Navigating Adolescent Grief

By Diana Mahoney, New England Bureau. Share your thoughts and suggestions at clinicalpsychiatrynews@elsevier.com

“So many feelings and so much pain

Your death really hurt me; I'll never be the same

I try to express it, try to explain

So many feelings and so much pain.”

These lyrics by Thomas A. Dalton, a West Palm Beach, Fla.-based music therapist and licensed mental health counselor, give voice to the inner turmoil that many grieving adolescents feel but cannot speak.

The death of a parent, sibling, other family member, or friend can be devastating. To adolescents, the magnitude of such a loss may be exacerbated because it inevitably disrupts the normal trajectory of adolescent development.

In his seminal model of psychosocial development, Erik H. Erikson identified adolescence as a milestone of personality formation, defined primarily by the conflicting extremes of integration and separation. According to his theory, adolescents are struggling to belong and to be accepted, but they also are struggling to become individuals. Successful passage through this developmental stage requires a delicate balance (“Childhood and Society” New York: Norton, 1950).

The loss of a loved one can wreak havoc on these struggles, both by rendering the teen “different” from his peers when he longs to be one of the crowd and by inducing a heightened sense of vulnerability that can disrupt the teen's burgeoning sense of independence The adolescent might be torn between needing family support but wanting to be independent, as E.B. Weller, R.A. Weller, and J.J. Pugh wrote in the chapter titled Grief in “Child and Adolescent Psychiatry: A Comprehensive Textbook” 2nd ed. (Baltimore: Lippincott Williams & Wilkins, 1996).

The stages of grief are fairly well defined in adults, but the bereavement process in adolescents is murky. Bereaved adolescents are faced with the challenge of coping “behaviorally, cognitively, and affectively” with certain core issues as their development proceeds from one level to the next, according to ego-development research by Stephen Fleming, Ph.D, and Reba Adolph, Ph.D., which often means reliving and readapting to their loss at each developmental phase (“Adolescence and Death” New York: Springer, 1986).

The impact of grief on these issues can be seen in the findings of the Harvard Child Bereavement Study, initiated in 1987 by J. William Worden, Ph.D., and Phyllis Silverman, Ph.D. The study examined the impact of a parent's death on children and adolescents aged 6–17 by interviewing 125 children who had experienced parental loss and their surviving parent at 4 months after the death, as well as 1 and 2 years later.

Compared with their nonbereaved peers, bereaved adolescents in the study were more fearful and anxious, considered themselves academically and behaviorally inferior, had more trouble getting along with peers and struggled with a sense of belonging. The findings persisted over time, with the grieving teens exhibiting more withdrawn behavior, as well as more anxiety, depression, and social problems as assessed on the Child Behavior checklist (“Children and Grief: When a Parent Dies” New York: Guilford, 1996).

Chief among the factors that influenced the course and outcome of the adolescents' adjustment to loss in the Harvard study was how the surviving parent responded to the death. Participants were at increased risk for emotional and behavioral problems if they had experienced multiple family stressors and changes, if the surviving parent had experienced depression or other health problems, or if the surviving parent had ineffective coping skills.

Similar findings were reported more recently by Julie Cerel, Ph.D., of the University of Kentucky, Lexington, and her colleagues. The investigators interviewed 360 parent-bereaved children between the ages of 6 and 17 and their surviving parents four times during the first 2 years after the death and compared psychiatric symptoms among the bereaved children with those of community control children and their parents.

The investigators also compared the symptoms of children and adolescents with simple bereavement (no significant other stressors) to those of complex bereaved children with an average of 1.7 additional stressors, such as another death or serious illness in the extended family (J. Am. Acad. Child Adolesc. Psychiatry 2006;45:681-90).

Compared with community controls, bereaved children and adolescents experienced significantly more psychiatric problems in the first 2 years after death, particularly among youth of depressed parents and those from families of lower socioeconomic status, the authors reported. The findings provide compelling evidence in favor of preventive efforts that include screening bereaved children and teens for such risk factors as depressive symptoms in the surviving parent, additional family stressors, and lower socioeconomic status to identify those youth who might require more careful monitoring and whose parents might be in need of support, the authors wrote.

A preventive approach to adolescent grief does not, however, imply that the grief is preventable, but rather that the potential negative consequences can be minimized by providing bereaved teens the support they need to develop into mentally healthy adults. Importantly, according to Donna Schuurman, Ed.D., national director of the Dougy Center for Grieving Children and Families in Portland, Ore., “Grief is not an illness that needs to be cured. It's not a task with definable, sequential steps. It's not a bridge to cross, a burden to bear, or an experience to recover from. It is a normal, healthy, and predictable response to loss.”

In this regard, grieving children and adolescents need to be allowed to grieve and to make their own meaning in a safe, healthy environment, Dr. Schuurman said.

The above song lyrics represent what can happen when bereaved adolescents are supported in their grieving process. The lyrics are a product of an integrated grief model and music therapy protocol called the Grief Song-Writing Process (GSWP) developed and implemented by Mr. Dalton, the music therapist and mental health counselor, and Robert E. Krout, Ed.D., head of the music therapy department at Southern Methodist University, Dallas (Music Therapy Perspectives 2006;24:94-107).

The development of the GSWP comprised three phases: a descriptive, thematic analysis of songs previously written by bereaved adolescents in individual music therapy; a comparison of existing grief models with the song theme areas, and the identification of an integrated grief model, including five grief process areas (understanding, feeling, remembering, integrating, and growing); and the actual songwriting protocol through which bereaved adolescents created music and wrote original lyrics that focused on each of the five grief process areas. The 7-week GSWP protocol was implemented with four groups of bereaved adolescents ranging in age from 12 to 18 years old. Each of the seven sessions had a specific purpose. The first session was designed to develop group cohesion, clarify guidelines, and explore instruments and recording technologies. Education about grieving myths and normal grief reactions was incorporated into this session. In the second session, which focused on the grief theme of understanding, group members were encouraged to share their stories and individual experiences using the following chorus lyric from a precomposed song as a guide: “This is how it happened.”

Sessions three, four, and five, respectively, focused on the themes of feeling, remembering, and integrating, also using a precomposed lyric as a starting point. The focus of the sixth session was the theme of growing. Finally, session seven was a memorial and celebration of the lives of the loved ones who had died, according to the authors.

“Songwriting using the GSWP proved to be engaging and offered a safe, creative method of addressing the difficult subject matter of a loved one's death,” the authors wrote. The findings of a pilot study measuring progress in the five grief process areas addressed by the GSWP using a 30-item measure called the Grief Processing Scale developed and validated by the authors suggested positive changes for participants in the treatment groups relative to controls in overall scores as well as in scores from each of the five grief subscales, the authors reported.

Healthy, adaptive grief will be an ongoing challenge for bereaved adolescents. But the development of flexible interventions such as the GSWP should be promoted in order to provide adolescents with “creative ways in which to progress through their own unique journeys of healing,” the authors stressed.

Perspective

If you have models for how life works, you feel a sense of mastery and power because, as a result of knowing, you can adjust your thinking and behavior to make yourself less vulnerable. This is a critical component of building resiliency in bereaved adolescents.

Helping adolescents develop and understand models of how life and death operate, for example, aids in the development of their cognitive capacity to understand where overwhelming feelings originate and how to control them. By being able to talk about patterns in life–that predictability marks some but not all events and that fairness and justice mark some but not all outcomes, as per the Fleming/Adolph construct–an adolescent gains some frontal lobe understanding of the emotional storm that has been set off by the death.

Through that understanding, the adolescent becomes better equipped to actively respond to the emotional storm rather than passively reacting to it. Thus, instead of “feel and react,” the adolescent learns to “feel, stop, think, then act consciously.” In this way, therapy can help guide youth to engage in acts of mastery and self-control over their grief, which translates into a sense of power and self-confidence.

The simple act of feeling connected to an empathetic therapist who can name and understand the adolescent's pain and who provides a safe environment in which to ask the “Why me?” question and make the “God is not fair” accusation helps relieve the pain. It can also play an important role in mitigating the issues that can plague grieving adolescents, including self-consciousness; fear of being labeled abnormal; feelings of detachment, shame, and guilt; behavioral disturbances; alcohol and drug use; violence; and sexual acting out.

The need for such a connection is especially important as adolescents move through developmental stages and achieve different levels of understanding. Having a safe place in which to revisit the death and fit the accompanying emotions into the bigger grief puzzle gives the adolescent insight into the complete picture.

By Diana Mahoney, New England Bureau. Share your thoughts and suggestions at clinicalpsychiatrynews@elsevier.com

“So many feelings and so much pain

Your death really hurt me; I'll never be the same

I try to express it, try to explain

So many feelings and so much pain.”

These lyrics by Thomas A. Dalton, a West Palm Beach, Fla.-based music therapist and licensed mental health counselor, give voice to the inner turmoil that many grieving adolescents feel but cannot speak.

The death of a parent, sibling, other family member, or friend can be devastating. To adolescents, the magnitude of such a loss may be exacerbated because it inevitably disrupts the normal trajectory of adolescent development.

In his seminal model of psychosocial development, Erik H. Erikson identified adolescence as a milestone of personality formation, defined primarily by the conflicting extremes of integration and separation. According to his theory, adolescents are struggling to belong and to be accepted, but they also are struggling to become individuals. Successful passage through this developmental stage requires a delicate balance (“Childhood and Society” New York: Norton, 1950).

The loss of a loved one can wreak havoc on these struggles, both by rendering the teen “different” from his peers when he longs to be one of the crowd and by inducing a heightened sense of vulnerability that can disrupt the teen's burgeoning sense of independence The adolescent might be torn between needing family support but wanting to be independent, as E.B. Weller, R.A. Weller, and J.J. Pugh wrote in the chapter titled Grief in “Child and Adolescent Psychiatry: A Comprehensive Textbook” 2nd ed. (Baltimore: Lippincott Williams & Wilkins, 1996).

The stages of grief are fairly well defined in adults, but the bereavement process in adolescents is murky. Bereaved adolescents are faced with the challenge of coping “behaviorally, cognitively, and affectively” with certain core issues as their development proceeds from one level to the next, according to ego-development research by Stephen Fleming, Ph.D, and Reba Adolph, Ph.D., which often means reliving and readapting to their loss at each developmental phase (“Adolescence and Death” New York: Springer, 1986).

The impact of grief on these issues can be seen in the findings of the Harvard Child Bereavement Study, initiated in 1987 by J. William Worden, Ph.D., and Phyllis Silverman, Ph.D. The study examined the impact of a parent's death on children and adolescents aged 6–17 by interviewing 125 children who had experienced parental loss and their surviving parent at 4 months after the death, as well as 1 and 2 years later.

Compared with their nonbereaved peers, bereaved adolescents in the study were more fearful and anxious, considered themselves academically and behaviorally inferior, had more trouble getting along with peers and struggled with a sense of belonging. The findings persisted over time, with the grieving teens exhibiting more withdrawn behavior, as well as more anxiety, depression, and social problems as assessed on the Child Behavior checklist (“Children and Grief: When a Parent Dies” New York: Guilford, 1996).

Chief among the factors that influenced the course and outcome of the adolescents' adjustment to loss in the Harvard study was how the surviving parent responded to the death. Participants were at increased risk for emotional and behavioral problems if they had experienced multiple family stressors and changes, if the surviving parent had experienced depression or other health problems, or if the surviving parent had ineffective coping skills.

Similar findings were reported more recently by Julie Cerel, Ph.D., of the University of Kentucky, Lexington, and her colleagues. The investigators interviewed 360 parent-bereaved children between the ages of 6 and 17 and their surviving parents four times during the first 2 years after the death and compared psychiatric symptoms among the bereaved children with those of community control children and their parents.

The investigators also compared the symptoms of children and adolescents with simple bereavement (no significant other stressors) to those of complex bereaved children with an average of 1.7 additional stressors, such as another death or serious illness in the extended family (J. Am. Acad. Child Adolesc. Psychiatry 2006;45:681-90).

Compared with community controls, bereaved children and adolescents experienced significantly more psychiatric problems in the first 2 years after death, particularly among youth of depressed parents and those from families of lower socioeconomic status, the authors reported. The findings provide compelling evidence in favor of preventive efforts that include screening bereaved children and teens for such risk factors as depressive symptoms in the surviving parent, additional family stressors, and lower socioeconomic status to identify those youth who might require more careful monitoring and whose parents might be in need of support, the authors wrote.

A preventive approach to adolescent grief does not, however, imply that the grief is preventable, but rather that the potential negative consequences can be minimized by providing bereaved teens the support they need to develop into mentally healthy adults. Importantly, according to Donna Schuurman, Ed.D., national director of the Dougy Center for Grieving Children and Families in Portland, Ore., “Grief is not an illness that needs to be cured. It's not a task with definable, sequential steps. It's not a bridge to cross, a burden to bear, or an experience to recover from. It is a normal, healthy, and predictable response to loss.”

In this regard, grieving children and adolescents need to be allowed to grieve and to make their own meaning in a safe, healthy environment, Dr. Schuurman said.

The above song lyrics represent what can happen when bereaved adolescents are supported in their grieving process. The lyrics are a product of an integrated grief model and music therapy protocol called the Grief Song-Writing Process (GSWP) developed and implemented by Mr. Dalton, the music therapist and mental health counselor, and Robert E. Krout, Ed.D., head of the music therapy department at Southern Methodist University, Dallas (Music Therapy Perspectives 2006;24:94-107).

The development of the GSWP comprised three phases: a descriptive, thematic analysis of songs previously written by bereaved adolescents in individual music therapy; a comparison of existing grief models with the song theme areas, and the identification of an integrated grief model, including five grief process areas (understanding, feeling, remembering, integrating, and growing); and the actual songwriting protocol through which bereaved adolescents created music and wrote original lyrics that focused on each of the five grief process areas. The 7-week GSWP protocol was implemented with four groups of bereaved adolescents ranging in age from 12 to 18 years old. Each of the seven sessions had a specific purpose. The first session was designed to develop group cohesion, clarify guidelines, and explore instruments and recording technologies. Education about grieving myths and normal grief reactions was incorporated into this session. In the second session, which focused on the grief theme of understanding, group members were encouraged to share their stories and individual experiences using the following chorus lyric from a precomposed song as a guide: “This is how it happened.”

Sessions three, four, and five, respectively, focused on the themes of feeling, remembering, and integrating, also using a precomposed lyric as a starting point. The focus of the sixth session was the theme of growing. Finally, session seven was a memorial and celebration of the lives of the loved ones who had died, according to the authors.

“Songwriting using the GSWP proved to be engaging and offered a safe, creative method of addressing the difficult subject matter of a loved one's death,” the authors wrote. The findings of a pilot study measuring progress in the five grief process areas addressed by the GSWP using a 30-item measure called the Grief Processing Scale developed and validated by the authors suggested positive changes for participants in the treatment groups relative to controls in overall scores as well as in scores from each of the five grief subscales, the authors reported.

Healthy, adaptive grief will be an ongoing challenge for bereaved adolescents. But the development of flexible interventions such as the GSWP should be promoted in order to provide adolescents with “creative ways in which to progress through their own unique journeys of healing,” the authors stressed.

Perspective

If you have models for how life works, you feel a sense of mastery and power because, as a result of knowing, you can adjust your thinking and behavior to make yourself less vulnerable. This is a critical component of building resiliency in bereaved adolescents.

Helping adolescents develop and understand models of how life and death operate, for example, aids in the development of their cognitive capacity to understand where overwhelming feelings originate and how to control them. By being able to talk about patterns in life–that predictability marks some but not all events and that fairness and justice mark some but not all outcomes, as per the Fleming/Adolph construct–an adolescent gains some frontal lobe understanding of the emotional storm that has been set off by the death.

Through that understanding, the adolescent becomes better equipped to actively respond to the emotional storm rather than passively reacting to it. Thus, instead of “feel and react,” the adolescent learns to “feel, stop, think, then act consciously.” In this way, therapy can help guide youth to engage in acts of mastery and self-control over their grief, which translates into a sense of power and self-confidence.

The simple act of feeling connected to an empathetic therapist who can name and understand the adolescent's pain and who provides a safe environment in which to ask the “Why me?” question and make the “God is not fair” accusation helps relieve the pain. It can also play an important role in mitigating the issues that can plague grieving adolescents, including self-consciousness; fear of being labeled abnormal; feelings of detachment, shame, and guilt; behavioral disturbances; alcohol and drug use; violence; and sexual acting out.

The need for such a connection is especially important as adolescents move through developmental stages and achieve different levels of understanding. Having a safe place in which to revisit the death and fit the accompanying emotions into the bigger grief puzzle gives the adolescent insight into the complete picture.

By Diana Mahoney, New England Bureau. Share your thoughts and suggestions at clinicalpsychiatrynews@elsevier.com

“So many feelings and so much pain

Your death really hurt me; I'll never be the same

I try to express it, try to explain

So many feelings and so much pain.”

These lyrics by Thomas A. Dalton, a West Palm Beach, Fla.-based music therapist and licensed mental health counselor, give voice to the inner turmoil that many grieving adolescents feel but cannot speak.

The death of a parent, sibling, other family member, or friend can be devastating. To adolescents, the magnitude of such a loss may be exacerbated because it inevitably disrupts the normal trajectory of adolescent development.

In his seminal model of psychosocial development, Erik H. Erikson identified adolescence as a milestone of personality formation, defined primarily by the conflicting extremes of integration and separation. According to his theory, adolescents are struggling to belong and to be accepted, but they also are struggling to become individuals. Successful passage through this developmental stage requires a delicate balance (“Childhood and Society” New York: Norton, 1950).

The loss of a loved one can wreak havoc on these struggles, both by rendering the teen “different” from his peers when he longs to be one of the crowd and by inducing a heightened sense of vulnerability that can disrupt the teen's burgeoning sense of independence The adolescent might be torn between needing family support but wanting to be independent, as E.B. Weller, R.A. Weller, and J.J. Pugh wrote in the chapter titled Grief in “Child and Adolescent Psychiatry: A Comprehensive Textbook” 2nd ed. (Baltimore: Lippincott Williams & Wilkins, 1996).

The stages of grief are fairly well defined in adults, but the bereavement process in adolescents is murky. Bereaved adolescents are faced with the challenge of coping “behaviorally, cognitively, and affectively” with certain core issues as their development proceeds from one level to the next, according to ego-development research by Stephen Fleming, Ph.D, and Reba Adolph, Ph.D., which often means reliving and readapting to their loss at each developmental phase (“Adolescence and Death” New York: Springer, 1986).

The impact of grief on these issues can be seen in the findings of the Harvard Child Bereavement Study, initiated in 1987 by J. William Worden, Ph.D., and Phyllis Silverman, Ph.D. The study examined the impact of a parent's death on children and adolescents aged 6–17 by interviewing 125 children who had experienced parental loss and their surviving parent at 4 months after the death, as well as 1 and 2 years later.

Compared with their nonbereaved peers, bereaved adolescents in the study were more fearful and anxious, considered themselves academically and behaviorally inferior, had more trouble getting along with peers and struggled with a sense of belonging. The findings persisted over time, with the grieving teens exhibiting more withdrawn behavior, as well as more anxiety, depression, and social problems as assessed on the Child Behavior checklist (“Children and Grief: When a Parent Dies” New York: Guilford, 1996).

Chief among the factors that influenced the course and outcome of the adolescents' adjustment to loss in the Harvard study was how the surviving parent responded to the death. Participants were at increased risk for emotional and behavioral problems if they had experienced multiple family stressors and changes, if the surviving parent had experienced depression or other health problems, or if the surviving parent had ineffective coping skills.

Similar findings were reported more recently by Julie Cerel, Ph.D., of the University of Kentucky, Lexington, and her colleagues. The investigators interviewed 360 parent-bereaved children between the ages of 6 and 17 and their surviving parents four times during the first 2 years after the death and compared psychiatric symptoms among the bereaved children with those of community control children and their parents.

The investigators also compared the symptoms of children and adolescents with simple bereavement (no significant other stressors) to those of complex bereaved children with an average of 1.7 additional stressors, such as another death or serious illness in the extended family (J. Am. Acad. Child Adolesc. Psychiatry 2006;45:681-90).

Compared with community controls, bereaved children and adolescents experienced significantly more psychiatric problems in the first 2 years after death, particularly among youth of depressed parents and those from families of lower socioeconomic status, the authors reported. The findings provide compelling evidence in favor of preventive efforts that include screening bereaved children and teens for such risk factors as depressive symptoms in the surviving parent, additional family stressors, and lower socioeconomic status to identify those youth who might require more careful monitoring and whose parents might be in need of support, the authors wrote.

A preventive approach to adolescent grief does not, however, imply that the grief is preventable, but rather that the potential negative consequences can be minimized by providing bereaved teens the support they need to develop into mentally healthy adults. Importantly, according to Donna Schuurman, Ed.D., national director of the Dougy Center for Grieving Children and Families in Portland, Ore., “Grief is not an illness that needs to be cured. It's not a task with definable, sequential steps. It's not a bridge to cross, a burden to bear, or an experience to recover from. It is a normal, healthy, and predictable response to loss.”

In this regard, grieving children and adolescents need to be allowed to grieve and to make their own meaning in a safe, healthy environment, Dr. Schuurman said.

The above song lyrics represent what can happen when bereaved adolescents are supported in their grieving process. The lyrics are a product of an integrated grief model and music therapy protocol called the Grief Song-Writing Process (GSWP) developed and implemented by Mr. Dalton, the music therapist and mental health counselor, and Robert E. Krout, Ed.D., head of the music therapy department at Southern Methodist University, Dallas (Music Therapy Perspectives 2006;24:94-107).

The development of the GSWP comprised three phases: a descriptive, thematic analysis of songs previously written by bereaved adolescents in individual music therapy; a comparison of existing grief models with the song theme areas, and the identification of an integrated grief model, including five grief process areas (understanding, feeling, remembering, integrating, and growing); and the actual songwriting protocol through which bereaved adolescents created music and wrote original lyrics that focused on each of the five grief process areas. The 7-week GSWP protocol was implemented with four groups of bereaved adolescents ranging in age from 12 to 18 years old. Each of the seven sessions had a specific purpose. The first session was designed to develop group cohesion, clarify guidelines, and explore instruments and recording technologies. Education about grieving myths and normal grief reactions was incorporated into this session. In the second session, which focused on the grief theme of understanding, group members were encouraged to share their stories and individual experiences using the following chorus lyric from a precomposed song as a guide: “This is how it happened.”

Sessions three, four, and five, respectively, focused on the themes of feeling, remembering, and integrating, also using a precomposed lyric as a starting point. The focus of the sixth session was the theme of growing. Finally, session seven was a memorial and celebration of the lives of the loved ones who had died, according to the authors.

“Songwriting using the GSWP proved to be engaging and offered a safe, creative method of addressing the difficult subject matter of a loved one's death,” the authors wrote. The findings of a pilot study measuring progress in the five grief process areas addressed by the GSWP using a 30-item measure called the Grief Processing Scale developed and validated by the authors suggested positive changes for participants in the treatment groups relative to controls in overall scores as well as in scores from each of the five grief subscales, the authors reported.

Healthy, adaptive grief will be an ongoing challenge for bereaved adolescents. But the development of flexible interventions such as the GSWP should be promoted in order to provide adolescents with “creative ways in which to progress through their own unique journeys of healing,” the authors stressed.

Perspective

If you have models for how life works, you feel a sense of mastery and power because, as a result of knowing, you can adjust your thinking and behavior to make yourself less vulnerable. This is a critical component of building resiliency in bereaved adolescents.

Helping adolescents develop and understand models of how life and death operate, for example, aids in the development of their cognitive capacity to understand where overwhelming feelings originate and how to control them. By being able to talk about patterns in life–that predictability marks some but not all events and that fairness and justice mark some but not all outcomes, as per the Fleming/Adolph construct–an adolescent gains some frontal lobe understanding of the emotional storm that has been set off by the death.

Through that understanding, the adolescent becomes better equipped to actively respond to the emotional storm rather than passively reacting to it. Thus, instead of “feel and react,” the adolescent learns to “feel, stop, think, then act consciously.” In this way, therapy can help guide youth to engage in acts of mastery and self-control over their grief, which translates into a sense of power and self-confidence.

The simple act of feeling connected to an empathetic therapist who can name and understand the adolescent's pain and who provides a safe environment in which to ask the “Why me?” question and make the “God is not fair” accusation helps relieve the pain. It can also play an important role in mitigating the issues that can plague grieving adolescents, including self-consciousness; fear of being labeled abnormal; feelings of detachment, shame, and guilt; behavioral disturbances; alcohol and drug use; violence; and sexual acting out.

The need for such a connection is especially important as adolescents move through developmental stages and achieve different levels of understanding. Having a safe place in which to revisit the death and fit the accompanying emotions into the bigger grief puzzle gives the adolescent insight into the complete picture.