipation more difficult. School Considerations It is important for schools as a whole, especially teachers, to understand the problems that arise while living with a chronically ill person. Problems such as; remissions and relapses, lengthened periods of anticipatory grief, increased financial , social, physical, and emotional pressures, long-term family disruption, progressive decline of the patient, longer periods of uncertainty, intensive treatment regimens and side effects, and dilemmas about decision making, treatment choices, and funeral arrangements are all day-to-day realities of a youth living with a terminally ill loved one (Rando, 1986). Supplemental Readings Corr, C. , & Balk, D. (1996). Handbook of adolescent death and bereavement. New York, NY: Springer Publishing Company. Corr and Balk write to improve our understanding of the challenges faced by adolescents when coping with death, dying, and bereavement. Readers are introduced to adolescence as a special time in the human life cycle, a period quite separate from childhood and adulthood. They 54 discuss normative adolescents and explain developmental tasks that are typical of early, middle, and late adolescence. Doka, K.J. , & Davidson, J. ( 1997). Living with grief When illness is prolonged. Bristol, PA: Taylor & Francis. Written in conjunction with the Hospice Foundation of America's yearly teleconference, this book provides education to all about bereavement issues. Doka reminds us of the role that loss plays in all of our lives while focusing on the losses and concurrent griefs that individuals with prolonged illness, their families, and caregivers experience through the course of the illness. Kubler-Ross, E.M.D. (1969). On death and dying. New York, NY: The Macmillan Company. Based on her research and interviews with patients who were dying, Kubler-Ross describes five stages by which people cope and deal with grief and tragedy, especially when diagnosed with a terminal illness or experience a catastrophic loss. Additionally, her book brought mainstream awareness to the sensitivity required for better treatment of individuals who are dealing with a fatal disease or illness. Prince George Hospice Society. http://www.hospiceprincegeorge.ca Website provides information and local links to grief resources. Rando, T.A. (1986). Loss and anticipatory grief Lexington, KY: D.C. Heath and Company. This book examines the phenomenon of anticipatory griefwhile also outlining the specific and practical interventions that can maximize positive benefits and minimize negative outcomes. 55 Traumatic Loss This section of the resource manual will focus on the adolescent's grieving process when someone close to him has died suddenly. Sudden loss can include a car accident, heart attack/stroke, homicide, and suicide. When death is sudden, the youth has no opportunity to say good-bye and slowly move into the grieving process, or have any thoughts or discussion about a future without that loved one. The youth also has not had the chance to say "I'm sorry" if there was any unresolved issue in the relationship. Without the ability or time to prepare mentally and emotionally, the survivor can be overwhelmed by an emotional wave following a sudden, traumatic death (Clements et al., 2004). This leaves many youth feeling dangling, distraught, and helpless as they have had no chance for closure (Fitzgerald, 2000). Youth will revisit time and again the last contact they had with their loved one, last words that were said, last laugh, and perhaps last tears. We can hope that this last encounter was a happy one, but it might not have been. It is an immense task to comprehend what has happened, and the family will have many tasks to complete and decisions to make all at once, such as notifying friends, making funeral arrangements, organ donation processes, and accommodations for out of town relatives, to name just a few. When sudden death is violent in nature, the grief process is further complicated. The youth must work through all of the above mentioned grief aspects plus come to grips with the horror of what has happened, what it must have been like for his loved one in the last few moments of life. As Fitzgerald (2000) has researched, sometimes the horror is to bear and media, working with the judicial system, and concerns about personal safety 56 further complicate the grieving process. The griever may find themselves working through complicated mourning which includes symptoms very similar to those of posttraumatic stress disorder (PTSD) (Doka, 1996). Table 2. Suggestions for Helping a Youth Grieving a Loved One who has been Murdered -Assist youth in looking for a therapist (if you feel you cannot competently counsel) or support group for families of murder victims. Familiarize yourself with PTSD. - Listen to what youth is going through. Encourage youth to share anxieties with others in his/her family. Be open and communicative. -Feelings are very intense after a murder- shock, anger, guilt, the whole range of feelings can set in. -Encourage youth to write a letter to his/her loved one expressing all of the thoughts he/she may have: anger at the murderer, regrets for not doing something to save her from this fate , sorrow in the senseless termination of her life. Place the letter in the casket, in a balloon, or burn and scatter with the ashes. - Encourage youth to write a letter to the murderer, expressing all of hi s/her pent-up anger. Then, tear it up or, as one woman did, nail it to the back fence and beat it with a hammer. - Provide resources such as books, websites, support groups on recovering from the trauma of a loved one ' s murder, that the youth can choose to utilize. (Fitzgerald, 2000, p. 163) 57 Fitzgerald (2000) states that one of the most important things an adolescent can do after suffering a traumatic loss is to talk. Counsellors need to work with the youth on not isolating from friends and family, instead talking and sharing grief with others. Talking can help keep strong emotions from becoming internalized and creating additional problems such as symptoms ofPTSD. Special Considerations Sudden, traumatic death frequently brings dramatic change to a family system, triggering an unexpected need for evaluation of roles and structure (Clements et al., 2004). Having no time to prepare for the loss often results in impulsive and disorganized attempts to regain balance for both the individual and the family as a whole. Clements et al. (2004) further state that a survivor typically presents for therapy when the complications of bereavement have derailed the ability of the family to function in the world without the deceased. As counsellors, we must remember that the experts on grief are truly the surviving family members who are seeking support from someone to help guide them on their unique and painful journey. Those who are left to grieve the completed suicide of a loved one are not only left with a sense of loss, they are also left with a legacy of shame, fear, rejection, anger, and guilt (Harvard, 2009; Worden, 2002). Amongst all of the confusing feelings associated with grief, shame is one of the most predominant feelings when someone is bereaved after the successful suicide of a loved one. Survivors of suicide loss, particularly close family and friends , are more likely to grieve longer and more intensely than those who lose loved ones to other illnesses (Harvard, 2009). Due to this sense of shame that some will feel , counsellors may find that they need to be more proactive in reaching out to 58 survivors than they generally would with other clients. Guilt is another common feeling among survivors of suicide victims. They often take on responsibility for the action of the deceased and have a gnawing feeling that there was something they should have or could have done to prevent the death. This can be especially difficult as many suicide attempts are made quickly. Harvard (2009) found that of people who have survived suicide attempts, 70% said later they had tried to take their lives less than an hour after first thinking about doing so, and one in four said they made the attempt within five minutes. Due to the intensity of the guilt, some people may feel the need to be punished and they may interact with society in such a way that society, in turn, punishes them (Worden, 2002). Adolescents may turn to delinquency or become involved in excessive use of drugs or alcohol. Guilt can also manifest into blame. Finding someone to blame can be an attempt to establish control and find a sense of meaning in a difficult-tounderstand situation. People who survive a death by suicide also often experience intense feelings of anger as they perceive the death as a rejection. A correlation of this anger is low self-esteem. Survivors may speculate that the deceased did not think enough of them or they would not have committed suicide. This rejection can be a reflection of the survivor's self-worth, leading to low esteem and intense grief reactions (Worden, 2002). Clinical case illustration. Morgan is a fifteen year-old girl who has chosen to come and speak to her school counsellor. A week ago her friend , Kristen, successfully committed suicide and she is feeling overwhelmed by the loss and is feeling guilty that she didn't do something to stop it. Morgan sits down and immediately begins telling a very detailed story of how she had spoken with Kristen, who was upset over a family argument, and the two had made plans to 59 meet up later as Morgan was on her way to an appointment; no-one saw Kristen alive again. Morgan continued her story of the events of the next week, the counsellor barely able to get a word in, instead simply staying present and listened to Morgan. After almost an hour, Morgan looked up at her counsellor and said, "Thank-you for listening. No-one else wants to talk about it, but I need to." For this youth, simply having someone who wasn't going to interrupt her story was what she needed, not a number of interventions and tactics. As the counsellor, it is important to read the client and be there for him/her in the capacity that he/she needs, not so much focusing on specific technique. Survivors of suicide often carry a special burden throughout their grieving process, including higher levels of guilt, shame, and anger. Additionally, survivors are often left with many unanswerable questions such as why a loved one killed herself, and what, if anything, might have been done to prevent the suicide. Feelings and questions such as these may prolong the grieving process, leaving the survivor in the shadow of the death for far longer than is healthy. Survivors also often struggle with issues such as how others will view them and, if religious, the fate of their dead loved one in the hereafter since many religions view suicide as a mortal sin (Doka, 1996). As Doka (1996) indicates, research to date shows that suicide survivors are viewed more negatively than survivors of other types of death, and that they may have complicated and extended grief reactions. This particular group of survivors needs support from the community and may benefit from additional professional help, either individually or in group sessions. 60 Counselling Language and Techniques When counselling a suicide survivor, it is important to remember that death by suicide is one ofthose socially unspeakable losses. Both the survivors and those around them are hesitant to speak about the death, some survivors will even choose not to reveal the cause of death, or lie about it (Harvard, 2009). The choice of therapy will depend on the patient's preferences and needs, but a few key therapeutic goals are outlined by Harvard (2009). They are ; normalize the grief, ease guilt, respect differences, encourage openness, plan ahead, and make connections. As a counselor, it is important to encourage the patient or family to engage in the same rituals they would use to grieve any death. It may also be helpful to remind them that suicide can be a tragic outcome of depression or mental illness, the same as death by heart attack may result from cardiovascular disease. Survivors of suicide often place tremendous amounts of unrealistic guilt on themselves as they try to figure out what they could have done to prevent a loved one's death . It may be helpful to remind them that trained professionals cannot predict when such a death might occur, and how little control one has over someone else's behavior. It is also important that the counselor reminds the patient or family that everyone grieves in different ways and at different paces, while also encouraging them to talk about their loved one and reveal whatever details surrounding the death they are comfortable sharing. As the family comes to terms with the present, it is important that a part of the therapy is to assist in the planning of future events that may be difficult. Assist the family in finding ways to mark a lost loved one's birthday, family holidays, or other milestones. Lastly, provide the family with options for further supports. This may be support groups, organizations, medical doctors, or other 61 counselling agencies, each individual will choose the option that best suits his/her grieving process accordingly. Regardless of type of therapy, a counselor can help to fill in the gaps caused by the loss of communication with others. Outlined below are interventions of this type as outlined by Worden (2002). Reality test the guilt and blame. Much of the survivor's guilt will be unrealistic and will yield itself to reality testing, allowing for some relief. (Ex. "I should have been there," or "Ifl hadn 't of bought the rope for the boat cover." Help correct denial and distortions. Survivors need to face the reality of the suicide in order to work through it. Using tough words with them such as "killed himself' or "hanged herself' can facilitate this. People who witnessed the suicide may be plagued by images ofthe scene, and may display co-morbid symptoms of post-traumatic stress disorder (PTSD). For people who were not present, the imagined scene can sometimes be worse than the actual one. Exploring these graphic images can be difficult, but discussing them can help with reality testing. The images usually fade with time. Some survivors will see the victim as all good or all bad, illusions that may need to be challenged. Explore fantasies of the future. Reality test the fantasies the survivors have as to how the death will affect them in the future . As realities are discovered explore ways to cope with that reality. Examples of this might be ; "when I have children, how can I tell them that their grandmother killed herself," and "when I get married, should I have my brother's picture where he would have been standing beside me?" Work with anger. Working with the anger and rage a suicide death can harbor for the survivor allow for its expression while reinforcing personal controls the survivor has 62 over these feelings. Especially for teens, anger can manifest with such strength that they are unable to control the ways in which it escapes their bodies. It is important for the counsellor to recognize and help the youth recognize the anger that he may have within, before he makes poor or drastic decisions. Safety for those who are grieving is extremely important, and education for friends and family will be imperative to creating this safety. Test the sense of abandonment. Feeling abandoned is perhaps one of the most devastating results of a suicide. People who lose a loved one through natural death feel abandoned, and in the case of a death by choice, the sense of abandonment can be extreme. It is also important that there may be some reality in this feeling, but the level of reality can be assessed through counselling. Help them in their quest to find meaning in the death. The existential quest for meaning is activated with any bereavement and is related to task three, exploring fantasies of the future , to adjust to an environment in which the deceased is missing. Survivors of suicide are confronted additionally by a death that is sudden, unexpected, and sometimes violent. There is a need to search for an answer to why the loved one has taken his life and to determine the state of mind of the deceased before the death. Survivors of suicide often feel obliged to explain the suicide to others when such an explanation is typically beyond their own understanding. Table 3. Suicide Intervention Strategies I . Contact the family right away. Family myths and rumors begin early. 2. Watch for acting-out in counselling. The client may try to get the counselor to reject her in order to fulfill her own negative self-image. 63 3. Many survivors of suicide deaths feel that no one can understand them unless they have undergone a similar loss experience. If there are a number of people grieving this type of loss, consider starting a group, this may be particularly beneficial in a high school setting. 4. If possible, counsellors should involve the family and support system ofthe survivor. (Worden, 2002, p. 124) Postvention with suicide survivors. Approaches used by counsellors and other professionals as they attempt to meet the needs of suicide survivors have come to be known as postvention programs (Doka, 1996). These activities are generally organized by committees and staffed by interdisciplinary groups of professionals and volunteers who are prepared to react as a crisis intervention team as soon as the need arises. An immediate and effective reaction is especially important after an adolescent has successfully committed suicide as cluster and copycat suicides are more prevalent in this group (Doka, 1996). Cluster suicides occur when a group of people who live in near proximity commit suicide over a relatively short time span and copycat suicides occur when people, often adolescents, take their lives using the same methods that have been used in a publicized suicide. Adolescents are at an impressionable developmental stage that may be marked by extremes in mood, which is perhaps why this age group seems more reactive than others to deaths by suicide. Additionally, many adolescents cope with stressors by using imitation and modeling, or may feel that the successful suicide of a peer had opened the door and given others who are unhappy 'permission' to do the same. 64 Clements, eta!. , (2004) states that it is important to understand the complicating factors inherent to sudden, traumatic death in order to promote successful navigation through the grief process, and practitioners must help guide and educate survivors about the normal reactions to grief as well as the factors that may result in complicated bereavement. School Considerations Traumatic events produce loss, whether it is actual or threatened. These losses include; loss of loved ones, friends , relationships, security, hope, health, feelings of trust, childhood innocence, and many others. When dealing with loss, adolescents may display a variety of behaviours including emotional numbing, guilt, anger, or fear ofthe future , and schools must learn how to best manage while remaining compassionate. Emotional numbing varies from a brief period of shock to a refusal to feel anything at all as it hurts too much. Guilt and anger may result in either apathy, (withdrawing from life), or acting out, (verbal abuse, physical fighting , self-harm or self-punishment.) Fear of the future stems from the realization that the future is unpredictable and unknown, and the youth may be unable to cope with further crises that can occur suddenly. If left unaddressed, these fears may develop into anxiety. Effects of anxiety may show up at school in forms such as; shorter attention span, difficulty in concentrating, drop in grades, depression, daydreaming, and withdrawal from peers. Students experiencing anxiety ofthis nature also complain of physical aches and pains more often than their peers (Doka, 1996). Table 4. Eight Principles from Suicide Postvention Programs for Schools 1. Begin as soon as possible after the tragedy. 2. Expect resistance from some survivors, but not all. 65 3. Be willing to explore negative emotions toward the victim when the time is right. 4. Provide ongoing reality testing for the survivors. 5. Be ready to refer when necessary. 6. Avoid cliches and banal optimism. 7. Be prepared to spend significant amounts of time in one school. 8. Develop the postvention program within a comprehensive health care setting that also includes prevention and intervention. (Dok~ 1996, p.49) The most effective way of assisting schools to cope more effectively with traumatic crises is to do so in advance of any such situation (Doka, 1996). During times of crisis there is not the time for reflection, evaluation, or education, which means having protocols established beforehand and offering ongoing educational programs is imperative. With this said, no program can prevent the pain of loss, nor address all possible effects of traumatic losses, but programs can aid students and staff through the grieving process after a traumatic loss. In times of traumatic loss, people often feel a loss of control over their lives. This is especially true with adolescents who may already be dealing with feelings of helplessness from prior losses or feeling powerless in a world largely controlled by adults . There are a number of programs available that have been shown to help teachers, students, and parents cope with a traumatic loss. One such program is Rainbows. Rainbows is an international grief-support charity for children, adolescents, and adults who are confronting a death, divorce, or other painful family 66 transition (Marta, 2003). Rainbows offers support and direction as the bereaved journey toward acceptance of their loss. Rainbows has developed five age-directed programs; Sunbeams for preschool age children; Rainbows for elementary school age children; Spectrum for high school adolescents; Kaleidoscope for adults, and Prism for single parents and stepparents. The majority of Rainbows efforts are focused on children and teens. All youth sessions are offered at no charge and most are offered at easily accessible community sites, such as schools, hospice houses, or churches. Rainbows provides training for the volunteers who facilitate each group as they help the youth grapple with their immediate grief and deal with hidden and often simmering emotions, all while teaching positive coping strategies. Each group is a closed group and is completed in twelve weeks. A youth may choose to participate in more than one cycle of twelve weeks. These programs help students build self esteem and feelings of selfworth, regain control, cope with feelings of guilt, and show students how to reach out to support systems such as family, friends, educators, counsellors or religious advisors. Table 5. Assisting Students during Traumatic Crisis - Allow time for students to meet with teachers and counsellors. Following a traumatic loss, the needs of the students must take priority over inflexible schedules. - Listen. Pay attention to what the student is saying. Do not offer possible answers until she is finished. - Encourage the student to identify and list all of the issues to be discussed. This may include both the recent loss and past losses still being dealt with by a student. Do not try 67 to limit the student' s list because the length of this list is not a problem. A long list may at first appear frightening or overwhelming, but it can also be used to show a young person how much strength they have shown in being able to cope with so many past losses. - Allow the student to establish priorities. Ask the student, " What do you want to deal with first?" With this starting point, the student can identify the meaning he has given to each event. - Understand how the adolescent views the traumatic event. If the student believes this loss has created a void, how will this void be filled ? If it' s seen as an enemy, what resources will the student use to combat it? The traumatic event may even offer some gain, such as a more stable environment after the protracted illness and death of a family member. If so, how will the student cope with possible feelings of guilt? - Help the student distinguish between actual and anticipated losses. Is the student more concerned with the effect of past and present losses, or with the possibility of losses in the future? - Stress the student' s right to let others know his feelings. If a student needs to talk about the loss, he has a right to do so. If the student wants others to be able to help or to understand his behavior, he has a responsibility to speak of his loss. A traumatic loss can make a person different. Others can be of help, but the student must be willing to let them help. - Focus on one issue at a time. This will avoid the overwhelming situation of trying to deal with several issues at once. It can also reduce the confusion of moving too quickly from one issue to another. 68 - Remember that the school's function is to educate the whole person. Each student carries baggage in the form of a history containing personal events that can have a major effect on learning. A traumatic loss interacts with these events and cannot be dealt with in isolation. In the wake of traumatic loss, life can seem like a puzzle where no two pieces match and some are missing. Teachers and parents together can provide many of the pieces that the young person may need to make sense of this puzzle and to complete the picture of her future. - Remember that young people may see some losses as traumatic that would not be judged as that serious by adults. With less experience of significant life events (deaths, divorce, violence), youth may experience a loss as traumatic partly because such an experience is new to them. They have been thrust into a completely strange situation, and they can ' t be sure what will happen, or what they will feel next. - Maintain regular lines of communication between school and home. Home-school efforts to assist youth following a traumatic loss must be marked by cooperation, not by competition. Youth see clearly how well the important adults in their lives are coping with a traumatic loss. If educators and parents send contradictory messages, it will only complicate the recovery of the child. By keeping home-school communication open, such apparent contradictions may be minimized . - Support efforts must be appropriate to the age and developmental level of the youth and to a school setting. Adolescents may not wish to be singled out in any class setting. Their communications and contact related to their loss will often be kept private. They may want class to go on as usual to reinforce the feeling that there are still things in life that are not touched by the loss, that they are as they were before the loss occurred. 69 (Doka, 1996, p. 208 - 21 0) As the chance to say good-bye and resolve unfinished business is taken away when a sudden death occurs, Fitzgerald (2000) has provided a number of ideas and rituals that may be beneficial for an adolescent griever. A youth could write a letter to the person who died, saying everything that she feels is important and asking all the questions that she might still want answers to. This Jetter could be placed in the casket, read at the gravesite, placed in a memory box, or burned to release the feelings and words. Another suggestion is to get biodegradable helium balloons. Youth can write messages on them, take them outside, and release them to the heavens. The messages do not have to be shared with others, unless the youth wants to. Part of this process is also deciding on the ritual that will take place as the balloons are released. Youth may choose to sing, play a song, read a poem, or simply stand silently. This balloon ceremony has proven to be very popular for grievers of all ages as it provides a visual representation of each person's desire to reach out to their lost loves ones and at the same time literally Jet go. During the ceremony don't be surprised if everyone becomes quiet, each deep in their own thoughts letting the sadness escape. Many are left with a sense of peace and quiet when it is over. Supplemental Readings Alexander, D. (1993). Books for teens: The way !feel: A story for teens coping with crime or trauma. Huntington, NY: Bureau for At-risk Youth. Part of a 6-volume series designed for teens who have been exposed to crime and trauma, providing both information and exercises. 70 American Association of Suicidology. http ://www.suicidology.org/web/guest/survivorresources Website provides suicide facts , information for family and friends to help support a survivor of suicide, additional books and resources, and links to a variety of support groups. Doka, K.J. (1996). Living with grief after sudden loss: Suicide, homicide, accident, heart attack, stroke. Bristol: PA: Taylor & Francis. Doka writes ofthe unique issues presented to survivors of sudden loss. Their grief is often intensified since there is little or no opportunity to prepare for the loss, say good-bye or finish unfinished business. Additionally, the nature of the loss can bring on intensified grief reactions. Dunne, E., Mcintosh, J. , & Dunne-Maxim, K. (1987) . Suicide and its aftermath: Understanding and counselling the survivors. New York, NY: W.W. Norton. A compilation of articles and writings that captures the many different aspects of surviving after a suicide loss. Fitzgerald, H. (2000). The grieving teen. New York, NY: Simon & Schuster. Helen writes of the special needs of adolescents struggling with loss, while also providing tools they may need to work through their pain and grief. She addresses the wide range of strong and difficult emotions teens may experience and the new situations they will face, including family changes, issues with friends , problems at school, and the courage needed to move forward. Lord, J. (2006). No time for goodbyes: Coping with sorrow, anger, and injustice after a tragic death. Burnsville, NC: Compassion Press. Appropriate for older adolescents, 71 this book deals with the sorrow, anger, and feelings of injustice after a violent or sudden death. Mothers Against Drunk Driving http://www.madd.ca Website provides facts, current news, services and links for victims, as well as research and volunteer opportunities for both adults and youth. Rainbows. http://www.rainbows.org International charity dedicated solely to helping youth successfully navigate the grief process. 72 Other Losses This section of the resource manual will focus on a short list of other common losses for adolescents. Parents and teachers cannot protect students from the inevitable losses that occur in the natural progression of life. The Joss of one ' s place in the family due to the birth of a sibling, the Joss of an older sibling due to the natural process of leaving home, the Joss of self-confidence when one fails at a sought-after goal, and the loss of one ' s youth when choosing to grow up too soon, are all losses experienced by many students (Davidson & Doka, 1999). Examples of other losses include parents ' divorce, moving, loss of culture, romantic relationships, illness and disability, being placed in care, and realism (ie. I won 't be a star athlete after high school). Adolescence is a time of unwritten rules. Through all the good and bad , emotional and social development through all the major milestones are critical to becoming a wholesome and healthy adult, adding various stressors that can interrupt an adolescent' s development. Special Considerations Adolescence is the time when many youth are entering into and experiencing their first attempts at romantic relationships. With these attempts will also come failures, as most of these relationships will come to an end before their high school careers are complete. As adults working in a school where we can ' t seem to keep up with who is holding hands with who, we generally don 't place much importance on the relationship, however, the youth involved do. We still must recognize any relationship loss and provide a place for mourning when teen relationships come to an end. Boyfriends, girlfriends, and best friends. If one of these important people should die, teens need the opportunity to mourn. Their grief is not always acknowledged 73 because society tends to focus on the ' primary' mourners, the dead person' s immediate family (Wolfelt, 2003). The boyfriend or girlfriend of the deceased may not receive any acknowledgment from the family, but will need support to work through his or her own grief process. It is also important for the counsellor to be aware that the period of adolescence is also the time for exploring sexuality and they need to be conscious about the fact that some teen relationships will be a secret, from parents, friends, or both. Some teens will lose a same-sex partner, but if they had not yet made the relationship known to the public he or she will also be grieving in solitude. There is a delicate balance between supporting a teen that has recently ended a relationship and helping the youth understand that daily tasks, such as going to class, will need to be resumed in a short time frame. Moving often results in a change of school , loss of friends , and lifestyle losses, including cultural losses, which can be very stressful for youth (McLachlan, 2008). Some youth will adjust smoothly, while others are at risk for developing physical and mental health problems and other adjustment problems such as ; drug use, academic failure, and health risk behaviours (Bradshaw, Sudhinaraset, Mmari, & Blum, 2010). Bruce and Waelde (2008) have found that ethnic identity is associated with better adjustment and lower levels of delinquency, particularly among ethnic minority youth. Adolescents who either move to an ethnically different city or country, or those who may be removed from their traditional home and placed in care are at risk as they are now thrust into the grieving process as they come to terms with a life that is now lost. Loss is an everyday occurrence for many adolescents, but some losses will pose greater threats and greater challenges as each youth moves through normative development. 74 Divorce. Parent' s divorce in early childhood can have major implications throughout adolescence . While it may seem extreme, Marta (2003) suggests that a divorce can have as great an impact on a child or teen as a parent's death. This is due to the vast number of similarities between the two as they effect the youth involved. A youth experiencing either a parent's death or divorce may experience: sadness, anger, blame, shame, memories revered, guilt, worry, parent dating, family life different, economic changes, fear of losing the other parent, regrets, changes in lifestyle, and an unknown future (Marta, 2003). A child may feel responsible for his or her parents choosing to get divorced, and may hold onto this grief and feeling of responsibility for many years. Talking with kids, in order to explain why the divorce is happening and what it will mean for their lives is probably the single most painful event in the divorce process (Marta, 2003). Youth are not capable of quickly processing information about the demise of their parents ' marriage. They need time to hear the news, mull it over, ask questions about the decision, and begin comprehending what the event will mean. Initially, the kids will want to know the particulars of the divorce, such as, where will everyone be living, how will birthdays and holidays be celebrated, how often will they see the parent they won 't be with daily? This emphasis on the practical doesn 't mean that they are heartless or don't care about the divorce of their parents, but rather that they are trying to shore up their crumbling foundation of security. Beyond these practical issues, though, Marta (2003) suggests there are three questions, often unasked, that youth of all ages have when their parents ' divorce: 1), "Did I cause this?" Even though parents have already assured their children that it is not their fault, they may feel a sense of guilt for a long time. 2), "Who will keep me safe?" From a young age, youth have a sense of 75 security that comes from having two people to take care of them. Now there will only be one, and the youth may worry that the remaining parent will also leave. Youth may fear that everything upon which they depend on will crumble, this is a fundamental anxiety of most adolescents. While teens are pulling away from their families, they still want and need to know they have a protective haven to return to when the world gets frightening or a problem arises. 3), "Is this going to happen to me to?" Youth may worry that history will repeat itself when they grow up and marry, or wonder if every marriage leads to divorce. During divorce, parents often are so involved in the details of their own lives and dealing with their own anger and pain that they do things they wouldn' t normally do. A youth living through her parent' s divorce may disclose to a counsellor that she is now constantly yelled at, isn' t allowed to go out with friends , meals aren' t being made, or laundry isn't being done. All of these stressors and changes will impact her choices, behaviours, and success at school. It also puts the counsellor in a tricky position as it may push the boundaries of neglect in the home. A parent must responsibly provide the basic needs for their children, and hopefully also provide a stable and supportive home environment. If a parent is not providing these things, while also possibly creating a home environment that is hostile, is this by definition true neglect? And if yes, is the child truly better off also having the ministry involved knowing that he/she potentially may be removed from the home? Anger. It' s OK to be angry. Youth dealing with a death of any kind have a right to be angry, but do not have a right to take that anger out on others, or on themselves. All too often we vent our anger on those we love the most. Youth may be snapping at family 76 and friends over trivial matters and saying things they don 't really mean. Feelings get hurt, tension mounts, and families and friendships fall apart, anger can be destructive and dangerous. As Fitzgerald (2000) points out, anger can lead to bizarre, stupid, and idiotic behaviour and destructive acts such as driving recklessly, taking unnecessary risks, using drugs and alcohol, and inflicting harm on oneself. Anger is exhausting, and anger not expressed can be internalized and come out as depression. It is important for youth to recognize angry feelings , identify them, and express them, but in ways that won 't cause hurt or end in trouble. Counselling Interventions and Techniques Adolescents may not readily reach out for adult guidance in times of loss. Many will cling to their peer group and confide in friends who have good listening skills. This is a time marked by rebellion and distrust of authority, and, although frightening and frustrating to adults, it is developmentally appropriate for adolescents to pull away in search of independence (Davidson & Doka, 1999). Teachers and counsellors must take the initiative and reach out to them. Fitzgerald (2000) outlines a number of ways youth may learn to understand their anger and express it appropriately. Following are questions and techniques that may be useful when counselling a youth overcome with grief-related anger, of course remembering that each youth will grieve in their own manner. 77 Table 6. Counselling Techniques with Youth and Anger - Learn to identify your anger. How do you know you are feeling mad? What pushes your buttons? Where do you feel it first in your body? Do you tense up? Do you start to cry? The more you know about your anger, the more you will control it rather than have it control you. - List everything that makes you angry. Get in touch with the particulars. Identify what is making you angry. Analyze your list. What angers you most? When this happens, what is your usual response? Do you later regret this? What can you do to control your temper? Intellectualizing your own responses will help you defuse your anger and break it into more manageable bits. It won't seem so powerful , so looming, or so scary. - Talk, talk, talk. Find someone to talk to whom you trust, someone who will hear you, someone who will not be afraid of your anger and not try to talk you out of it. Talking really is magic: even though you still have the situation to cope with, talking it out will make you feel lighter and more energized to go on. It is comforting to know that there is a person who understands how you are feeling. - Keep a journal of your feelings. Writing about your anger will help you externalize it and be more objective about it. - If you are angry with a particular person, write him or her a letter. Say everything you would like that person to know. Leave out nothing. Do not mail it. After you have finished your letter, throw darts at it, rip it up, burn it, or throw it in the garbage. You will be getting this baggage out of your system. 78 - Get a biodegradable helium balloon and write on it everything that makes you angry. This can work as it creates a true visual of all that angry baggage being carried away. - Music helps. Choose some music that has special meaning to you, especially when you are in an angry mood. - Record yourself saying everything you need to say then play it back to listen to yourself being mad. You might choose to share it with someone. - Get physically active. If you are feeling angry, go for a run, a bike ride, kick a ball around. - Be creative. Paint a picture, write a poem, or sculpt your feelings. Use whatever medium you feel comfortable with. - Ask for help. Don't hesitate to seek help if you see problems developing around you. (Fitzgerald, 2000, p. 96) School Considerations Grief is the process of reacting to all of the losses that occur in one's life. For a grieving adolescent this means that he or she has lost something significant and will react in his or her own unique way. Teachers and counsellors must understand the emotions involved in the grief process and must respond with compassion creating both physical and emotional safety for the youth. Communication within the school environment, while respecting the boundaries of confidentiality, is crucial to effectively responding to a student experiencing grief. It is also important that someone, usually a counsellor, communicates with the family , if it is possible. One of the most important things a parent can do is to communicate with their child ' s school , no matter how old their child is 79 (Davidson & Doka, 1999). Many parents will assume their adolescent children will communicate the news of a loss to their teachers and counsellors, yet many do not. As Davidson & Doka (1999) state, the goal of education is multifaceted; to nurture academic success, to encourage preparation for the workplace, to promote artistic, athletic, and individual potential, and to attempt to motivate students to achieve their intellectual capacity. Educators of all types are on a mission to teach the life skills necessary for the development of responsible, healthy, moral, and compassionate adults who will become our leaders, community members, and parents of the next generation. As a part of these educational lessons, school personnel must prepare for and plan effective intervention strategies to address the needs of students grieving in the school environment. Supplemental Readings British Columbia Bereavement Helpline http://www.bcbereavementhelpline.com. Phone numbers and links to additional resources . Group wishes to increase public understanding of bereavement as a normal life process through education, advocacy, and networking. Marta, S.Y. (2003). Healing the hurt, restoring the hope. USA: Rainbows Inc. Information and personal accounts combine to assist professionals in guiding youth through times of divorce, death, and crisis. 80 Grief Techniques Worden (2002) outlines a number of useful techniques for counsellors working with grieving clients. Some components may seem a bit brash, requiring the counsellor to read each client individually and provide support as he/she is utilizing the more confronting language while other components require the counsellor to provide some leadership and expertise in order to aid the client to open up and attempt to move forward in his/her grief. Table 7. Useful Techniques for GriefCounselling 1. Evocative language. Counsellor can use tough words that evoke feelings. Example, "your son died" vs. "you lost your son". This language helps people deal with reality issues surrounding the loss can stimulate some of the painful feelings that need to be felt. Also, speaking of the deceased in the past tense can be helpful. 2. Use of symbols. Have the mourner bring photos of the deceased to the counselling sessions. Helps the counsellor get a sense of who the person was and creates a sense of immediacy of the deceased and a concrete focus for talking to the deceased rather than about him or her. Audio, video tapes, articles of clothing, and jewellery also work. 3. Writing. Have the survivor write a letter to the deceased expressing thoughts and feelings. Writing a farewell letter to the deceased is also encouraged. Keeping a journal of one's grief experience or poetry writing can also facilitate the expression offeelings and lend personal meaning to the experience of loss . 81 4. Drawing. Drawing pictures that reflect one's feelings as well as experiences with the deceased. Good technique to use with bereaved children, but works with adults as well. 5. Role playing. Helping the bereaved role play various situations that they fear or feel awkward about, useful in working with Task 3 issues. The counsellor can enter into the role-playing, either as a facilitator or to model possible new behaviours for the client. 6. Cognitive restructuring. Here the underlying assumption is that our thoughts influence our feelings, particularly the hidden thoughts and self-talk that constantly go on in our minds. By helping the client to identify these thoughts and reality test them for accuracy or overgeneralization, the counsellor can help to lessen feelings triggered by irrational thoughts such as "no-one will ever love me again ." 7. Memory book. An activity that a family can do together is to make a memory book of the lost family member. This book can include stories about family events, memorabilia such as photographs, poems, and drawings. This can help the family reminisce and mourn a more realistic image of the dead person. Additionally, children and youth can revisit the book in order to reintegrate the loss into their growing and changing lives. 8. Directed imagery. Helping the person to imagine the deceased, either with their eyes closed or visualizing their presence in an empty chair, and then encouraging them to say what they need to say to the deceased ; can be very powerful. The power comes from being in the present and talking to the person rather than about the person. 9. Metaphors. Use metaphors as visual aids. Metaphors can be useful tools for lowering the resistance to the pain of bereavement when patients cannot directly confront feelings 82 that are associated with the death. Metaphor offers a more acceptable symbolic representation through which the mourner may express feelings and work through the second task of mourning. The use of metaphor allows the grieving person to focus on a graphic image that may symbolize their experience in a more acceptable way. (VVorden,2002,p. 68) Conclusions It is my hope that this resource book will motivate others to take the time to learn, meet, and listen to the adolescents who are in their lives. The group of people we refer to as teenagers bring their own energies, opinions, and flare to our everyday existence. This is a group that I feel truly honoured to work with ; I learn a new life-lesson each day that I take the time to listen to a new story. This is also a group of people who require guidance, authentic role-modeling, and a certain amount of push to safely move beyond their boundaries, but a group who still needs to know that someone has their back. Adding the grief work associated with death to an already complex existence poses a major challenge to an adolescent. I believe this resource book will aid counsellors and care providers in areas such as language and technique when they meet and begin to work with a grieving teen. 83 Appendix 1 Grief Pattern Inventory Please respond to each of the following statements using the key below. If appropriate, choose the response that best describes you in the past two weeks. KEY A=ALWAYS U=USUALLY S = SOMETIMES R=RARELY N=NEVER Please circle the best response for you: 1. A U S R N I am more emotional than most people I know. 2. A U S R N It is easy for me to cry and show my feelings to others. 3. A U S R N Even though I have returned to my normal routine, I still have strong and painful feelings about my loss. 4. A U S R N Even though I feel like crying, I do not cry in front of others. 5. A U S R N Although I am grieving in my own way, others may think me cold and unfeeling. 6. A U S R N I don 't seem to get as upset as most other people I know. 7. A U S R N I feel overwhelmed by feelings of grief. 8. A U S R N I appreciate when others encourage me to share my painful feelings with them . 9. A U S R N I avoid highly emotional or "touchy-feely" situations of any kind . 84 10. A U S R N It is important to me that others view me as being in control. 11. A U S R N I have been told that I am avoiding my grief even though I don 't think that I am. 12. A U S R N I have been controlling my painful feelings by drinking or by using other prescription or non prescription drugs. 13. A U S R N I believe that a bereavement support group is (would be) very helpful for me. 14. A U S R N I worry that I am not as upset by my loss as I should be, and feel guilty that I don't have more intense feelings. 15. A U S R N I resent efforts to get me to show feelings that I don ' t have. 16. A U S R N I think more about my loss than feel things about my loss. 17. A U S R N I believe it is very important to be aware of, and in touch with, all of my feelings . 18. A U S R N I find that solving problems associated with my loss helps me. 19. A U S R N Although I can sometimes control my painful feelings, they usually return and overwhelm me. 20. A U S R N Since my loss, I feel like l ' mjust pretending to be strong in front of most people. 21. A U S R N I find that I can't stop my grieving by thinking of other things. 22. A U S R N I have taken deliberate action to honour the memory of my loved one, even though I have not been as upset as most others who are grieving my loved one. 23. A U S R N Others seem surprised by my recovery from my loss. 85 24. A U S R N Although I took care of things immediately after my loved one' s death, I was surprised when I eventually "crashed" and began to have intense and painful feelings. 25. A U S R N I would describe myself as more intellectual than emotional. (Martin & Doka, 2000, p.l63) Item Analysis and Scoring of the Grief Pattern Inventory The Grief Pattern Inventory contains 25 items with response choices ranged along a continuum: always, usually, sometimes, rarely, and never. This reflects the belief that patterns exist on a continuum from profoundly intuitive to intensely instrumental. What follows is a brief description of each question and/or the pattern suggested by a positive response. 1. I am more emotional than most people I know. The basis of the patterns lies in the individual ' s customary choice of feelings over thinking and vice versa. Positive= intuitive. 2. It is easy for me to cry and show my feelings for others. A willingness to disclose feelings is associated with the intuitive pattern. Positive= intuitive. 3. Even though I have returned to my normal routine I still have strong and painful f eelings about my loss. Positive = intuitive. 4. Even though I f eel like cry ing, I do not cry in front of others. This is the first of six questions where a positive response could reveal a tendency toward a dissonant response, it could include instrumental grievers who have no other outlets for expressing whatever degree of feelings they experience. Positive = dissonant. 86 5. Although I am grieving in my own way, others may think me cold and unfeeling. Instrumental grievers are often perceived as lacking feelings. Positive= instrumental. 6. I don't seem to get as upset as most other people I know. Positive = instrumental. 7. !feel overwhelmed by my feelings of grief Positive= intuitive. 8. I appreciate when others encourage me to share my painful feelings with them. While this could measure a griever's tendency towards introversion it is most likely an example of intuitive grieving. Positive = intuitive. 9. I avoid highly emotional or "touchy-feely" situations of any kind. Instrumental grievers rarely choose to place themselves in situations designed to elicit the experience and expression of feelings. Positive = instrumental. 10. It is important to me that others view me as being in control. This is especially important for intuitive grievers who may become image managers in the wake of a loss. Positive = dissonant. 11. I have been told that I am avoiding my grief even though I don 't think that I am. Positive = instrumental. 12. I have been controlling my painful feelings by drinking or using other prescription or nonprescription drugs. Positive = dissonant. 13. I believe that a bereavement support group is (would be) very helpful for me. Positive = intuitive. 14. I worry that I am not as upset by my loss as I should be and feel guilty that I don 't have more intense feelings. Penitent instrumental grievers feel unusually guilty about their lack of pain. Positive= dissonant. 15. I resent efforts to get me to show feelings that I don 't have. Positive= instrumental. 87 16. I think more about my loss than feel things about my loss. Positive= instrumental. 17. I believe it is important to be aware of, and in touch with, all of my feelings. Positive = intuitive. 18. !find that solving problems associated with my loss helps me. Positive= instrumental. 19. Although I can sometimes control my painful feelings, they return and overwhelm me. Positive = intuitive. 20. Since my loss, !feel like I'm pretending to be strong in .front of most people. Positive = dissonant. 21. !find that I can 't stop my grieving by thinking of other things. Positive= intuitive. 22. I have taken deliberate action to honour the memory of my loved one, even though I have not been as upset as most others who are grieving my loved one. Positive = instrumental. 23. Others seem surprised by my recovery from my loss. Positive = instrumental. 24. Although I took care of things immediately after my loved one 's death, I was surprised when I eventually "crashed " and began to have intense, painful feelings. Even strongly intuitive grievers can sometimes manage certain post-death activities before being overwhelmed by their feelings. Positive= intuitive. 25 . I would describe myself as more intellectual about problems than emotional. Positive = instrumental. We again remind readers that the Grief pattern Inventory is designed to augment other methods for assessing a client's grief. In addition, it is always a sound practice toreadminister the GPI after several weeks have passed. Dissonant responses, in particular, 88 are often temporary in nature. Finally, we would advise waiting at least two to three weeks after the death to begin evaluating patterns. Suggested guidelines for interpreting a griever's scores follows: Key:A=+2 U=+1 S=O R = -1 N=-2 Intuitive Pattern: Questions #1 , 2, 3, 7, 8, 13, 17, 19, 22 , 24. Score: 16-20 Profoundly intuitive pattern 11-15 Moderate intuitive pattern 6-10 Blended intuitive pattern -5 -5 Blended balance pattern Instrumental Pattern: Questions #5 , 6, 9, 11, 15, 16, 18, 22, 23, 25. Score: 16-20 Profoundly instrumental pattern 11-15 Moderate instrumental pattern 6-1 0 Blended instrumental pattern -5 -5 Blended balance pattern Dissonant Responses: Questions #4, 10, 12, 14, 20. Each dissonant response should be evaluated separately. 89 Appendix 2 Teen Grief Realities The following statements and implications are based on both research and Wolfelt's (1996) years of counselling experience with teens. Use what is helpful, discard what is not. 1. Many teens have a great resistance to counselling and/or support groups. Implication: We as counsellors must be outreach-oriented in our helping efforts. 2. Several studies have found that a teen's reconciliation of a death is a function of family system issues, and many parents oftoday's teens grew up in a mourning-avoiding culture. Implication: Family systems must be a focus of helping efforts. 3. A differential response has been found between male and female teens. Males tend to have a more aggressive grief response . They may act out physically or use drugs or alcohol. Females in contrast often feel a longing for comfort and reassurance. Implication: Be aware of and responsive to these differences, and the possibility that they will be reversed. 4. Teens mourn in doses. Implication: They need permission to not always be openly mourning. Some teens may need some distractions or 'time-outs' from active mourning. In contrast, others may benefit from encouragement to create 'mourning times' or they could get caught up in distractions. 5. While it is important for healthy mourning that adolescents be able to openly express feelings, they may not do so if it sets them apart from their peers. Implication : Create opportunities for peer support from teens who have 'been there.' 90 6. In times of ongoing stress, many teens report a need for some privacy or 'alone time.' Implication: Don 't be threatened by this while at the same time staying available to the teen . 7. Many teens fear loss of emotional control and may be frightened by normal feelings of grief. Implication: To help prevent the ' going crazy syndrome,' we need to help bereaved teens understand the multitude of thoughts and feelings they may have. Teens need to know that sleep disturbances, appetite changes, anxiety and fears , irritability, explosive emotions, etc. are all common responses to death. 8. Most teens are unfamiliar with the intensity and the duration of grief responses. Implication: Teens need to know that grief is a process, not an event. The pace of healing will be unique to each person. They need a realistic timeframe for doing the work of mourning. They may be surrounded by adults who are impatient with them and project they should ' be back to normal ' quickly and efficiently. 9. Shy, quiet teens will naturally have a more difficult time expressing their grief in words. Implication: Nonverbal teens may need support in accessing nonverbal means of expressing their grief. Art, music and journaling may be more appropriate avenues of expression than talking for these teens. But watch closely, these teens are easy to miss because they are more withdrawn. 10. Some teens invite adults into defensive interactions, usually through expressing hostility and a sense that ' no one understands or cares about me,' that serve to distract everyone from the underlying pain of the Joss. Implication: Recognize that in companioning bereaved teens you may be a whipping post for some who are likely to express their underlying pain through anger. The key is to not get involved in a defensive 91 interaction that might cause you to miss the communication about underlying feelings of helplessness. Appropriate behavioural limits need to be set while the underlying pain is explored and expressed. (Wolfelt, 2003, p. 285) 92 Appendix 3 How Schools Can Help Students with the Tasks of Grieving Task 1: To accept the reality of the loss. School Response: Acknowledge the loss. Don't ignore what happened, but make sure it is talked about in a structured, controlled manner. Your taking active control is one way to minimize the situation's getting out of control. Stick to the facts. Use written communication whenever possible to minimize speculation, rumours, or gossip about the death. Steer clear of making value judgments, offering explanations or attributing blame. Having data that is as factual as possible assists in helping people acknowledge that the loss has really occurred. Task 2: To work through the pain of the loss. School Response: Provide a time and place to grieve. Recognize that the first day after the death is the most chaotic and that the level of visible grief will decrease after the funeral. Provide students and staff with opportunities for individual and group expression of their grief. Assess the needs of high-risk students and use community resources to provide them with assistance. Anticipate the critical times when the intensity ofthe loss might resurface (anniversaries, holidays, special school events) and reach out to those who might have trouble getting through. Remember that close friends of the deceased may have more difficulty 6-9 months after the death with the long-term implications of the loss and may benefit from support at that time. Task 3: To adjust to an environment in which deceased is missing. School Response: Assist people in managing without the deceased. This may be as simple as arranging for substitute teachers or as complicated as helping people recognize 93 and reassign the emotional roles filled by the deceased. Recognize that the empty desk, locker, or parking space left by the deceased student is a concrete reminder to the entire school of the loss. Involve students in problem-solving to address how to handle these reminders in unsensationalized ways that both respect the deceased and recognize the fact that life must go on. Task 4: To emotionally relocate the deceased and move on with life. School Response: Give your school time to come to terms with the loss. Remember the resolution of grief is a focus on the meaning of the life of the deceased, not on his/her death. Use caution in your selection of memorialisation activities and avoid expressions that will be continual reminders of the traumatic death. Recognize members of the school community who seem to be stuck in the process and refer them for additional help. ( ubhc.umdnj .edu/brti/FreeholdStudents VehicularDeaths.doc) 94 Appendix 4 Are You Worried About Saying Something Stupid? There are times that our anxiety over something will prompt us to giggle inappropriately or say something that comes out wrong. As a teen either dealing with loss or trying to help a friend who is suffering, the fear of saying something wrong is often in the forefront. We all do our best, and a friend will probably understand and forgive after such a blunder, but following are a few suggestions of things to avoid saying. 1. "I know how you feel. " Even ifyou have had a death in your family, your grief is probably different. You might have a good idea of how your friend is feeling, but you could be wrong as grief grips each person differently. Instead, indicate that you may have an idea of how your friend is feeling, but would appreciate if he/she told you . 2. " You shouldn 't feel that way." This comment often follows after a person has said that he feels guilty or responsible for something about the death. Even if what your friend is saying makes no sense to you, it is important that you hear him out. The important fact is that he feels guilt and is looking for someone to listen. You don ' t have to fix it, just simply be there. 3. "It's part of God's plan." A faith in God and life hereafter can be helpful, but when people hear this comment they often feel angry and respond with something like, "Plan, what plan? Nobody asked me about any plan." 4. "He's in a better place now." This may be true for some ways of thinking, but the griever may not agree . She may feel that her loved one was in a better place when he was alive and sharing her life here on earth. 95 5. "Call me if you need anything." 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