v av a. my special thanks to… kenneth adams rod baker sandra harris mark hinterthuer terrykeane...

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My special thanks to…My special thanks to…

Kenneth Kenneth AdamsAdams

Rod BakerRod Baker Sandra Sandra HarrisHarris

Mark Mark HinterthueHinterthue

rr

TerryTerry

KeaneKeaneKathy Kathy

McNamaraMcNamara

Ed Ed NightingalNightingal

ee

Judith Judith PattersonPatterson

Walter Walter PenkPenk

Family Perspectives Family Perspectives on on

Coping with LossCoping with Loss Gerald P. Koocher, Ph.D., ABPPGerald P. Koocher, Ph.D., ABPP

Simmons College, Boston, MASimmons College, Boston, MA

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The Animal Model for Bereavement Research

The Insect Model for Bereavement Research

Family Bereavement Family Bereavement ProjectProject

Preventive Intervention Following a Preventive Intervention Following a Child’s DeathChild’s Death

Supported by National Institute of Mental Supported by National Institute of Mental HealthHealth

Grant No. R01 MH41791Grant No. R01 MH41791Gerald P. Koocher, Ph.D. Principal Investigator Gerald P. Koocher, Ph.D. Principal Investigator

and and Beth Kemler, Ph.D. Co-Principal InvestigatorBeth Kemler, Ph.D. Co-Principal Investigator

Typical loss of social support over Typical loss of social support over time following a loss eventtime following a loss event

Time elapsed since death

Per

ceiv

ed s

ocia

l sup

port

Mean social support

Week 1

Week 6

Patterns of family interaction Patterns of family interaction following a deathfollowing a death

External social support rises sharply External social support rises sharply after the loss event and then declinesafter the loss event and then declines

Intra-familial support can be variableIntra-familial support can be variable

Congruence

Complementary

Mutual Escape

Distancer and Pursuer

Understanding Basic Tasks of Understanding Basic Tasks of MourningMourning

Accepting the reality of the lossAccepting the reality of the loss Grieving: experiencing the pain Grieving: experiencing the pain

and emotion associated with the and emotion associated with the lossloss

Adjusting to the new realityAdjusting to the new reality Commemoration: relocating Commemoration: relocating

representation of the deceased representation of the deceased in one’s own lifein one’s own life

Fundamental Intervention Fundamental Intervention StrategiesStrategies

Avoid parallel Avoid parallel service delivery; service delivery; partner with partner with medical team.medical team.

Focus on family Focus on family intervention intervention whenever whenever possible.possible.

Normalize the Normalize the family’s distress.family’s distress.

Suggest active Suggest active coping strategies; coping strategies; providing sense of providing sense of control.control.

Engage around Engage around common fears and common fears and attributionsattributions

Pay attention to Pay attention to symptom relief.symptom relief.

Strategies for Helping Children Strategies for Helping Children CopeCope

Find out what the child already Find out what the child already knows.knows.

Anticipate the child’s fears.Anticipate the child’s fears. Correct misconceptions.Correct misconceptions. Give clear information.Give clear information. Invite questions and participation.Invite questions and participation.

Children’s Unasked Children’s Unasked QuestionsQuestions

Did I make that happen?Did I make that happen? Is it my fault?Is it my fault?

Is that going to happen to me?Is that going to happen to me? Is it going to happen to someone else Is it going to happen to someone else

I care about?I care about? Who will take care of me?Who will take care of me?

Unique Phenomena inUnique Phenomena inPre-Operational ThinkingPre-Operational Thinking

Imminent JusticeImminent Justice

Bad things happen as the result of Bad things happen as the result of bad behavior or bad thoughtsbad behavior or bad thoughts

Limited perspective-taking skillsLimited perspective-taking skills

Inability benefit from another’s Inability benefit from another’s viewpoint or experiencesviewpoint or experiences

AdolescentAdolescents’ Issues--s’ Issues--

Hey, Grandpa, is deathbed one word or two?

What factors mediate the What factors mediate the mourning process?mourning process?

The nature of the loss The nature of the loss eventevent

Pre-existing Pre-existing relationshipsrelationships

RitualsRituals Functioning of survivorsFunctioning of survivors Family and community Family and community

influences (social influences (social support systems)support systems)

Individual Individual characteristicscharacteristics

Therapeutic Family Therapeutic Family ActivitiesActivities

Exploring the loss Exploring the loss event (sharing event (sharing perspectives)perspectives)

Discussing loss Discussing loss histories (families histories (families of origin)of origin)

Circular Circular questioning about questioning about copingcoping

BibliotherapyBibliotherapy

Discussing Discussing objects of objects of remembranceremembrance

Letter writingLetter writing Understanding Understanding

attributionsattributions CommemorationCommemoration Family coping Family coping

planningplanning

Model Intervention Session I: Model Intervention Session I:

Understanding each other’s loss Understanding each other’s loss experienceexperience

Part I – 90 minutesPart I – 90 minutes Family members tell their storiesFamily members tell their stories

Assure that all speak for themselvesAssure that all speak for themselves Exploration of copingExploration of coping

Circular questioning about perceptions Circular questioning about perceptions of self and othersof self and others

Education about griefEducation about grief Child versus Adult patternsChild versus Adult patterns

Session I: Session I: Understanding each other’s loss Understanding each other’s loss

experienceexperience Part I – 90 minutes (continued)Part I – 90 minutes (continued)

Acknowledge pain and discomfort of Acknowledge pain and discomfort of discussing the loss againdiscussing the loss again

Give parents reading materialGive parents reading material The Bereft Parent (Schiff)The Bereft Parent (Schiff)

Assign Homework for Session IIAssign Homework for Session II Each family member to choose memory Each family member to choose memory

object for next session, but avoid object for next session, but avoid discussing the choice at home.discussing the choice at home.

Session I: Session I: Understanding each other’s loss Understanding each other’s loss

experienceexperience Part II: parents only- additional 30 Part II: parents only- additional 30

minutesminutes Explore dyadic issuesExplore dyadic issues

Sources of tension in the relationship (e.g., Sources of tension in the relationship (e.g., sexual disruption, replacement child, etc.)sexual disruption, replacement child, etc.)

Discuss losses in family of origin contextDiscuss losses in family of origin context How were you taught to deal with loss?How were you taught to deal with loss?

Review personal loss historiesReview personal loss histories What important losses have you suffered What important losses have you suffered

previously?previously?

Session II: Session II: Making contact with the emotional Making contact with the emotional

lossloss Part I: parents only - first 30 minutesPart I: parents only - first 30 minutes

Explore interval since first sessionExplore interval since first session Address any recent concernsAddress any recent concerns Normalize the distress of reawakening Normalize the distress of reawakening

griefgrief Provide encouragement for coping Provide encouragement for coping

efforts made to dateefforts made to date

Session II: Session II: Making contact with the emotional Making contact with the emotional

lossloss

Part II: family meeting- 90 Part II: family meeting- 90 minutesminutes Two Exercises:Two Exercises:

Remembering the deceased childRemembering the deceased child

Family letter writingFamily letter writing

Session II: Session II: Making contact with the emotional Making contact with the emotional

lossloss Remembering the deceased childRemembering the deceased child

What reminder has each person brought?What reminder has each person brought? Discuss the meaning of the item.Discuss the meaning of the item.

How is the child remembered.How is the child remembered. Where are the reminders at home?Where are the reminders at home?

Assess idealization.Assess idealization. Are negative memories tolerated?Are negative memories tolerated? What has been done with the child’s room and What has been done with the child’s room and

belongings?belongings? Explore cemetery visits.Explore cemetery visits.

Discuss how the family has changed.Discuss how the family has changed.

Session II: Session II: Making contact with the emotional Making contact with the emotional

lossloss Family letter writingFamily letter writing

May be literal or figurative, written or taped.May be literal or figurative, written or taped. Young siblings can draw pictures.Young siblings can draw pictures. Goal: create emotional object to take home.Goal: create emotional object to take home. Content:Content:

Things left unsaidThings left unsaid Memories sharedMemories shared Unanswered questionsUnanswered questions

Session III:Session III:Moving on with our livesMoving on with our lives

Anticipating anniversary phenomena.Anticipating anniversary phenomena. Which will be most difficult for whom?Which will be most difficult for whom?

Review normal grief and “warning signs.”Review normal grief and “warning signs.” Discuss re-involvement in the world for each Discuss re-involvement in the world for each

person.person. Explore meaning-making for each person.Explore meaning-making for each person.

Philosophy of lifePhilosophy of life Hope for the futureHope for the future

Plan family activity outside the home.Plan family activity outside the home.

Warning Signs:Warning Signs:When is professional help When is professional help

needed?needed? Staying withdrawn from Staying withdrawn from

family and friendsfamily and friends Persistent blame or guiltPersistent blame or guilt Feelings of wanting to Feelings of wanting to

diedie Persistent anxiety; Persistent anxiety;

especially when especially when separating from parents separating from parents or surviving childrenor surviving children

Unusual and persistent Unusual and persistent performance problems performance problems at work or schoolat work or school

New patterns of New patterns of aggressive behavioraggressive behavior

Accident pronenessAccident proneness Acting as though Acting as though

nothing happened, or nothing happened, or happier than normalhappier than normal

Persistent physical Persistent physical complaintscomplaints

Extended use of Rx or Extended use of Rx or non-Rx drugs and non-Rx drugs and alcoholalcohol

That which does not kill me postpones the inevitable.