The grief process of a child survivor
Helping children who lost their loved ones to natural disaster can be challenging for family members, teachers, counsellors, as well as psychiatrists. The case presents here is an eleven-year-old boy who was interdependent with his single mother before the 921 Earthquake. Unfortunately, he lost his mother to the catastrophe. The boy experienced some traumatic reactions, such as refused to talk about the disaster and showed no emotions about his great loss. He seemed not know how to cope with his grief for his deceased mother. Through the utilization of expressive art materials, the boy was able to cope with his grief and move on with his life. This paper intends to demonstrate how to use expressive art materials as the vehicle of grief counselling to help those traumatized children to cope with their grief.
Helping children who lost their loved ones to natural disaster can be challenging for family members, teachers, counsellors, as well as psychiatrists. Through the utilization of expressive art materials, the boy was able to cope with his grief and move on with his life. The reason for using expressive art materials is that children are familiar with those materials. Most of them enjoy drawing, playing, coloring, and sculpturing. It provides children a safe place to do something they are familiar with. Additionally, it creates a non-threatening and relaxing environment for the children to express themselves. In this case report, the therapist demonstrate s how to use expressive art materials as the vehicle of grief counselling.
The case presents here is an eleven-year-old boy who was interdependent with his single mother before the 921 Earthquake. Unfortunately, he lost his mother to the catastrophe. The boy experienced some traumatic reactions, such as refusal to talk about the disaster and showing no emotions about his great loss.
The single mother was not able to raise her boy all by herself. In order to provide and care for her son, she had to entrust her sister to take care of her boy during the weekdays while she worked out of town to be financially independent. Weekends were the boy’s only chance to spend time with his mother. Not having a father and other siblings around, the single mother was the boy’s closest family.
T he 921 Earthquake (also known as Chi-Chi Earthquake) which struck central Taiwan on September 21, 1999, with a magnitude of 7.6 on the Richter scale, was responsible for approximately 2,415 deaths. Houses in affected areas were collapsed or severely damaged. Many residents were crushed to death in their sleep. The boy’s mother was one of those victims. Her body was dug out two weeks later.
After discovering the deceased single mother from a collapsed building, the boy was notified to identify her. Upon seeing the corpse from the rubbles, he could not contain himself and immediately wailed over his deceased mother. Contrary to his initial reactions to his mother’s death, the boy became withdraw shortly after his realization of his mother’s death. He became unusually quiet and anxious. Those reactions alerted his school teachers and counsellors. With the boy’s refusals to neither speak nor express feelings, counselling became challenging to the teachers and counsellors. Consequently, a professional psychotherapist was introduced to the boy. A total of 7 grief counselling sessions were conducted. The therapist assisted the boy to cope with his grief through the utilization of expressive art materials.
The grief process of children
Cohen, Mannarino, Pardio, and Shipley (2002) claim that childhood traumatic grief (CTG) consists of normal bereavement process and posttraumatic stress disorder (PTSD). Typical symptoms include reliving the event, avoidance, feeling numb and hyperarousal. Other symptoms include irritability, anger, guilt, shame, depression, hopelessness, suicidal ideations, feeling alienated and alone, substance abuse, insomnia, decreasing concentration, dropping grade, stomach ache, headache, chest pain and hyper vigilance. Fears about ones own or other’s safety are examples of hyper arousal. It is called Acute Stress Disorder (ASD) if the symptoms last for a minimum of 2 days and a maximum of 4 weeks and occurs within 4 weeks of the traumatic event (DSM IV, 1994). These symptoms interfered with a child’s ability to navigate the typical bereavement process. Any thoughts or reminders, even happy ones, of the person who died could lead to frightening thoughts, images or memories of how the person died. And it maybe invalid on the child’s ability to complete the tasks of reconciliation.
The conceptualization of death for a presumed mature adult is similar to that for the adult. They should understand that all living creatures must die (universality), the physical body cannot be made alive over again once it dies (irreversibility), it cannot do anything it ever did when it was alive, such as eating, breathing, loving, learning (nonfunctionality). The bereavement responses of children include emotional, behavioral, interpersonal, thinking, perceptional, physical, and academic parts (Brent, Speece, Lin, Dong, &Yang, 1996).
After the psychological assessment, the therapist found that the boy experienced dizziness, mild headache, increased vigilance of earthquake, anxiety without any reasons, fear for ones own or other’s safety, and had intrusive thoughts on the traumatic event involuntarily. However, he also acted as if he was not upset, not only seldom talked about the earthquake, but also rarely expressed sad feelings. According to the symptoms, CTG or ASD is the impression for the boy after losing a loved one.
The tasks of grief are to accept the established fact of loss, to go through the grief process with the pain, to adapt to the new lifestyle, to modify the emotion in order to move on with life. The key point of CTG is not the ability of children to understand, but the ability to feel pain feelings. The problems of children under the impression of CTG are limited ability to express their feelings, to tolerate the pain during confirming their experience of loss. Children are afraid of and sensitive to the difference from others. After the loss of loved ones, adults usually get other people's care and comfort, but children don’t like to talk about this topic with other kids to preclude the discomfort of remembering their loss. Therefore, the author suggests that therapists may abandon traditional ways of talking therapy and teach children how to express their feelings to cope with grief.
The application of expressive art materialsIt is common to use expressive art materials in psychotherapy, especially for children. There are many kinds of expressive art materials including creative materials e.g. markers, crayons, play dough, colored paper), nurturing materials (e.g. baby’s bottle, dolls, small blankets, medical kits), dramatic materials (e.g. puppets, stuffed toys, doll house, animals, vehicles), and aggressive materials (e.g. air percussion stick, boxing bag, knife, sword) (Irwin & Malloy, 2001). In the context of fun-filled and non-threatening playing, children would easily feel interested and safe. Those expressive art materials would help open children’s mind and improve their interactions between microcosm and internal world. Hopefully, the context would effectively direct them to explore the core of the problem and reveal the experience which might be hardly expressed before. Through the utilization of expressive materials, children may reveal their inherent thoughts and feelings, learn to deal with terrible emotions, find solutions to their concerns, and then activate the healing process. For example, the process of painting usually makes children aware of some feelings towards their hidden wounds.
The therapists from the previous debriefing groups indicated that the boy was quite frightened. During the group sessions, the boy asserted, "Evil and Cyclops revived, so it was dangerous everywhere, and the world would be destroyed. There were some armed persons looking for magic treasure to save people." It seems that the utilization of expressive art materials would suit the boy’s needs well. Thus, the author planned to use expressive art materials to assist the boy in exploring his hidden emotions and engage him into the context of treatment.
Session 1: Oct. 18, 1999
Markers, papers, play dough, and puppets were prepared for the session.
After the therapist and client greeted each other, the client picked out two sets of play dough and handed one set to the therapist. He said, “This one is for you so that you can play with it, too”. He appeared to be much more mature than most boys of his age. He had shown how he took ownership of his life and he also cared about sharing with others.
Later, when the therapist started talking about the event of the 921 Earthquake and his mother, the boy became quiet and he grabbed a puppet in his hand not knowing what to do. His reactions indicated that he might not know how to cope with his grief. With his refusal to talk about the traumatic event, the therapist changed her tactics and started to play with the set of play dough that the boy had handed her earlier. The boy started playing with his set of play dough as well. He first made a caterpillar and then he made a house with some decorations. While making the house, he started making comments. With a bleak look, he stated, “All was gone! There was no house. Mother was no longer there. There were no toys. No one could come to the rescue…I did not know what to do.” With tears in his eyes, he stopped talking.
At that moment, the therapist grabbed some markers and started drawing. She explained to the boy that colours could represent feelings, and encouraged him to express his feelings as well as thoughts through drawing. He followed the therapist’s instruction and commented, “Black represents fear, blue represents sadness, pink represents confusion, and white represents helplessness.” As soon as he finished his drawings, he began to cover each colour up with the play dough and asserted, “No more fear, no more sadness, and no more confusion.” He then opened up and started telling the therapist about the night of the 921 Earthquake. When he finished talking, the therapist ended the session and thanked him for sharing his thoughts and feelings with her. The utilization of expressive art materials seemed to have successfully opened up the boy’s heart and helped him to express his feelings.
Session 2: Oct 25, 1999
Markers, papers, play dough, and puppets were again prepared for the session. In addition, the boy helped to prepare and select the medical kit and stethoscope.
At the beginning of the session, the boy picked up the medical kit, stethoscope and then the puppet. However, he dropped the puppet shortly after he touched it. The puppet had reminded him of the painful reality - his mother’s death. Though he tried to compose himself to remain calm, he was still on the verge of crying. Then he quickly masked his emotions.
Upon accepting the established fact of his mother’s death, he started talking about his mother and how he would like to live with her forever if possible. He also expressed his anger toward his father. According to the boy, his father was an angry man. He had never supported the family and was violent toward family members. In order to protect her boy from harm, the mother had filed for divorce, which was finalized two years before the earthquake occurred. When the catastrophe happened, the father was in jail serving a sentence. Seemingly, the boy was quite lonesome and forced to face reality alone. The boy carried on talking about how he had numerous nightmares about his mother after the tragedy, but he simply refused to talk about anything in the future.
The boy appeared to be struggling with his memories of his mother. He refused to draw pictures of her, but he would pick up some play dough to sculpt the image of his mother. While making the sculpture, he would point out the details and explained, “Mom had long hair and she was a neat person. This is her head, her eyes, her nose, her neck and her body, but she could not stand up anymore.” When he got too emotional, he protested, “I could not finish the sculpting.” The therapist comforted him, and then encouraged him to complete it and he did. Upon completion of the artwork, he spotted a crack and he proclaimed, “There is a crack.” His comment sounded as if he was saying that my memories of my mother had been broken just like the crack on the sculpture and was no longer complete. It was heartbroken to see the sadness in him when he finally started to open up.
Session 3: Nov 1, 1999
Markers, papers, play dough and puppets were prepared as usual. Additionally, the boy selected the vampire puppet to play for this session.
The vampire puppet was the boy’s first pick when the session started. He soon switched to the play dough sculpture of his mother that he had made last session. He started colouring the sculpture and carried some small conversations from time to time. Mainly, he talked about his mother of how she used to make the most delicious corn soup and how she’d like to cruise around with her convertible. He also expressed how sad he was toward his mother’s unexpected death. Then, he decided that it maybe for the best that his mother was no longer alive so that she did not have to work so hard to provide and to care for him. The sacrifices and the heavy load of financial responsibility of being a single mother had always pained his grandmother strongly to see her daughter struggling so hard to build a life for her and her son. Though he had tried to comfort his grandmother, but he could never take away her pain completely.
The therapist shared her grief experience of her deceased father with the boy when she felt the ambivalence shown by him. The thoughts of her deceased father had made her sad again and she could not stop tearing. Being a sweet sensitive boy, he started to comfort the therapist and said, “Please don’t cry. You will ruin the moment. How old were you when your dad passed away?” The therapist appreciated his consideration and told him that it was okay to cry over a loss of loved ones. It was not healthy to keep it all to self. It’s necessary for people to channel their emotions so that they can move on to live a healthy happy life. He then admitted how he had been wondering and worrying about his future, but he simply did not know what to do. Up to this point, the boy opened up even more and started to share his thoughts.
Session 4: Nov 8, 1999
This week, the therapist added water-based colorants to the usual expressive art kit. The boy also picked the air percussion sticks to play with. He even brought some candies and cookies from the teacher’s office to share with the therapist.
At the beginning of the session, the boy acted like any boy of his age being playful. He ran around and waving his blue percussion sticks in the air. He even blew the whistle on the percussion sticks a few times. Then, all of a sudden, he stopped his play and he said that he would like to do something for his mother at the funeral. Typically, paper-built house, paper-built cars, fake paper bills, clothes and some personal belongings would be burnt at the funeral to accompany the deceased to the world of after-life so that the deceased person would have continued wealth to live comfortably in another world. The boy knew that his mother would have everything that she needed, but he still liked to give her some kind of gift. He then decided to make a pot with play dough to give it to his mother at the funeral.
Later, the therapist brought up the subject of saying a formal goodbye to his mother. Upon hearing her suggestion, he became quiet. The therapist did not know if he was rejecting the thoughts of saying goodbye to his mother or simply because he did not know how. The therapist picked up all the puppets and told him to pretend that these puppets were his family. Then, the therapist asked the boy who would say goodbye to his mother. He picked up a puppet and said that grandma would. With tears in his eyes, he moved the puppet close to the sculpture of his mother that he had made a couple weeks ago, and pretending that grandma was saying goodbye to his mother. The therapist asked him, “Who’s next?” He got close to the sculpture and said his goodbye to his mother with a much light-hearted attitude. His responsiveness and trust denoted his improvement on coping with his grief.
Session 5: Nov 15, 1999
The therapist followed the same routine to prepare the expressive art kit and the boy picked out his air percussion sticks again this week.
The boy started to play with the percussion sticks for a while. When he was done playing, he could not decide what he would like to do next. The therapist started to review his progress with him. While doing the review, he picked up a marker and a piece of paper started drawing. He listened to the therapist without making any comments. After a while, he raised his head and said, “I would like to fold some paper cranes for my mother in heaven and sent all these things to her as well”. He meant to burn the pot and sculpture of his mother that were made of play dough, along with all the paper cranes in order to deliver them to heaven. Then, the therapist started to look for a lighter and a metal can so that he could burn those items and send them to his mother in heaven. While the therapist was looking for a lighter and metal can, he started to fold some more paper cranes. Toward the end of the session, he still had some paper cranes that he could not finish folding. Because the therapist could not find a lighter and a metal can, she decided to postpone the delivery ritual for the next session.
Session 6: Nov 22, 1999
The therapist prepared a lighter and a metal can to finish up the ritual for the boy. The ritual took place at the dumpsite where they could safely burn those items.
The boy had made a lot of paper money worth millions of dollars and he thought that should be plenty for his mother. To be on the safe side, he decided to make two paper blank checks so that his mother would have the option of cashing the checks if she needed more. Then he moved on to fold two paper servants so that his mother could be well taken care of in heaven. Next, he made two paper babies, one is male and another is female, because his mother wanted a daughter all the time. The babies could keep his mother busy and to accompany her as well. Finally, he thought of making paper earthquakes. He said, “I could make some paper earthquakes and put bans on them so that they could never come back and hurt people again.”
When the boy finished preparing everything that he would like to burn, the therapist took a moment to talk with him before the ritual. The therapist tried to explain and to make him understand that his mother would be a beautiful memory from now on. He may dream about his mother from time to time, but he shall not continue to dwell on his grief. He would live with his aunt and learned to be independent. When the therapist finished talking, he was so anxious to start the ritual. The therapist finally started the fire and he started to toss items that he had prepared into the fire. As he tossing them, he yelled, “Burn, burn, burn, and never come back.” The ritual of burning symbolizes that his fears have turned to ashes and gone with winds. The bell rang and it was time for his gym class, but he was reluctant to leave. He waited until the fire died down.
Session 7: Nov 29, 1999
This was the final session. The therapist and the boy went back to the dumpsite to check on the stuff that they had burned the week before.
< progress>As soon as they got to the dumpsite, the boy went straight to the pile of ashes and checked to see if there was anything left. He found nothing, but ashes. He said, “I wish there were a river so that we could spread the ashes into the river and let the ashes flow with the river. Because there was no river around, the therapist suggested that they buried ashes.” Then, he looked for a spot and started digging and burying the ashes all by himself. The therapist reminded him that it was time to say his final goodbye, but he was not ready for it and he protested. The therapist talked with him a little more and explained the importance of saying his final goodbye. After the therapist’s explanations, he said his final goodbye to his mother. After saying goodbye, he talked a little bit more about his aunt’s family and how he despised his father. The therapist allowed the boy to speak his mind and vent a little. Finally, it was time for them to say goodbye. The therapist gave the boy a present and wished him the best for his future.
In the very beginning, the boy’s silence and lack of expressions made the therapist worry. However, his level of responsiveness was improved after the therapist used play dough and other expressive art materials to work with him. The therapist found that play dough and painting materials work well in helping the boy express feelings. Expressive art materials seem to work well for school-aged clients because they are familiar with those materials. Therefore, the therapist recommends using art materials when working with children who lost their loved ones to natural disaster or sudden death.
The therapist found that good rapport would be a key factor to the success of a treatment. Because of the relationship of trust, the client was willing to share his fears and concerns with the therapist. Being familiar with the client’s culture and sensitive to his needs moves the sessions toward the treatment goals. It helps the boy to find meaning of death and life. Knowing that his mother is in heaven with plenty of helpers and wealth comforts the boy’s frightened heart and minimizes his worries. Creating a non-threatening and relaxing environment helps the boy to verbalize his concerns and fears, and helps the therapist to have a better understanding of his inner world.
It is clear that expressive art materials can be useful when working with traumatized children. However, it is not clear how much it contributes to the success of this treatment. It is believed that the boy’s personality, the therapist’s approach, and the nature of the settings all have impacts on the outcomes of the treatment. The therapist needs to apply this method to more cases, and develop a systematic evaluation tool to assess its effectiveness. Further studies are needed.
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Brent, S. B., Speece, M. W., Lin, C., Dong, Q., &Yang , C. ( 1996) . The development of the concept of death among Chinese and U.S. children 3-17 years of age: From binary to ‘fuzzy’ concepts? Omega: Journal of Death and Dying, 33, 67-83.
Cohen, J. A., Mannarino, A. P., Pardio, S., & Shipley , C. (2002) . Childhood traumatic grief: concepts and controversies. Trauma, Violence & Abuse, 3, 307-327.
Irwin, E . C., & Malloy, E. S. (2001). Family puppet interview. In C. E. Schaefer, & L. J. Carey (Eds.), Family play therapy (pp. 21-33). NY: Jason Aronson.
Massey University, New Zealand
15 December, 2010