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My special thanks to… Kenneth Adams Rod Baker Sandra Harris Mark Hinterthuer TerryKeane Kathy McNamara Ed Nightingale Judith Patterson Walter Penk

Family Perspectives on Coping with Loss Gerald P. Koocher, Ph.D., ABPP Simmons College, Boston, MA V A 

The Animal Model for Bereavement Research

The Insect Model for Bereavement Research

Family Bereavement Project Preventive Intervention Following a Child’s Death Supported by National Institute of Mental Health Grant No. R01 MH41791 Gerald P. Koocher, Ph.D. Principal Investigator and Beth Kemler, Ph.D. Co-Principal Investigator

Typical loss of social support over time following a loss event Time elapsed since death Perceived social support Mean social support Week 1 Week 6

Patterns of family interaction following a death External social support rises sharply after the loss event and then declines External social support rises sharply after the loss event and then declines Intra-familial support can be variable Intra-familial support can be variable Congruence Complementary Mutual Escape Distancer and Pursuer

 Understanding Basic Tasks of Mourning  Accepting the reality of the loss  Grieving: experiencing the pain and emotion associated with the loss  Adjusting to the new reality  Commemoration: relocating representation of the deceased in one’s own life

Fundamental Intervention Strategies Avoid parallel service delivery; partner with medical team. Avoid parallel service delivery; partner with medical team. Focus on family intervention whenever possible. Focus on family intervention whenever possible. Normalize the family’s distress. Normalize the family’s distress. Suggest active coping strategies; providing sense of control. Suggest active coping strategies; providing sense of control. Engage around common fears and attributions Engage around common fears and attributions Pay attention to symptom relief. Pay attention to symptom relief.

Strategies for Helping Children Cope  Find out what the child already knows.  Anticipate the child’s fears.  Correct misconceptions.  Give clear information.  Invite questions and participation.

Children’s Unasked Questions 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 I care about? Is it going to happen to someone else I care about? Who will take care of me? Who will take care of me?

Unique Phenomena in Pre-Operational Thinking Imminent Justice Imminent Justice Bad things happen as the result of bad behavior or bad thoughts Bad things happen as the result of bad behavior or bad thoughts Limited perspective-taking skills Limited perspective-taking skills Inability benefit from another’s viewpoint or experiences Inability benefit from another’s viewpoint or experiences

Adolescents’ Issues-- Hey, Grandpa, is deathbed one word or two?

 What factors mediate the mourning process?  The nature of the loss event  Pre-existing relationships  Rituals  Functioning of survivors  Family and community influences (social support systems)  Individual characteristics

Therapeutic Family Activities Exploring the loss event (sharing perspectives) Exploring the loss event (sharing perspectives) Discussing loss histories (families of origin) Discussing loss histories (families of origin) Circular questioning about coping Circular questioning about coping Bibliotherapy Bibliotherapy Discussing objects of remembrance Discussing objects of remembrance Letter writing Letter writing Understanding attributions Understanding attributions Commemoration Commemoration Family coping planning Family coping planning

Model Intervention Session I: Understanding each other’s loss experience Part I – 90 minutes Part I – 90 minutes Family members tell their stories Family members tell their stories Assure that all speak for themselves Assure that all speak for themselves Exploration of coping Exploration of coping Circular questioning about perceptions of self and others Circular questioning about perceptions of self and others Education about grief Education about grief Child versus Adult patterns Child versus Adult patterns

Session I: Understanding each other’s loss experience Part I – 90 minutes (continued) Part I – 90 minutes (continued) Acknowledge pain and discomfort of discussing the loss again Acknowledge pain and discomfort of discussing the loss again Give parents reading material Give parents reading material The Bereft Parent (Schiff) The Bereft Parent (Schiff) Assign Homework for Session II Assign Homework for Session II Each family member to choose memory object for next session, but avoid discussing the choice at home. Each family member to choose memory object for next session, but avoid discussing the choice at home.

Session I: Understanding each other’s loss experience Part II: parents only- additional 30 minutes Part II: parents only- additional 30 minutes Explore dyadic issues Explore dyadic issues Sources of tension in the relationship (e.g., sexual disruption, replacement child, etc.) Sources of tension in the relationship (e.g., sexual disruption, replacement child, etc.) Discuss losses in family of origin context Discuss 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 histories Review personal loss histories What important losses have you suffered previously? What important losses have you suffered previously?

Session II: Making contact with the emotional loss Part I: parents only - first 30 minutes Part I: parents only - first 30 minutes Explore interval since first session Explore interval since first session Address any recent concerns Address any recent concerns Normalize the distress of reawakening grief Normalize the distress of reawakening grief Provide encouragement for coping efforts made to date Provide encouragement for coping efforts made to date

Session II: Making contact with the emotional loss Part II: family meeting- 90 minutes Part II: family meeting- 90 minutes Two Exercises: Two Exercises: Remembering the deceased child Remembering the deceased child Family letter writing Family letter writing

Session II: Making contact with the emotional loss Remembering the deceased child Remembering 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 belongings? What has been done with the child’s room and belongings? Explore cemetery visits. Explore cemetery visits. Discuss how the family has changed. Discuss how the family has changed.

Session II: Making contact with the emotional loss Family letter writing Family 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 unsaid Things left unsaid Memories shared Memories shared Unanswered questions Unanswered questions

Session III: Moving 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 person. Discuss re-involvement in the world for each person. Explore meaning-making for each person. Explore meaning-making for each person. Philosophy of life Philosophy of life Hope for the future Hope for the future Plan family activity outside the home. Plan family activity outside the home.

Warning Signs: When is professional help needed? Staying withdrawn from family and friends Staying withdrawn from family and friends Persistent blame or guilt Persistent blame or guilt Feelings of wanting to die Feelings of wanting to die Persistent anxiety; especially when separating from parents or surviving children Persistent anxiety; especially when separating from parents or surviving children Unusual and persistent performance problems at work or school Unusual and persistent performance problems at work or school New patterns of aggressive behavior New patterns of aggressive behavior Accident proneness Accident proneness Acting as though nothing happened, or happier than normal Acting as though nothing happened, or happier than normal Persistent physical complaints Persistent physical complaints Extended use of Rx or non-Rx drugs and alcohol Extended use of Rx or non-Rx drugs and alcohol

That which does not kill me postpones the inevitable.