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Play and expressive therapies to help bereaved children:Individual, family, and group treatmentNancy Boyd Webb DSW, BCD, RPT‐SPublished online: 17 Feb 2010.

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Smith College Studies in Social Work 73(3), 2003

PLAY AND EXPRESSIVE THERAPIES TO HELP BEREAVEDCHILDREN: INDIVIDUAL, FAMILY, AND GROUP TREATMENT

Nancy Boyd Webb, DSW, BCD, RPT-S

Abstract

Different types of expressive therapies permit bereaved children toexpress and process their feelings through a variety of child-friendlynon-verbal methods such as art, creative writing, and music. Theselection of a particular method depends on considerations related to theparticular needs of each child, the circumstances of the death, and thefamily/community narrative about it. This article demonstrates howexpressive therapies may be used in individual, family, or group sessionswhich, through play and other modes of expression, provide children withan opportunity to communicate feelings about and reactions to theirbereavement experiences in symbolic form.

Do bereaved children need therapy? If so, what kind of therapy isappropriate, and what modality of treatment (individual, family, or group)would be most helpful? This paper presents some specific treatmentmethods to help children who have had difficulty dealing with a particu-lar death experience. Because most children have limited verbal abilityand because they communicate their feelings and reactions to their lifeexperiences through play, I recommend and will discuss therapeuticmethods that respect and conform to most children's typical forms ofmetaphoric, non-verbal communication. This paper provides an overviewof a variety of expressive therapies, especially play therapy, and presentscase vignettes to demonstrate how these different therapies can helpchildren process their various grief experiences.

A brief explanation about expressive therapy and play therapy will helpensure that readers understand the types and purposes of the interventionsthat will be presented. The terms "expressive therapy" and "play therapy"both refer to the use of a variety of non-verbal methods such as art, music,writing, and movement that assist individuals in expressing their feelings.These methods, sometimes referred to as "creative arts therapies," areused by counselors and mental health specialists to assist them in theirwork with adults and children. Play therapy has been used primarily withchildren and adolescents, but it also can be used with adults as an adjunctor stimulus to verbalization. In addition to the methods already men-tioned, play therapists may use board and card games, doll and puppet

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406 BOYD WEBB

play, storytelling, and sand play. Play therapists are registered bya national organization that regulates the training, experience, andcontinuing education of practitioners who are licensed by their ownprofessional associations.

Play therapy and expressive therapy are similar in pursuing the goals ofassisting individuals to express their feelings through a variety of creativeand play methods. Art therapy, dance and movement therapy, sand playtherapy, and music therapy are treatment specializations that focus on onespecific method of intervention. The rationale of all these methods is thatfeelings often are released more readily in non-verbal form. Of course, inbereavement counseling with children there is always some verbalizationbetween the therapist and the client, depending on the child's age andability to communicate directly about the painful topic of death. As I haverepeatedly warned my students, therapy or counseling with a child usingonly verbal communication is foolhardy and probably futile.

I typically explain to a child in the first meeting that "I am someonewho helps children and families with their troubles and worries and thatsometimes we talk and sometimes we play" (Webb, 1996, p. 68). If thechild is uncomfortable or not ready to talk about his/her worries, a trainedplay therapist can communicate with the child in a displaced, indirectmanner, by talking about the baby tiger or the little girl doll, for example,without making a direct connection between the themes of the child'schoice of play objects/productions and his/her life. As we will see in theexamples presented later in this chapter, children may be uncomfortableanswering questions or talking directly about their feelings about death;however, they readily reveal their feelings through their play, and thisopens a door for the therapist to name and validate the feelings thatinevitably surface. The play therapist always listens to the child andobserves the play to determine whether it suggests that the child isconflicted or confused about some details regarding the death.

CHILDREN AND DEATH

If I free associate from the word "children," what comes to mind are ideassuch as energy, growth, beginnings, the future, and limitless possibilities.On the other hand, if I think about the word "death," my mind associatesto connotations such as finality, the end, and closure. Although other peo-ple would have different associations from mine, I think the distinctionsbetween the two words would be evident for most individuals. We do noteasily pair the words "death" and "children" because doing so links the

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PLAY AND EXPRESSIVE THERAPIES FOR CHILDREN 407

completion of life with its beginning. We like to think that death appliesmostly to older people, who are infirm and ill, and that children, who arevibrant and just beginning to learn about the wonder of life should notthink about its end until they are older. However, children do, in fact,experience death in their families and their communities, as well as in sto-ries on television, in movies, and in children's books. Some children havetheir first personal contact with death when a pet dies, and many in thetwenty-first century will learn about death when a grandparent or agreat-grandparent dies.

How children comprehend and understand the reality and complexity ofdeath depends on many factors, the most relevant of which are the child'slevel of cognitive development, the nature of his/her relationship with theperson who died, and the specific manner of the death (for example, acci-dental, terminal illness, natural, or suicidal). In several previous publica-tions (Webb, 1996; 2001), I presented the 'Tripartite Assessment ofChildren's Bereavement" (see Table 1) as a way to conceptualize the mul-tiplicity of factors that impact on a particular child's response to a death.In this paper I will focus on the meaning of the death to a child in termsof his/her cognitive level, and on the nature of the death, in terms ofcausal and timeliness factors. In addition, knowing the family (or com-munity) story about the death contributes to understanding the particularmeaning the child ascribes to the death. However, the child's attributionof meaning is not always immediately evident and may surface laterduring individual, group, or family therapy sessions. The therapeuticprocess sometimes entails helping the child create his/her story about thedeath, to serve as a source of comfort and meaning in future years.

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Table 1

Tripartite Assessment of Children's Bereavement

Individual factors Death-related factors Family/social/religious/cultural factors

Age

Development stageCognitive levelTemperamental characteristicsPast coping/adjustment

HomeSchoolInterpersonal/peers

Hobbies/interestsGlobal assessment of functioningDSM-IV-TR, Axis VMedical historyPast experience with death/loss

Type of death

Anticipated/sudden"Timeliness'Vpreventability of deathDegree of painPresence of violence/trauma

Element of stigmaContact with deceasedPresent at deathViewed dead bodyAttended ceremoniesVisited grave/mausoleumExpression of "good-bye"Relationship to deceasedMeaning of lossGrief reactions

Nuclear family-grief reactionsExtended family-grief reactionsSchool-recognition of bereavementPeers-response to bereavement

Religious affiliation membership/participation

Beliefs about deathCultural affiliationExtent of child inclusion

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PLAY AND EXPRESSIVE THERAPIES FOR CHILDREN 409

CASE VIGNETTE

While writing this chapter I am also anticipating attending a memorialservice for my mother-in-law, who died recently at the age of 103. Her7-year-old great granddaughter had been told that "old Gramma" wasgetting weak and tired and that she "probably would die soon." Thismemorial service was intended to celebrate a full and wonderful life. Thefamily speakers planned to emphasize that Gramma was ready to die andtherefore they wanted to express their thankfulness that her wish wasgranted when she died peacefully in her sleep. As a special remembranceat the reception that followed the service, 7-year-old Katherine and hermother planned to serve her great-grandmother's much loved molassescookies that they had baked two days before.

This illustrates how a family can help a child remember and mourn theloss of a relationship with a beloved family member she had visited onspecial occasions (e.g., birthdays and holidays), when aunts, uncles, andcousins reminisced about their past experiences and took lots of pictures.Because the great-grandmother did not play a pivotal role in this child'slife, and because the family story about the death conveyed such positivemessages, the child will probably accept the death in a matter-of-factmanner. The situation would be quite different for this child if the deathwere that of one of her grandparents, with whom she has a very closerelationship, or that of one of her parents. The meaning a family ascribesto a death will certainly affect its meaning to a child.

Sometimes a death may stimulate a 7-year-old child to wonder aboutwhether other family members will die, and to ask questions about whathappens after death. However, a child's age and ability to comprehend thereality of death is only one factor determining his/her response. Thenature of the relationship with the person who died, the manner of thedeath, and the accompanying family story about the circumstances of thedeath also have a major impact in how any child will react.

After a brief review of the developmental progression in children'sunderstanding of death, this paper reviews different types of expressivetherapies that have been useful in helping children who needed assistancein understanding and dealing with different death experiences. The use ofindividual, group, and family therapy will be presented in terms of theusefulness of specific approaches in different death circumstances.

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410 BOYD WEBB

DEVELOPMENTAL FACTORS IN CHILDREN'SUNDERSTANDING AND RESPONSES TO DEATH

Comprehension of the reality and meaning of death involves bothcognitive and affective responses. The emotional responses relate to theloss of a person. For the very young child who does not yet have a firmsense of object constancy, every separation is as if the person hasdisappeared forever. The game of peek-a-boo holds universal fascinationfor a baby precisely because s/he believes that by covering and uncover-ing her/his eyes she can magically make the other person appear ordisappear. Once the child realizes that when the mother leaves the roomshe does not disappear forever, separation anxiety tends to subside.

Much of the literature discussing children's cognitive understanding ofdeath relies on Piaget's general theory of cognitive development (1954).Most children have difficulty comprehending the irreversibility, finality,non-functionality, and universality of death until they are about 7 or 8years old. Even when relatives have patiently tried to explain to a childthat death is permanent the child may continue to expect the dead personto return for special occasions, such as holidays or birthdays.

Piaget's views of children's cognitive development have been applied tochildren's understanding about death with regard to three major phases:

The Young Child. Ages 2-7: The Pre-Operational StageThis developmental stage is characterized by magical thinking andegocentricity. The child believes that the world revolves around him/herand that events happen because of his or her own good or bad behavior.Piaget referred to this stage as characterized by concrete (literal) thinking.

Children in this phase are often confused by the terms we use to referto death. For example, a 4-year-old girl whose father was killed in a housefire responded in her first play session to my question about the where-abouts of the daddy doll, "We can't find him, he's lost." When adultseuphemistically refer to "losing" someone through death, young childrenmay take the expression literally, and believe that like a missing toy, a lostdead person can be found.

The School-Age Child. Ages 7-11: The Concrete Operational StageChildren of this age usually realize that death is irreversible. They knowthat death is final and that it will happen to everyone sooner or later.However, they usually believe that it does not occur until late in life. Thedeath of a parent during this developmental period can cause the child

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PLAY AND EXPRESSIVE THERAPIES FOR CHILDREN 411

genuine sadness and longing because s/he knows that s/he will not see theparent again. In the family of the fireman killed in a house fire, both his7-year-old and 9-year-old sons played out their longing for their father.The younger boy played over and over a rescue scene in which ambu-lances and various helpers rescued a family in a burning building. The 9-year-old boy, on the other hand, brought his extensive collection ofmatchbox cars to several therapy sessions, and talked as he played withthem, about how he and his father had enjoyed riding dirt bikes and goingto car races together.

The Middle-School Age Child. Ages 9-12: The Formal Operational StageThis stage is characterized by mature thought and understanding, and bythe ability to deal with abstractions and hypotheses. Children of this agenot only feel the pain of loss, but as they get older (11-12 years) they mayponder the significance and meaning of death. For example, the 12-year-old daughter in the fireman's family told me she believed that wheneversomeone dies, someone else is born. Accordingly, the spirit of the personlives on in the baby. These beliefs, while important to the girl, did not easethe pain of her loss. This girl, at age 12, was very articulate, and able toexpress herself verbally, so it was not necessary or appropriate to use anyplay therapy methods with her.

SELECTING THE METHOD OF THERAPYFOR BEREAVED CHILDREN

The previous example of the deceased fireman's children illustrates theinterweaving of family, individual, and group therapy for bereavedchildren, according to the particular needs of each person. Following anydeath, and especially one that is sudden and traumatic, my preference isfirst to see the family as a unit, and then to determine if counseling seemsindicated for the different family members, and if so, what type. Holdinga family session helps begin a relationship with all family members, whilealso permitting them to reflect on their shared experience of death. It alsogives the therapist the opportunity to model a respect fordifferences by pointing out that different people respond differently aftersomeone dies, and that there is no one right way to grieve.

I typically ask the parent to bring pictures of the family to the firstsession, especially ones showing the children with the deceased familymember. This provides a direct resource for recalling happy family mem-ories. Children, and especially elementary-school age boys, do not like to

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cry or express their sadness in public, since they believe that this form ofemotional expression is babyish. Therefore, my usual approach in aninitial family session following a death, is to ask people to think about afavorite memory involving the person who died. I then invite them todraw a picture of that memory. As they draw and describe their memoriesof a happy time together, they are beginning the mourning process.

During the initial family session with the fireman's family (Webb,2000), it became apparent that the wide age span of the four children(from 4 to 12 years) presented a challenge in terms of meeting each per-son's individual needs. Because the 4-year-old had limited verbal anddrawing ability, her mother helped her make a picture. The two boys bothdrew and spoke about specific family outings, while 12-year-old "Mary"drew a single flower and fought to hold back her tears as we looked at thefamily photos and talked about her father's funeral and the tremendousoutpouring of support offered by the fire department and the community.

Because of the age differences and special needs of these children,I made appointments to see Mrs. Turner (the mother) and each childseparately. I said I knew it was hard to think and talk about someone youloved who had died, but I also expressed my belief that doing so wouldbe helpful to them. I mentioned again that we could draw and play as wellas talk. My plan in future sessions with the individual children was to useplay therapy techniques with the two younger children (ages 4 and 6),mostly verbal therapy with Mary (age 12), and a combination of talkingand playing with the 9-year-old boy. After the family session, Mary toldher mother that she didn't want to come back. She did, however, agree toparticipate in a bereavement support group at school. A year later Marydecided that she was ready for individual sessions, which actually con-tinued for several months. This case, thus, illustrates the interweaving ofindividual, group, and family therapy in helping four children and theirmother in a bereaved family.

THERAPY OPTIONS

Depending on the age of the bereaved child, the nature of the death, andthe availability of different treatment alternatives, the following treatmentmethods may be appropriate for helping:

• family therapy

• bereavement groups

• individual therapy

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PLAY AND EXPRESSIVE THERAPIES FOR CHILDREN 413

These different forms of treatment may be available in a variety ofsettings, such as hospitals, schools, hospice programs, bereavement campprograms, clinics, churches, and through private practitioners. Regardlessof the counseling/therapy method and the setting in which it is offered, itis important for the therapist/counselor to be mindful about the child'sdevelopmental stage, as well as about normal and problematic griefresponses in children. The therapist should also be able to interact withthe child using various play and expressive therapy methods. The follow-ing discussion (which also appears in Webb, in press, 2002) presents thethree major forms of professional intervention with bereaved children.Consideration is given to the advantages/disadvantages of each approachand to the specific indicators for selecting one approach over another.Table 2 summarizes the advantages/disadvantages and special indicationsfor family, group, and individual counseling/therapy options.

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Table 2

Comparison of Counseling/Therapy Options

ADVANTAGES DISADVANTAGES SPECIAL INDICATIONS

FAMILY Observation of child'srole in family

Assessment of "availability"of family members to the child

Members share reality of death

"Education" of family members,re: different pace and form ofchildren's grieving

Child's "voice" maynot be heard by adults

Family so involved inown grieving, theycannot empathize with child

Early in grief process

Purposes/goals

To establish allianceTo assist in engaging childTo offer psycho-educational guidance

GROUP Relieves isolation of child

"Normalize" death experience

Child sees others inlater stage of griefwho have "survived"

Child may hear"horror" stories fromothers in group

Child may be over-whelmedby intense feelings of othergroup members

Shy child may not participate

Most appropriate for childdealing with tasks of middlestage of bereavement

INDIVIDUAL Child's needs receiveone-to-one attention

Therapy/counseling can bepaced according to thechild's individual needs

Permits in-depth explorationof idiosyncratic feelings

Sense of stigma/blamefor being "singled out"

Engagement of the bereavedchild is often difficult

For traumatic bereavement

For suicide bereavement

For complicated bereavement

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PLAY AND EXPRESSIVE THERAPIES FOR CHILDREN 415

Because the focus of this chapter is on play and expressive therapytechniques, rather than on the rationale for using a particular modality oftreatment, readers who want more discussion of the material in Table 2should refer to the second edition of Helping Bereaved Children (Webb,in press, 2002).

FAMILY THERAPY

It is important to have some knowledge about how the child's familyinteracts and communicates with one another in order to appreciate theunique significance of a particular child's bereavement. That is why it isso useful to see the entire family together following a death, as alreadymentioned. Depending on the nature of this first meeting, a decision maybe made to offer ongoing counseling to the family as a unit, or to suggestother options. Family sessions would be appropriate, for example, whenthe family has been advised of a terminal diagnosis and the members needto process this information together over time, during which they mayneed to make care-taking and other arrangements for the sick person. Thishappened in the Martini family, as discussed below.

Because children's verbal skills are not as developed as those of adultsit is imperative that family therapists plan their bereavement sessions withthe ages of the children in mind. Young children cannot sit quietly andtalk for 45 minutes, and the therapist should be prepared to offer toysand/or art activities that can facilitate the expression of feelings of allfamily members, not just the verbal adults. As already mentioned, review-ing photographs and drawing pictures of happy memories can bemeaningful to family members of different ages.

Another example of an activity in a family therapy bereavement sessionoccurred in the Martini family (Webb, 1993) following the terminal diag-nosis of the godfather of 10-year-old Linda. I had been working with thefamily around the parent's pending marital separation when thegodfather's illness exacerbated. The circumstances meant that the twosisters, ages 8 and 10, would be "losing" two important male familymembers: their father, who planned to move out of the home, and theirgodfather, who had pancreatic cancer and who was not expected to sur-vive. Six weeks later, when the godfather died, I engaged the family inmaking a collage that they subsequently displayed at his memorial ser-vice. Because the girls were competitive with one another, I suggested thecreation of the collage since this activity would not give the older child anadvantage (as sometimes occurs in drawing). I provided a collection of

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magazines, scissors and a large piece of poster paper, and instructed thefamily to find and cut out pictures and words from the magazines thatreminded them of "Uncle Robert," the godfather. This offered a richopportunity for each family member to talk about his/her memories ofRobert and also to express some negative feelings about some of hisbehavior, such as his smoking.

In subsequent work with this family I treated them using a variety ofmethods including sibling therapy, individual therapy, parent-childcounseling, and family therapy. Often it is desirable to employ a combi-nation of treatment methods since one approach does not negate the other,and in fact, different purposes are served through each modality.

Depending on the therapist/counselor's evaluation, the decision may beto recommend a limited number of individual sessions, with a follow-upfamily session after 6-8 weeks. Referral of a child to a bereavementgroup might occur following an initial period of individual and familytherapy/counseling. Terr (1989, p. 18) states, with reference to workingwith traumatized children, "Most likely the treatment of childhood trau-ma will remain a multifaceted one, relying on several different approach-es used simultaneously or in tandem" (emphasis mine). This statement isequally applicable to work with bereaved children who have not beentraumatized.

BEREAVEMENT GROUPS

Because children dislike being considered different from others, bereavementgroups should be considered the treatment of choice for the bereavedchild because they offer the peer support the child so greatly craves. Thegroup, which may be school or community based, helps the child realizethat other children have also lost loved ones to death.

Many of the children in Krementz's book (1981/1991) mentioned theirfear of being pitied because someone had died in their family. The ratio-nale for bereavement groups is based on the fact that because everyone inthe group has suffered a loss, the group members can offer support to oneanother because of their similar experiences.

Short-Term Bereavement Groups. There is growing awareness in theprofessional community about the importance of interventions specifical-ly designed for bereaved children. A typical format is a time-limited(8-10 weeks) group that uses a planned agenda of drawing, writing, andother group activities and exercises to enable the children to express their

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PLAY AND EXPRESSIVE THERAPIES FOR CHILDREN 417

feelings about death. In addition to the peer support that counteracts thebereaved child's sense of isolation, the group is a place where questionscan be aired, either verbally or anonymously, through the use of aquestion box.

Tait and Depta (1993) describe the process of one such 8-session groupconsisting of 10 children, ages 7-11, each of whom had experienced thedeath of a parent, stepparent, grandparent, or other family member. Someof the play/expressive therapy activities included in bereavement groupsfor children include the following:

• Drawing with distinctive colors the location of different feelingsassociated with grief on a body profile;

• Writing or drawing a picture of the funeral or other experienceconnected to the death;

• Making paper plate masks showing on one side the feelingsshown to the outside world, and on the other one's inner, private .feelings;

• Creating a memory book or box containing items and remindersspecifically related to the person who died.

Although these same activities can be included in family or individualtherapy, the advantage of using them in group therapy relates to the senseof sharing that occurs when the child reads or shows his/her production toother children who have had similar experiences.

School-Based Groups for Children Exposed to Violent Death. Because ofthe proliferation of violence in our society, children may be exposed toviolent deaths in their everyday lives on the streets, the playground, intelevision and movies, and even in their schools. Reports of mental healthinterventions following violent events involving children includeaccounts of a sniper attack on a school playground (Pynoos et al., 1987),a massacre of 21 people in a McDonald's restaurant (Hough et al., 1990),and the responses of children following random urban bombings at theWorld Trade Center in New York and in Oklahoma City (Webb, 1999).Because children come together in school, this is the ideal locale forimplementing a preventive mental health intervention in a group format(Pynoos & Nader, 1988). Implicit in the school-based approach is theprinciple of timely "first-aid" intervention in which fears of recurrence ofthe trauma, and anxiety about dying and loss can be addressed. Terr(1989, p. 6) believes that "teachers can be trained to use art, musical

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expression, poetry, or storytelling as expressive therapeutic techniquesafter traumatic events."

In an earlier publication (Webb 1999), I described the format of an ini-tial group debriefing of children following urban bombings. This ideallyincludes both verbal and non-verbal approaches such as art and play tohelp children release feelings they cannot articulate. Typical groupdebriefing sessions with children in schools begin by asking some lead-ing questions about the crisis event. Children who are able describe thedetails of their experience and are prompted to emphasize the involve-ment of all their senses in response to specific questions by the teacher ormental health professional, such as, what did you see, smell, hear, do,feel? (Alameda County, 1990). When the children have verballydescribed their recollections, they then are invited to draw what theyexperienced. Often the graphic memories have a special poignancy andpower not evident in die verbal accounts.

Individual Therapy. "Some of the distinct advantages of individualtherapy over group or family therapy are that it permits maximumattention to the special needs of the child, and allows the therapist tomove at the child's pace in a careful in-depth exploration of the child'sunderlying feelings about the death" (Webb 1993, p. 51).

In situations of traumatic bereavement or following a suicidal death,individual counseling is always the preferred modality. The therapist canhelp the child cope with some of the intrusive memories and fears asso-ciated with the trauma. Often this occurs through drawing, doll play, andother play techniques to help the child express his/her feelings and gainsome support. A range of play therapy methods, such as art techniques,doll play, puppet play, storytelling, and board games are all described andillustrated through detailed case examples in Play Therapy with Childrenin Crisis (Webb, 1999). Since death is a crisis, many of the techniques areapplicable to work with bereaved children.

Often an individual (child or adult) must deal with his/her frighteningmental ideas/images about the gruesome nature of the death before s/hecan engage in the normal mourning process (Nader, 1996). Mourning, bydefinition, requires remembering the person who died. When the deathhas been traumatic, very frightening elements become superimposed onthese memories and interfere with peaceful and healing recollections.Counseling the traumatically bereaved is a stressful process for bothclient and therapist. Before undertaking this anxiety-producing work, thepractitioner should receive special training in conducting therapy withtraumatized individuals.

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PLAY AND EXPRESSIVE THERAPIES FOR CHILDREN 419

An example of individual play therapy with a traumatized childinvolved the sudden, mutilating death of a classmate friend in a car acci-dent (Webb, 1993; Webb, in press, 2002). Susan, age 9, was unwilling totalk about the death of her friend, but she readily drew pictures, playedboard games, and even made up stories about the "squiggle stories" sheand the therapist drew together. These play techniques actually allowedSusan to express her fears about sudden and violent death without havingto speak specifically about her friend.

The squiggle story technique (Winnicott, 1971a, 1971b) is an idealactivity to use with children who refuse to draw or who say that they can'tdraw, or with children who seem resistant and difficult to engage. Thegame requires the child and therapist to take turns closing their eyes,while.the partner counts to three. The designated player then openshis/her eyes and makes some kind of scribble/squiggle lines on paper. Theother person then must turn the squiggle into a drawing of a real or imag-inary figure or object. The drawings are made in rapid succession, and thechild gives a name to each. After five or six drawings have beencompleted, the child selects two favorites and makes up a story thatincorporates the chosen drawings.

Susan's story had themes of danger and threatening death in her invent-ed story about a princess being stalked by a dangerous "rabbit-dog" (or"rabid dog") who planned to shoot an arrow into her heart. My therapeu-tic responses to Susan's story tried to validate the feelings of helplessnessand fright she probably had in connection with her friend's unexpecteddeath. I made statements about the unpredictability of death in the worldand about how frightening and unfair this was for the innocent princesswho didn't even know she was in danger of dying. My tone of voice con-veyed a sense of outrage and unfairness about these circumstances, whichI believed were probably emotions Susan felt regarding her friend's sud-den and traumatic death. However, my comments always remained with-in the metaphor of her play scenario, and I made no connection betweenthe story's dangerous themes and Susan's own life experience.

The traumatic nature of her friend's death interfered with Susan'sability to think about him without imagining the terrible way he died. Ina follow-up session with her ten years later (Webb, in press, 2002), shetold me that everyone at school had referred to her friend as having beendecapitated in the car accident. She assumed this was true and onlylearned several years later, that he had bled to death at the scene. Thechild's belief, based on stories told to her by others, constituted herreality. Given Susan's mental image of how she thought her friend had

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died, of course she wouldn't want to think about him! Her symptoms, typ-ical of Post-Traumatic Stress Disorder, permitted her to avoid anythingthat reminded her of her beloved friend (and of his terrible death). In a sit-uation such as this, the therapist deliberately joins the child's need todistance from reality, fully believing that the child will "play out" the anx-ieties in a displaced way with dolls, drawings, games, and other playmaterials or activities. The therapy occurs through symbols that are onceremoved from the reality of the child's life.

Another example of this form of therapeutic displacement in work withSusan occurred through her repeated interest in playing the board game,Battleship. As with the squiggle-story game, I used the opportunityembedded in her play choice to express and validate the feelings implicitin the play situation. In this case, I referred to the people in the boats thatwere sunk during the play, and I expressed their feelings of fear and ter-ror about not knowing whether or when their boat would be bombed andsunk. In my mind (and I believe in Susan's subconscious) thesecomments were intended to be sympathetic and empathic with herfriend's situation. Terr states that "an entire treatment through play maybe engineered without stepping far beyond the metaphor of the 'game'"(1989, p. 14).

Susan's symptoms of irritability, withdrawal, nightmares, andheadaches subsided after six weeks of individual play therapy, althoughwe never openly addressed her friend's death during this time. I believethat individual therapy was the appropriate treatment for this girl, andbecause of the circumstances of the death, that she would nothave received the same validation and relief in either group or familytreatment.

In terms of the three areas of focus in this chapter (cognitiveunderstanding, the nature of the relationship with the deceased, and thefamily/community narrative about the death), it is clear that Susan had amature understanding about death, and that her close relationship with herfriend resulted in substantial feelings of loss. The difficulties she experi-enced in expressing her grief, however, related to the horrific rumorsabout the traumatic nature of her friend's death, and the mental image ofhis decapitation.

CONCLUSIONS

Children, like adults, cannot avoid the reality of death in their lives. Ihave seen this repeatedly in my practice as a child and family therapist,

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when a child in treatment for a school or peer-related difficulty becomessuddenly bereaved. Death often comes unexpectedly, interrupts everydaylife activities, and requires immediate attention. Death happens to allpeople at all ages, and children, who are usually ill prepared for itsoccurrence, often need help dealing with their concerns and worries.

The impact of a particular death on a child must be understood in termsof the three factors emphasized in this article. These are: (1) the child'slevel of cognitive development, (2) the nature of the child's relationshipwith the person who died, and (3) the family and community "story"about the death. When a child is confused or upset because of any one ofthese factors, s/he may begin to develop symptoms that indicate the needfor help.

Children respond positively to an array of treatment methods thatconvey their feelings without requiring them to abstract and verbalize. Itis important for bereavement counselors to be aware that play andexpressive therapies are the preferred methods for helping bereavedchildren. Furthermore, when the bereavement situation has beentraumatic, the therapist should have an understanding and training in bothplay/expressive therapies and in work with traumatized individuals.

While all bereaved children do not require treatment, schools andcommunity programs should be aware of the importance of debriefinggroups for children who have been exposed to death. Often one or twosuch group sessions will help children put the death situation behind themand move on with their lives.

Working with the child's family is always an essential component ofhelping the child. The response of the child's family can help or hinderhim/her in coping with a death. When family members are all bereavedthey may not be able to focus adequately on the child, and this argues forindividual or group therapy for the child in order to ensure that s/hereceives necessary support and attention. In most situations, groups offergreat support and companionship to the bereaved child.

Whether the therapeutic modality is family therapy, group therapy, orindividual therapy, the methods and techniques of play and expressivetherapies provide the language of communication with the child client. Itis the responsibility of all therapists working with bereaved children tohelp them feel comfortable and understood. Play and expressive therapiesoffer ideal techniques for communicating and connecting effectivelywith the bereaved child.

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Krementz, J. (1991). How it feels when a parent dies. New York: Knopf. (Original workpublished 1981.)

Nader, K. O. (1996). Children's exposure to traumatic experiences. In C. A. Corr & D. M.Corr (Eds.), Handbook of childhood death and bereavement (pp. 201-220).New York: Springer.

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Pynoos, R., Frederick, C., Nader, K., Arroyo, W., Eth, S., Nunex, W., Steinberg, A.,& Fairbanks, L. (1987). Life threat and posttraumatic stress in school age children.Archives of General Psychiatry, 44, 1057-1063.

Pynoos, R., & Nader, K. (1988). Psychological first aid and treatment approach forchildren exposed to community violence. Research implcations. Journal ofTraumatic Stress, 1, 445-473.

Tait, D. C., & Depta, J. (1993). Play therapy group for bereaved children. In N. B. Webb(Ed.), Helping bereaved children. A casebook for practitioners (pp.169-185).New York: Guilford Press.

Terr, L. C. (1989). Treating psychic trauma in children: A preliminary discussion. Journalof Traumatic Stress, 2(1), 3-20.

Webb, N. B. (1993). (Ed.). Helping bereaved children: A handbook for practitioners.New York: Guilford Press.

Webb, N. B. (1996). Helping bereaved children. A handbook for practitioners. New York:Guilford Press.

Webb, N. B. (1999). School-based crisis assessment and intervention with childrenfollowing urban bombings. In N. B. Webb (Ed.). Play therapy with children in crisis(2nd ed.): Individual, group, and family treatment (pp. 430-447). New York:Guilford Press.

Webb, N. B. (2000). Death of a parent. In A. Gitterman (Ed.), Handbook of social workpractice with vulnerable and resilient populations, 2nd ed. (pp. 481-499). New York:Columbia University Press.

Webb, N. B. (2001). (Ed.). Culturally diverse parent-child and family relationships.New York: Columbia University Press.

Webb, N. B. (in press, 2002). Traumatic death of peer/friend. In N, B. Webb (Ed.),Helping bereaved children: A handbook for practitioners, 2nd ed. New York:Guilford Press.

Winnicott, D. W. (1971a). Playing and reality. New York: Basic Books.

Winnicott, D. W. (1971b). Therapeutic consultations in child psychiatry. New York:Basic Books.

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