Guidelines For The Treatment Of Traumatic Bereavement

Unpublished draft – Please doe not quote or circulate w/o permission Version 15

Version 16

GUIDELINES FOR THE TREATMENT OF TRAUMATIC BEREAVEMENT IN INFANCY AND EARLY CHILDHOOD

DRAFT

Alicia F. Lieberman, Ph.D.

Nancy Compton, Ph.D.

Patricia Van Horn, J.D., Ph.D.

Chandra Ghosh Ippen, Ph.D.

Child Trauma Research Project

University of California San Francisco

c Lieberman, Compton, Van Horn & Gosh-Ippen

Draft: Please do not circulate without permission of the authors

Unpublished draft – Please doe not quote or circulate w/o permission Version 15

Guidelines for the Treatment of Traumatic Bereavement

in Infancy and Early Childhood

Alicia F. Lieberman, Nancy Compton, Patricia Van Horn, and Chandra Ghosh Ippen

Child Trauma Research Project

University of California San Francisco

Although we know that after such a loss the acute state of mourning will subside, we also know we shall remain inconsolable and will never find a substitute. No matter what may fill the gap, even if it be filled completely, it nevertheless remains something else. And actually this is how it should be. It is the only way of perpetuating that love which we do not want to relinquish.

Sigmund Freud

The death of someone we love is the most painful emotional experience faced by human beings, an event that changes our psychological landscape because, without the person that we loved in unique and specific ways, our personal world can never be the same again. Such a loss acquires cataclysmic dimensions when a child loses a parent because children focus a vast amount of emotional energy on their parents as their main source of love and security. Younger children are particularly affected because they are almost completely dependent on the parents for their sense of security and wellbeing.

The death of a young child’s parent is always premature because it is caused by accidents, violence, or an untimely disease. As Furman (1974, p. 102) stated, “There are no peaceful deaths for parents of young children. Whenever we merely say ‘his parent died’, we leave out the inevitable horror and tragedy that such a death entails”. Nobody is truly prepared for it, least of all the child, who finds himself suddenly bereft of the person who organized his sense of physical and mental wellbeing. The younger the child, and the more involved the parent who died was in the child’s caregiving routines and daily rituals, the more disorganizing the impact of the death on the child’s psychological functioning. The child suffers a failure of the developmental expectation that the parent will be reliably available as a protector, with concomitant injury to the integrity and continuity of his sense of self (Bowlby, 1980; Pynoos, Steinberg & Piacentini, 1999).

When the parent’s death occurs suddenly and violently, and especially when the young child is a witness to it, the emotional impact of the death is immeasurably compounded by the circumstances in which it occurred. The child is overwhelmed by the scenes of fighting and distress, body damage, loud sounds, agitated movements, and specific smells that precede and occur during the death. The parent’s protection fails when the child is most in need of it, and the child’s helplessness and fear are magnified when he confronts the immobile and unresponsive body of the dead parent. After the parent dies, other stressful and traumatizing events may occur, including the sight of blood or the maimed body, the arrival of the police and/or medical personnel, efforts to assist the injured, the grief reactions of other witnesses, and the child’s separation from the parent’s body. These experiences are encoded as intrusive memories that interfere with the child’s ability to mourn, because the child cannot remember the parent without also remembering and becoming intensely distressed by the specific manner of the death (Pynoos et al., 1999). Bereavement and acute anxiety become inextricably intertwined because the child is simultaneously suffering from the loss of the parent and from unmastered fears about the circumstances surrounding the death (Furman, 1972).

These considerations suggest that a parent’s death, regardless of its circumstances, can be conceptualized as a traumatic experience when it occurs in the child’s first five years life, before the child has established an autonomous sense of self that is relatively independent of the parent’s protection. The death of a parent, in itself, comprises what Bowlby (1980) called “the trauma of loss”. The continuum of traumatic experience depends on the interplay between the circumstances of the death, whether or not the child witnessed the death, and the child’s developmental stage during the course of infancy and early childhood. When the parent died at the end of a protracted illness that allowed for some anticipatory guidance, the child did not witness the death, and the child had some prior understanding of the nature of death and is capable of some self care, the traumatic experience consists of an internal collapse in the cohesiveness and continuity of the sense of self at the loss of protection and security afforded by the dead parent. When the death is violent and unexpected and the child witnesses it, the collapse of the sense of self is more acute and complete because the child is flooded by uncontainable anxiety caused by the sensory overload from the stimuli that accompanied the death, intrusive memories, and pervasiveness of traumatic reminders that maintain the experience of the death continually present for the child.

The parent’s death often leads to drastic changes in family life that may introduce additional stresses in the child’s life. The security of the child’s attachment to the surviving parent is often negatively affected because that parent may become emotionally unavailable through self-absorption in mourning and the pressure of attending to changed life circumstances, and/or because the child blames that parent for failing to prevent the death. Changes in family composition may occur when, for example, a relative comes to live with the family to help with the crisis or when a parent feels unable to care for the child and sends him to live elsewhere. Changes in daily routine are particularly stressful for young children, both because they represent a break in predictability and because they remind the child of how the parent did things with the child when he or she was alive. These secondary stresses and other adverse life circumstances have additive negative effects on the child’s emotional health, and may lead to a confluence of co-morbid conditions, such as traumatic stress disorder, anxiety, separation anxiety, and depression (Rutter, 1985). As a result, treatment modalities must be multifocal in order to maximize predictability and respond to the range of child responses. The treatment of bereaved young children must incorporate a range of approaches depending on the individual circumstances of the death and the child’s reaction to it, with grief and trauma work integrated and calibrated in response to the child’s and family’s needs (Pynoos & Nader, 1993). The traumatic circumstances surrounding the death can recede in the child’s mind when the anxiety responses are consistently addressed, facilitating the child’s work of mourning the loss of the parent (Furman, 1974).

These guidelines describe approaches to the treatment of infants, toddlers and preschoolers who experienced the death of a parent or other primary caregiver in a range of circumstances. Although addressed to clinicians for the purpose of therapeutic work, components of the guidelines may also be useful for teachers and caregivers seeking to provide emotional support to bereaved children.

The guidelines include common reactions to loss in infancy and early childhood, assessment and treatment approaches, concrete strategies for helping children cope with the loss, and clinical vignettes. The suggestions for intervention are informed by an integration of psychoanalytic theory and attachment theory with social learning and cognitive-behavioral interventions. The reference section includes basic sources as well as more recent contributions that were helpful in developing these guidelines, including bereavement manuals for the treatment of older children. The guidelines may also be extended to other forms of early loss, including the death of a sibling or grandparent. For the sake of brevity, the word “parent” is used to denote a caregiver with whom the child has a primary attachment relationship, regardless of the biological origins of it.

An important question that must be addressed by every practitioner providing treatment to bereaved children is: “What skills do I need to be of help to the child and his family?” Working with very young children who are grieving for a lost parent presents extraordinary challenges even to experienced clinicians. Witnessing a child’s profound suffering can evoke feelings of helplessness and despair when the clinician faces the impossibility of granting the child’s most intense wish -- bringing the parent back. The clinician’s own sorrow over past losses and anxiety over traumatic experiences are invariably awakened and may be enacted in unconscious ways. These enactments frequently include anger at the child’s current caregivers for their perceived failings in supporting the child, and vivid rescue fantasies of adopting the child or finding a new and perfect family for him. The emotional burden of treating bereaved young children calls for considerable personal maturity as well as specific knowledge of the emotional needs of infants, toddlers and preschoolers and understanding of the effects of trauma and loss on early development. Consistent access to emotionally supportive consultation or supervision is essential because it helps the clinician find and retain therapeutic clarity in the course of this difficult work.

The guidelines are written for clinicians with experience in treating young children or who are in training to acquire this experience. The basic premise is that the clinician’s emotional availability and empathic responsiveness must be grounded in a solid clinical background and a working knowledge of early development. It is important not to underestimate the toll on the clinician’s emotional wellbeing that this work entails, and to establish stable and knowledgeable sources of support.

The course of grief and bereavement, always subjected to wide individual variations, is particularly unpredictable in infancy and early childhood because it is deeply affected by the child’s constitutional strengths and vulnerabilities, the quality of surrogate caregiving, and the changing circumstances of the family, including the availability and quality of environmental supports. For these reasons, our focus is less on recommending specific intervention techniques than on promoting a therapeutic attitude informed by knowledge of developmental principles and the effects of trauma and loss. These guidelines endeavor to convey a state of mind about how to treat early traumatic bereavement rather than to prescribe specific interventions. The clinician’s own creativity, experience, and emotional maturity are essential ingredients in using these guidelines to structure what is always a uniquely individual therapeutic effort to engage the child and the family in weaving a joint narrative about the parent’s death.

Parental Loss in Infancy and Early Childhood

In infants, toddlers and preschoolers, the loss of a parent has such a devastating impact on the child's sense of personal safety that it is often impossible to say where grief ends and trauma begins. Both processes are intricately connected with each other. Whether one or the other predominates depends on a combination of external and internal circumstances. External circumstances include the manner of the death, the foreknowledge the child had of it, whether the child witnessed it, and how the child was told about it. Internal circumstances involve the child’s developmental stage, cognitive skills, and emotional resources. It is safe to say, however, that traumatic stress responses are commonly observed in conjunction with grief reactions and prolonged mourning in young children who lost a parent at an early age.

For children in the first five years of life, the death of a parent can be considered a traumatic loss regardless of the circumstances in which it occurs because young children need to trust that the parent will be reliably available and protective in order to develop a sense of physical and emotional integrity. When an attachment figure dies, the child loses intimate patterns of interaction that organize key developmental domains and constitute the building blocks for the child’s sense of self. The loss produces intense and long-lasting grief, and represents a risk factor for healthy development unless the child is supported in the protracted process of mourning. This process involves overlapping stages of grieving, relinquishing the hope that the parent will return, integrating the memories of the lost parent into an ongoing sense of self, and turning to another attachment figure that can provide renewed hope in the trustworthiness of intimate emotional bonds. These overlapping processes comprise the work of mourning.

The child-parent relationship in the early years shapes the child’s sense of self. The child acquires a sense of self through regulation of bodily rhythms (e.g., eating, sleeping, elimination), modulation of emotion (e.g., experiencing and expressing a range of feelings, managing distress, coping with anger and frustration), formation and socialization of interpersonal relationships (e.g., developing attachments and forming a hierarchy of attachment relationships, learning to differentiate and relate differently to acquaintances and strangers, internalizing cultural norms for what is expected, what is permissible and what is forbidden in social exchanges), and learning from exploration of the environment, including an increasingly accurate discrimination of what is safe and what is dangerous in the child’s particular physical environment and in the background of the family’s social and cultural expectations.

For infants, toddlers, and preschoolers, these processes unfold in the context of their relationships with the parents and/or a small number of emotionally salient individuals, whom the child identifies as the providers of a secure base for self-regulation and exploration of the world. These relationships are created and buttressed by daily, repeated interactions that for the very young child involve every facet of bodily experience, including feeding, diapering, bathing, and soothing, and for the older child involve disciplining and teaching in addition to social play. The memories that the young child has of the parent are essentially interactive: the mental representations consist of the way the parent did things with the child. When the parent dies, the child loses the parent’s protective intervention and the sense of security in interactive exchanges that emerges from such protective intervention (Bowlby, 1980; Pynoos et al., 1999).